CME: Chronic Renal failure


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CME: Chronic Renal failure

  1. 1. Prof.Dr.P.Vijayaragavan. Dr.A.Vijayalakshmi. M4 Unit .
  2. 2. <ul><li>Kidney damage for more than 3 months as defined by functional and structural abnormalities of kidney with or without decreased GFR, that can lead to decreased GFR manifest by either </li></ul><ul><li>1.Pathological abnormality </li></ul><ul><li>2.Markers of kidney damage, including abnormality in the composition of blood or urine and imaging. </li></ul><ul><li>3.GFR <60ml/min for >3 months with or without kidney damage . </li></ul>
  3. 3. <ul><li>Chronic renal failure is the process of continuing significant irreversible reduction in nephron number. </li></ul><ul><li>Classification </li></ul><ul><li>stage GFR, ml/min per 1.73m*2 </li></ul><ul><li>o >90 </li></ul><ul><li>1 >90 </li></ul><ul><li>2 60-89 </li></ul><ul><li>3 30-59 </li></ul><ul><li>4 15-29 </li></ul><ul><li>5 <15 </li></ul>
  4. 4. <ul><li>1.Equation from the modification of Diet in Renal Disease study </li></ul><ul><li>Estimated GFR(ml/min per 1.73m*2)=1.86x(Pcr)*-1.154 </li></ul><ul><li>X(age)*-0.203 </li></ul><ul><li>Multiply by o.742 for women. </li></ul><ul><li>2.Cockcroft-Gault equation </li></ul><ul><li>(140-agexbody weight in Kg)/72xPcr(mg/dl) multiply by 0.85 for women. </li></ul>
  5. 5. <ul><li>Nonmodifiable risk factors </li></ul><ul><li>Age - </li></ul><ul><li>The normal annual mean decline in GFR with age from the peak GFR12o ml/min, attained during the 3 rd decade of life is 1ml/min per year. And reaching GFR of 70ml at 70 years. </li></ul><ul><li>Gender </li></ul><ul><li>Male gender is associated with rapid decline in GFR. </li></ul><ul><li>Race </li></ul><ul><li>Africans ,Americans have increased incidence of CKD. And U.K, Indo-Asian Diabetics have faster rate progression of CKD. </li></ul>
  6. 6. <ul><li>Modifiable risk factors </li></ul><ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Obesity </li></ul><ul><li>Dyslipedimia </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol </li></ul><ul><li>Caffeine </li></ul><ul><li>Drugs;NSAID </li></ul>
  7. 7. <ul><li>1.Most frequent cause of CKD is Diabetic Nephropathy.(often type 2 DM). </li></ul><ul><li>2.Hypertensive nephropathy common cause in elderly. </li></ul><ul><li>3.Obesity has linked with IgA nephropathy . </li></ul><ul><li>4.Chronic glomerular nephritis . </li></ul><ul><li>5.Chronic interstitial nephritis. </li></ul><ul><li>6.Hereditary kidney diseases. </li></ul>
  8. 8. <ul><li>The primary damage can be glomerular, vascular, interstitial, tubular or combination </li></ul><ul><li>The kidney disease causes nephron destruction and loss of nephrons. </li></ul><ul><li>Metabolic dysfunction , heavy proteinuria, systemic hypertension. </li></ul>
  9. 9. <ul><li>Initiating mechanisms specific to the underlying etiology. </li></ul><ul><li>Progressive mechanisms, involving hyperfilteration and hypertrophy of the remaining viable nephrons,leading to increased pressure and flow predispose to sclerosis and drop out of the remaining nephrons . </li></ul>
  10. 10. <ul><li>Fluid and electrolyte disturbances </li></ul><ul><li>Volume expansion </li></ul><ul><li>Hyponatremia. </li></ul><ul><li>Hyperkalemia. </li></ul><ul><li>Hyperphosphatemia . </li></ul><ul><li>Endocrine metabolic </li></ul><ul><li>Secondary hyperparathyroidism. </li></ul><ul><li>Vit-D deficient osteomalacia. </li></ul><ul><li>Hyperuricemia. </li></ul><ul><li>Hypertriglyceridemia . </li></ul>
  11. 11. <ul><li>Infertility and sexual dysfunction . </li></ul><ul><li>Neuromuscular </li></ul><ul><li>Fatigue </li></ul><ul><li>Sleep disorders. </li></ul><ul><li>Headache. </li></ul><ul><li>Impaired mentation </li></ul><ul><li>Lethargy. </li></ul><ul><li>Asterixis. </li></ul><ul><li>Peripheral neuropathy </li></ul>
  12. 12. <ul><li>Cardiovascular </li></ul><ul><li>Hypertension </li></ul><ul><li>CCF </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Pericarditis </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Dermatology </li></ul><ul><li>Hyperpigmentation </li></ul><ul><li>Pruritis </li></ul><ul><li>Echymosis . </li></ul>
  13. 13. <ul><li>GIT </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Peritonitis </li></ul><ul><li>GI bleed. </li></ul><ul><li>Idiopathic ascites . </li></ul><ul><li>Hematology </li></ul><ul><li>Anemia </li></ul><ul><li>Lymphocytopenia </li></ul><ul><li>Thrombocytopenia, Leucopenia. </li></ul>
  14. 14. <ul><li>Between 50% t0 75% of individual with CKD stage 3 and 4 have H.T. </li></ul><ul><li>Patients with stage 3 CKD have dyslipidemia. </li></ul><ul><li>Anemia is associated with stage 3 CKD. The causes are 1.relative deficiency of erythropoietin 2.diminished RBC survival 3.bleeding diathesis 4.iron deficiency 5.chronic inflammation. 6.folate or vit B12 deficiency. </li></ul>
  15. 15. <ul><li>Elevation of growth hormones, Decrease T4,IncreaseT3 ,Decrease clearance of insulin. </li></ul><ul><li>Elevated prolactin in males.Alteration in pituitary ovarian axis in females are to be noted . </li></ul>
  16. 16. <ul><li>1.Dehydration. </li></ul><ul><li>2.Drugs. </li></ul><ul><li>3.Disease relapse. </li></ul><ul><li>4.Disease Acceleration </li></ul><ul><li>5.Infection. </li></ul><ul><li>6.Obstruction. </li></ul><ul><li>7.Hypercalcemia. </li></ul><ul><li>8.Hypertension. </li></ul><ul><li>9.Heart failure. </li></ul><ul><li>10.Interstitial nephritis . </li></ul>
  17. 17. <ul><li>1.Pericarditis. </li></ul><ul><li>2.Fluid overload.-Pulmonary edema. </li></ul><ul><li>3.Resistant Hypertension. </li></ul><ul><li>4.Hyperkalemia. </li></ul><ul><li>5.Uncompensated metabolic acidosis. </li></ul><ul><li>6.Seizures. </li></ul>
  18. 18. <ul><li>Glucose </li></ul><ul><li>High in DM. </li></ul><ul><li>Electrolytes </li></ul><ul><li>Na-usually normal or low.,K+ raised.,HCO3 decreased. </li></ul><ul><li>Serum Albumin-Hypoalbuminemia. </li></ul><ul><li>Serum Ca+ may be normal or high. </li></ul><ul><li>Phosphate high . </li></ul><ul><li>Urea-When blood urea high when compared to creatinine evidence of dehydration, GIT blood loss, infection should be thought. </li></ul><ul><li>Serum creatinine </li></ul><ul><li>SAP - raised when bone disease develops . </li></ul><ul><li>Serum PTH raised . </li></ul>
  19. 19. <ul><li>Serum cholesteral evidence of dyslipidemia . </li></ul><ul><li>Hematology - Normocytic normochromic anemia . </li></ul><ul><li>Serology </li></ul><ul><li>AutoAb,Antinuclear Ab, AntiGBM Ab, Hepatitis B, HIV . </li></ul><ul><li>Urine analysis </li></ul><ul><li>RBC-Sediments GBN.,Pyuria-Interstitial nephritis. </li></ul><ul><li>Spot urine collection for Total protein,creatinine ratio. </li></ul><ul><li>Normal-is <2 </li></ul><ul><li>24 urine forTotal protein and creatinine clearance. </li></ul><ul><li>Serum and urine protein electrophoresis . </li></ul><ul><li>ECG,ECHO - LVH . </li></ul>
  20. 20. <ul><li>Image </li></ul><ul><li>Xray Nephrocalcinosis. </li></ul><ul><li>U.S.G </li></ul><ul><li>Small kidneys with reduced cortical thickness, showing increased echogenecity, scarring and multiple cysts suggests chronic process(large kidney-DM initial stage, Amyloidosis, HIV, Polycystic kidney disease.) </li></ul><ul><li>CT ,MRI are helpful in Renal artery stenosis and renal vein thrombosis. </li></ul><ul><li>Renal biopsy . </li></ul>
  21. 21. <ul><li>Measure proteinuria which is the strongest single predictor of GFR decline. </li></ul><ul><li>Therapy induced proteinuria reduction ,slows GFR. </li></ul><ul><li>Each 1gm reduction in protenuria by 4 to 6 months of the antiprotenuric treatment, GFR decline is slowed by about 1 to 2 ml/min./yr. </li></ul><ul><li>Measure GFR ; </li></ul><ul><li>Serial creatinine measurement is usually sufficient. </li></ul><ul><li>Be aware the conditions can increase creatinine production </li></ul><ul><li>1.cooked meat, 2.fenofibrate therapy, 3.increased exercise 4.increased muscle mass. </li></ul><ul><li>Decrease creatinine production 1.vegetarian diet, 2.muscle wasting , 3.decreased exercise . </li></ul>
  22. 22. <ul><li>Stage I and II Usually asymptomatic patients. </li></ul><ul><li>To modify the risk factors.SRD, Protein restricted diet, </li></ul><ul><li>Stage3 : creatinine level 2mg/dl H.T, secondary Hyperparathyroidism </li></ul><ul><li>To start phosphate restriction, phosphate binders, treat H.T, immunize against hepatitis B. </li></ul><ul><li>Stage4 with serum creatinine level 4mg/dl +anemia </li></ul><ul><li>To restrict dietry potassium to 60mmol/day. </li></ul><ul><li>Add Erythropoietin </li></ul><ul><li>Advice moderate protein restriction and plan renal replacement therapy including vascular access . </li></ul>
  23. 23. <ul><li>Stage5 serum creatinine level 8mg/dl , +sodium and water retention, anorexia, vomiting, reduced higher mental functions. </li></ul><ul><li>To plan elective start of dialysis or pre-emptive renal transplantation. </li></ul><ul><li>Stage5 uremic emergency </li></ul><ul><li>17mg/dl +pulmonary edema, fits, coma, metabolic acidosis, hyperkalemia, death </li></ul><ul><li>To start dialysis or provide palliative care . </li></ul><ul><li>. </li></ul>
  24. 24. <ul><li>When to refer the patient to Nephrologists </li></ul><ul><li>Ideally when the patients reach CKD stage 3. </li></ul><ul><li>Be aware that an arteriovenous fistula typically takes 8 to 12 weeks to mature . </li></ul><ul><li>Prevent late presentation of patients to the nephrologists to start dialysis using central venous catheter s. </li></ul>
  25. 25. <ul><li>Hello Kidney _ </li></ul><ul><li>YOU Are a KID </li></ul><ul><li>KID NEE </li></ul><ul><li>We will take care of you by modifying the risk factors, And by retarding the progression ,,,,,,. </li></ul><ul><li>Physicians. </li></ul>
  26. 26. <ul><li>THANK YOU </li></ul>THANK YOU THANK YOU