| ID | 141 |
|---|---|
| Name | CHRONIC RENAL FAILURE (CRF) (CHRONIC KIDNEY DISEASE- CKD) |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnostic features:’ 1. Persistent & progressive uremia over weeks and months. 2. Features of many primary glomerular and tubular diseases. 3. Urinary abnormalities are usually according to the underlying diseases. 4. In majority cases heypertension develop. |
| Investigations | Investigation: For stages 1-3 CKD: 1. Full blood count- to see anemia and other blood pictures. 2. Blood glucose & HbAlc- to know diabetes and its condition. 3. B. urea, S. creatinine & S. electrolytes- to evaluate kidney function. 4. S. albumin- low albumin; consider malnutrition, inflammation. 5. C- reactive protein- high CRP indicates sepsis or inflammatory disease. 6. Lipid profile- high in CKD, a cardiovascular risk. 7. S. calcium, S. phosphate- to assess renal osteodystrophy. 8. Parathyroid hormone- to assess renal osteodystrophy. 9. Urinalysis- to see infection, haematuria, proteinuria (indicates risk of progressive CKD requiring preventive ACE inhibitor or ARB therapy). 10.Serological tests for hepatitis and HIV. 11. Renal ultrasound- to see kidney size & exclude obstruction or progressive CKD. 12. ECG- to exclude hyperkalemia or any risk factors for cardiac disease. |
| Management | Management: Management of stages 1-3 CKD: Most of the patients with stages 1-3 CKD, fortunately they will never develop ESRD- this is mainly due to the steep increase in the prevalence of CKD in elderly patients, particularly over the age of 70. Recommended management includes: General medical (& cardiovascular) advice: 1. Blood pressure control: Maximum target 130/80mmHg, reduced to 125/75mmHg in diabetes mellitus. Use of ACE inhibitors or angiotensin receptor blockers (ARBs) in those with proteinuria (anyone with an elevated PCR or ACR). 3. Lipid management: Dietary counselling and lipid-lowering therapies reduce risk of cardiovascular diseases. 4. Lifestyle advice: Regarding smoking, exercise, diet and weight. Nephrologist advice is required: Those patients who have potentially treatable underlying disease or who are deterioating renal function and likely to progress to ESRD should be referred to a nephrologist, such as: 1. Young age patients. 2. Renal damage referring to a nephrologist is recommended at- i. Stage 4 CKD, (in the absence of other indications), ii. Deteriorating renal function (e.g GFR fall >5ml/min/1.73m2 in 1 year, or >10ml/min/1.73m2 over 5 years)- monitoring can be reduced to annual if disease is stable or very slowly progressive, iii. Proteinuria: PCR >100mg/mmol or ACR >70mg/mmol has been suggested as a referral threshold, but this should be interpreted with reference to age comorbidity and other factors, iv. Hematuria: May be a marker for inflammatory nephritis. Management of progressive & stage 4+ CKD: The aims of management are to: 1. Findout the underlying renal disease where possible & treat it accordingly. Additional investigations may be required to specify the therapy, e.g immunosuppression in some types of glomerulonephritis. 2. Detection of reversible factors which are making renal function worse, (such as urinary tract obstruction, UTI, hypotension due to drug treatment, salt and water depletion, or nephrotoxic medication) & correct it properly. 3. Prevent further renal damage by maintaining proper diet, fluid and electrolytes. 4. Limit the adverse effects of the loss of renal function. 5. Address any associated cardiovascular risk/disease. 6. Renal replacement therapy as supportive measure (Dialysis): When progressive fall of renal functions occur. 7. Renal replacement therapy (as kidney transplantation) when appropriate. |
| Introduction | Chronic renal failure (currently termed as- chronic kidney disease) is an irreversible deterioration in renal function which classically develops over a period of years. Initially, it manifests only biochemical abnormalities, but gradually there are loss of the excretory, metabolic and endocrine functions of the kidney, leading to the clinical symptoms and signs of renal failure, which are referred to as uremia. In this stage, renal replacement is the mast for survival. When death is likely without renal replacement therapy, it is called end-stae renal disease or failure (ESRD or ESRF) Stages of Chronic kidney disease (CKD): Stage 1- Mild CKD- Kidney damage with normal or high GFR (>90). Clinical presentation: Asymptomatic. Stage 2- Kidney damage and GFR 60-89. Clinical presentation: Asymptomatic. Stage 3A- Moderate CKD- Kidney damage and GFR 45-59. 3B- Moderate CKD-Kidney damage and GFR 30-44. Clinical presentation: Usually asymptomatic; Anaema in some patients at 3B; Most are non-progressive or progress very slowly. Stage 4- Severe CKD- Kidney damage with GFR 15-29. Clinical presentation: First symptoms often at GFR <20. Electrolyte problems likely as GFR falls. Stage 5- Kidney failure- with GFR <15 or on dialysis. Clinical presentation: Significant symptoms and complications usually present. Dialysis initiation varies but usually at GFR <10. |
| History | |
| Etiology | Etiology of CKD & ESRD: Common casuses of ‘chronic kidney disease’ and/or ‘end-stage renal disease’ are as following: 1. Congenital and inherited (5%)- polycystic kidney, Alport’s syndrome. 2. Renal artery stenosis (5%). 3. Hypertension (5-20%). 4. Glomerular diseases (10-20%)- IgA nephropathy (most common), Proliferative GN, Crescentic GN, Membranous GN, Mesangio-capillary G.N, Secondary GN. 5. Interstitial diseases (20-30%)- Chronic pyelonephritis, T.B, analgesic nephropathy, nephrocalcinosis. 6. Systemic inflammatory diseases (5-10%)- e.g SLE, vasculitis. 7. Obstructive uropathy- Calculus, BEP, retroperitonial fibrosis. 8. Diabetes mellitus (20-40%). 9. Unknown causes (5-20%). |
| Clinical Features | Clinical features: May be asymptomatic; renal insufficiency may be revealed by discovery of proteinurea, anemia, hypertension & raised blood urea during routine check up. 1. General- anorexia, nausea, vomiting, weakness, lathergy, hiccup. 2. CVS- pericarditis, CCF, hypertension 3. Haemopoetic- anemia, decreased lymphocyte, abnormal bleeding. 4. Neurologic- Peripheral neuropathy CNS- seizure, hypertensive encephalopathy. 5. Musculoskeletal-Renal osteodystrophy, osteomalacia 6. Metabolic and endocrine dysfunction: glucose intolerence, sexual dysfunction, lipid abnorma-lities. 7. GIT-GIT bleeding 8. Electrolyte- hyponatraemia, hyperkalamia, met-abolic acidosis 9. Dermatologic- dry skin, itching. |
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