CHRONIC RENAL FAILURE Definitions – Azotemia - elevated blood urea nitrogen (BUN >28mg/dL) and creatinine (Cr>1.5mg/dL) – Uremia - azotemia with symptoms or signs of renal failure – End Stage Renal Disease (ESRD) - uremia requiring transplantation or dialysis – Chronic Renal Failure (CRF) - irreversible kidney dysfunction with azotemia >3 months

ETIOLOGY •

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There are about 50,000 cases of ESRD per year Diabetes: most common cause ESRD (risk 13x ) Over 30% cases ESRD are primarily to diabetes CRF associated HTN causes @ 23% ESRD cases Glomerulonephritis accounts for ~10% cases Polycystic Kidney Disease - about 5% of cases Rapidly progressive glomerulonephritis (vasculitis) - about 2% of cases Renal (glomerular) deposition diseases Renal Vascular Disease - renal artery stenosis, atherosclerotic vs. fibromuscular

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OTHERS

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Medications - especially causing tubulointerstitial diseases (common ARF, rare CRF) Analgesic Nephropathy over many years

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Recognizing Clues • • • • • •

Protein in urine Elevated biochemistry results i.e. Creatinine Urea Potassium Anaemia from decreased RBC production shortened RBC survival

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Uraemia symptoms; Bad breath (urinous,ammonia) Oedema (eyes, face, arms,hands, feet) Hypertension Extended neck veins Fatigue (anaemia,toxic substances) Neurological disturbances (lethargy, confusion,sleep disorders)

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Nausea & vomiting Headaches Pruritus (phosphate, calcium, aluminium) Breathlessness Bone & joint problems (calcium/phosphate imbalances,VitD deficiency,demineralization) • Bone pain Endocrine • • • • • •

Stunted growth in children Amenorrhea Male impotence ↑ aldosterone secretion Impaired glucose levels R/T impaired CHO metabolism Thyroid and parathyroid abnormalities

Hemopoietic • • • • •

Anemia Decrease in RBC survival time Blood loss from dialysis and GI bleed Platelet deficits Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses

Cardiovascular • • • • •

Hypertension Arrythmias Pericardial effusion CHF Peripheral edema

– GIT

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Stomatitis Ulcers Pancreatitis Uremic fetor Vomiting consitpation

– Respiratory • • • • •

↑chance of infection Pulmonary edema Pleural friction rub and effusion Dyspnoea Kussmaul’s respiration from acidosis

– Neurological • • • • •

Burning, pain, and itching, parestnesia Motor nerve dysfunction Muscle cramping Shortened memory span Apathy

• Drowsy, confused, seizures, coma, EEG changes Skeletal : Renal Osteodystrophy • • • •

Muscle and bone pain Bone demineralization Pathological fractures Blood vessel calcifications in myocardium, joints, eyes, and brain Skin » Yellow-bronze skin with pallor » Puritus » Purpura » Uremic frost » Thin, brittle nails » Dry, brittle hair, and may have color changes and alopecia

• LAB FINDING – BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis – Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is time for dialysis

– Creatinine clearance is best determent of kidney function. Must be a 12-24 hour urine collection. Normal is > 100 ml/min

• K+ – The kidneys are means which K+ is excreted. Normal is 3.5-5.0 ,meq/L. maintains muscle contraction and is essential for cardiac function. – Both elevated and decreased can cause problems with cardiac rhythm. – Hyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cell. – Kayexalate is also used • Ca – With disease in the kidney, the enzyme for utilization of Vit. D is absent – Ca absorption depends upon Vit.D – Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it. – Normal Ca. level is 4.5-5.5 mEq/L – Hypocalcemia = tetany • Treat with calcium with Vi. D and phosphate • Avoid antacids with magnesium

APPROACH TO PATIENT Evaluation •

Search for underlying causes (see above)

• Laboratory • • • • • • •

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Full Electrolyte Panel Calcium, phosphate, uric acid, magnesium and albumin Urinalysis, microscopic exam, quantitation of protein in urine (protein:creatinine ratio) Calculation of creatinine clearance and protein losses Complete blood count Consider complement levels, protein electrophoresis, antinuclear antibodies, ANCA Renal biopsy - particularly in mixed or idiopathic disease

Radiographic Evaluation Renal Ultrasound - evaluate for obstruction, stones, tumor, kideny size, chronic

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change Duplex ultrasound or angiography or spiral CT scan to evaluate renal artery stenosis MRA preferred over contrast agents 4. Bone Evaluation Severe secondary hyperparathyroidism can lead to osteoporosis Some patients will require parathyroidectomy to help prevent this Unclear when bone densitometry should be done on patients with CRF

TREATING ESRD • 4 forms of treatment; • • • •

HAEMODIALYSIS PERITONEAL DIALYSIS (CAPD) TRANSPLANTATION CONSERVATIVE

MANAGEMENT • • • • • • • • • • • • • • •

Pre-Dialysis Treatment Maintain normal electrolytes Potassium, calcium, phosphate are major electrolytes affected in CRF ACE inhibitors may be acceptable in many patients with creatinine >3.0mg/dL ACE inhibitors may slow the progression of diabetic and non-diabetic renal disease [13] Reduce or discontinue other renal toxins (including NSAIDS) Diuretics (eg. furosemide) may help maintain potassium in normal range Renal diet including high calcium and low phosphate Reduce protein intake to 2.5-3mg/dL Hypertension should be aggressively treated (ACE inhibitors are preferred) – Determine & treat cause – Optimise salt and water balance – Identify appropriate dietary advice – Control hypertension – Control electrolyte imbalance – Prevent and treat renal bone disease

EMOTIONAL SUPPORT • Realisation that there is no cure can trigger;

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Anxiety Denial Frustration Anger Depression Hopelessness

• Nursing care – – – – – – – –

Frequent monitoring Hydration and output Cardiovascular function Respiratory status E-lytes Nutrition Mental status Emotional well being

– Ensure proper medication regimen – Skin care – Bleeding problems – Care of the shunt – Education to client and family

Hemodialysis – Vascular access • Temporary – subclavian or femoral • Permanent – shunt, in arm

– Can be done rapidly – Takes about 4 hours – Done 3 x a week

Peritoneal dialysis – Semipermeable membrane – Catheter inserted through abdominal wall into peritoneal cavity

– Cost less – Fewer restrictions – Can be done at home – Risk of peritonitis – 3 phases – inflow, dwell and outflow

Automated peritoneal dialysis – Done at home at night – Maybe 6-7 times /week – CAPD – Continous ambulatory peritoneal dialysis – Done as outpatient – Usually 4 X/d

Transplant – Must find donor – Waiting period long – Good survival rate – 1 year 95-97% – Must take immunosuppressant’s for life – Rejection • Watch for fever, elevated B/P, and pain over site of new kidney

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