Budoor Al Shehhi
Aisha Al Shamsi
Raya Al Mazrouei
Amna Bedwawi
Manal Al Mazrouei
Plan..
•Case presentation
•Pathophysiology of Chronic Renal Failure
•Treatment of Chronic Renal Failure
Past medical History:
•Incidental Proteinuria 7mmol/L.
• tingling around tips & fingers.
• loss of tendon jerk.
• abdominal distention.
• arrythmia
• ECG changes:
- Tall T-wave, PR interval & QRS complexes are
lengthened.
Metabolic Acidosis
Causes:
-Inability to produce enough NH3 in prox.tubules.
-In advanced cases, accumulation of PO4,SO4 &
other organic anions cause the small anion gap.
Clinical Features:
•Hyperventilation.
•Respiratory distress.
•Fatigue.
•Reduced cardiac output.
•Confusion & drowsy.
Increase in ECV:
-When GFR>> low
erythropoiesis.
– Additional causes:
•Toxic uremic effect on bone marrow
•Bone marrow fibrosis due to increased PTH
•Reduced RBC survival>>> hemolysis
•Blood loss due to capillary fragility and poor platelet function
•Increased GI blood loss due to dialysis and use of heparin
•Decreased dietary intake and absorption of iron
WBC funtion
• Suppression of leukocytes >>>
increased susceptibility to infection.
Clotting & Bleeding
• Platelet aggregation, platelet factor III &
prothrombin >>>> prolonged bleeding time &
increased tendency of bleeding.
Secondary hyperparathyroidism
• Causes:
Hyperphosphatemia:
•Suppresses hydroxylation of 25-OH vit.D to
1,25 diOH vit.D
Hypocalcemia: develops because of :
•Decreased intestinal calcium absorption
•Calcium binding to high plasma levels of phosphate
Decreased renal production of 1,25 diOH vit.D:
Effects on Bone: Renal Osteodystrophy
High-bone turnover: Osteitis fibrosa:
- Due to hyperparathyroidism
Osteomalacia:
-Due to aluminium deposition
-Defective mineralization due to decreased active vitamin D
Adynamic bone disease:
-Predominant bone lesion in chronic peritoneal dialysis
Cysts at the ends of long bones:
-Due to dialysis related amyloidosis from beta2-microglubulin
accumulation in chronic dialysis (8-10 yrs)
Other manifestations of uremia in ESRD
• Pericarditis >>> cardiac temponade
• Encephalopathy >>> coma & death
• Peripheral Neuropathy
• GI symptoms: anorexia, nausea, vomiting, diarrhea
• Skin manifestations: Pallor, Dryness, Pruritus,
Ecchymosis
• Easy fatiguability, failure to thrive
• Malnutrition
• Erectile dysfunction, decreased libido, amenorrhea.
Management
Chronic kidney failure can not be
cured but there are four goals of
therapy:
1) Slow the progression of disease.
2) Treat underlying causes and contributing factors.
3) Treat complications of disease.
4) Replace lost kidney functions.
The previous goals can be achieved by the
following:
- Blood glucose and blood pressure control
(ACEI)
- Diet: low protein diet (controversial)
- Treatment of hyperlipidemia.
- Avoidance of nephrotoxins such as:
- IV radiocontrast.
- NSAIDs
- Aminoglycosides.
- Treating the complications:
a) Fluid retention by diuretics
b) Anemia by injections of a recombinant human
hormone, erythropoietin
c) Low calcium by calcium supplements
d) Hyperphosphatemia with dietary phosphate
binders and dietary phosphate restriction.
e) Hyperpathayroidism with calcitriol or vitamin D
analoges.
f) Metabolic acidosis with oral alkali supplements.
- Treating the uremic manifestations by the
following:
1- Hemodialysis: takes 3-4 hours and usually
performed about 3 times a week.
2- Peritoneal dialysis:
- It is done by putting 2 Liters of dialysis fluid into
the abdominal cavity through a catheter.
- The fluid will balance out electrolytes and toxic
waste products and it needs to be exchanged 4 times a
day.
3- Kidney transplant: can be from living related donors,
living unrelated donors or cadavers.
Complications of Haemodialysis:
1- Vascular problems ( CHF)
2- Metabolic complications (Hyperparathyroidism)
3- Neuromuscular (neuropathy)
4- Hematologic (Anemia)
5- GI (bleeding)
6- Genitourinary ( Sexual dysfunction)
Complications of peritoneal dialysis:
1- Infections (Peritonitis)
2- New onset diabetes (Hyperglycemia)
3- Hypervolemia (Hypertension, pulmonary edema)
4- Obesity
5- Hypokalemia
Complications of renal transplantation:
1- Infections
2- Malignancies
3- Cardiovascular diseases