Chronic Renal Failure David Dayya, D.O. St. Barnabas Hospital Dept. of Family Medicine Epidemiology Diabetes Mellitus = 30% Hypertension = 25% Glomerulonephritis = 15% Others i.e. Nsaids 8-10% African Americans and Hispanics > Caucasions Approximately 250,000 Dialysis and renal transplant patients in the U.S. Estimated Cost = 5-10 billion Definitions A loss or decrease in renal function measured as a loss or decrease in GFR An increase in nitrogenous waste ( BUN, CR) Azotemia Renal Insufficiency Renal Failure Acute vs. Chronic Reversible vs. progressive irreversible loss of renal function GFR determination Ideally agent neither absorbed or secreted Creatinine vs. Inulin (GFR estimation) 24 Hour Urine Analysis, Limitations in coll. CrCl = (Ucr/Pcr) X (Uvol/day) Cockgroft Gault Equation CrCl = [(140-age) X Wt.(kg)]/ (72 X Pcr) Pcr = 0.6 – 1.3mg/dl Ucr = ? mg/dl Uvol = 0.5cc/kg/hr GFR = 100-120ml/min ESRD = <10ml/min Uremia Syndrome occurs when Cr. Approximately 8-10 An excess of urea and nitrogenous waste in the blood that results in a complex of symptoms due to severe persisting renal failure that can be relieved by dialysis Metabolic Acidosis Hyperphosphatemia Hyperuricemia Hypermagnesemia No response to aldosterone Catabolic state Endocrine System PTH increases Active form of Vitamin D decreases GNRH decreases hence decreased FSH, LH Ammenorhea, Infertility, Oligospermia, Impotence Renal cells involved in gluconeogenesis and in Insulin metabolism Pulmonary System Immunodysfunction Risk of Pneumonias Pleural effusions, CHF, Pleuritis Cardiovascular System Increased incidence of CAD Accelerated atherosclerosis secondary to increased free radical production mediated via heavy metal catalysis which results in oxidative reactions causing an increase in oxidized LDL the central mediator in atherogenesis. CHF sec. to hypervolemia and cardiomyopathy Edema Pericardial Tamponade and Pericarditis Skeletal System Renal Osteodystrophy PTH, Vitamin D Alpha-hydroxylase mediated catalyzation of reaction forming active Vitamin D 1,25- Dihydroxy cholecalciferol PTH effect on Kidneys PO4 excretion and Ca reabsorption “ Renal Ricketts “/ Osteomalacia Osteitis Fibrosa Cystica Osteoporosis Aluminum deposition in growth plates Hematopoetic System Erythropoetin Anemia WBC function Immunosuppression Platelet function Coagulopathy K, Mg, Na Anion Gap Metabolic Acidosis Hypoosmolarity secondary to Total body sodium Nervous System Neurotoxicity of middle molecules Proteins/polypeptides Asterixis present short neural pathways affected first followed by longer neural pathways Autonomic Nervous System dysfunction leading to labile blood pressure, orthostasis Gastroparesis Dementia, Delerium, Seizures, Coma, Death Aluminum role in CNS disturbance Integumentary System Pruritis PTH related leading to neuronal stimulation Yellow skin discoloration secondary to “Urochrome deposition” Bronze skin discoloration secondary to hemochromatosis Dermal deposition of CaPO4 i.e. metastatic calcifications Management Restrict dietary protein to control uremia improves nausea, vomiting, malaise, and encephalopathy Calories to control catabolic breakdown products Limit high phosphate containing products Increase Fiber Consult Nutritionist Phosphate Binders Ca X PO4 >70 Diuretics D.O.C. for HTN and volume overload MGT. continued K-Binding Resins, Calcium Gluconate, Insulin, Dextrose, Bicarbonate Calcium/Vitamin D, Rocaltrol (0.25-1mcg po qd) supplementation Avoid heavy metal containing products Control coagulopathy, Transfuse, Epogen(50- 100U/kg SC/IV 3X/week) Pneumovax, Influenza vaccines Fertility referral i.e. invitro fertilization, artificial insemination, fertility drugs Dialysis Transplantation Complications Fluid Overload, HTN Pericardial Tamponade Hyperkalemia Hypermagnesemia Metabolic Acidosis Neurotoxicity (asterixis) ARF VS. CRF History Normal Incr. BUN/CR Kidney Size Normal Decreased Bone Films R.O. Absent R.O. Present H/H Normal Anemia Present Questions?
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