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									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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