Chronic Renal Failure DO YOU STILL PASS URINE NOW?

(GIVES AN ESTIMATION OF SEVERITY OF

Concise Long Case Approach RENAL FAILURE)
GONAH + skin + neuro + GIT
History
Growth (paeds) Height/ weight
Presenting complaint Osteodystrophy Bone pain
I have renal failure Fractures
complications Arthritis
unrelated problem Proximal myopathy
Nutrition Protein intake
Past history Water restriction (glomerular) or excess (interstitial)
first diagnosis when Electrolytes
Anemia Pallor, lethargy, fatigue
presenting complaint
SOB
o enquire about urinary symptoms
Hypertension treatment
frothy urine
Skin Sallow
hematuria Pruritis
oliguria/anuria/polyuria/nocturia GIT NVD
Neuro Seizures 20 electrolyte disturbances
etiology: Encephalopathy
Peripheral neuropathy
Commonest Other
DM Renal
Complications of treatment
ask for past history Renovascular
Dialysis bleeding/ infections/ occlusion
ask for polyuria/polydipsia/polyphagia Interstitial nephritis e.g. drugs
Immunosuppressive drugs cyclosporine/ azothioprine/ prednisolone
HTN Cystic kidney diseases family history
ask NSAIDsanalgesic nephropathy Functional days off work/school, change of job, financial
GN Pyelonephritis e.g. told of kidney The standard remaining history
VITAMIN infection? Fever?
Vascular HSP rashes/joint/abdpain Stones loin to groin pain, previous
Infectious strep sore throat/ HBV stones
Toxin gold/ penicillamine Anatomical e.g. VUR, BPH
Autoimmune SLE symptoms
Physical examination
Metabolic DM Extrarenal
10 causes General Ht/Wt
SLE Cachexia
systemic sclerosis Myoclonus 2o uremia
myeloma Cusingoid appearance 2o steroids
Skin Sallow
Investigations done Scratch marks
U/S anatomical malformations Hands/ Arms Asterixis
Biopsy - GN Leuconychia
Lindsays and nails (proximal white distal brown)
Management Palmar crease pallor
medications AV fistula thrill present is important sign of patency
dialysis Myopathy
AV grafts Face/ chest Fundoscopy HTN/DM changes
Anemia
Transplant/ waiting list? Central line
Tanner Staging
Disease progression and Complications of disease Rickety rosary ribs
Heart Pericardial rub U/E/Cr electrolyte imbalance
CCF Radiology CXR heart/lungs
Bruit suggest vascular cause of CRF Bone Xrays
Lungs Creps
Abdomen Nephrectomy scar usu. postero-lateral
Transplant scar (usu iliac fossa) and transplant kidney Management
Kidneys ballotable, bruit
Bladder DGIM Last updated March 2005 Growth failure Treat all contributors to growth failure
Enlarged prostate Malnutrition inadequate protein
Legs Edema Anemia
Neuropathy Osteodystrophy
PVD GH resistance
Genu varum
Other Bone and joint tenderness If ht<3%, velocity<50%, give rHGH tx
BP Osteodystrophy Phosphate binders (CaCO3)
Calcium supplements (CaCO3)
Manifestations of DM, HTN, SLE Vitamin D supplementation
Nutritional If HD/PD, give recommended daily allowance + additional
protein to compensate for losses from dialysis
Fluid fluid restriction in ESRF and fluid overload type CRF, if
salt-losing type CRF, encourage H20 intake
Investigations Na 2g/d
to confirm diagnosis of CRF K usu well maintained, treat as emergency if hyperK
to determine etiology of CRF Ca gluconate
to look for complications of CRF Insulin + dextrose
Salbutamol
Diagnosis U/E/Cr Creatinine to estimate GFR Resin (Ca Resonium)
By Cockcroft-Gault formula
Dialysis
by Schwartz formula
Anemia Causes of Anemia
GFR= k x Height(cm)/plasma creatinine
Decreased EPO synthesis
k=48.6 (children >3y)
Shortened RBC survival due to uremia
k=61 in males >13y
It tends to overestimate CRF Management
GFR = 100-120ml/min/1.73m2 Adequate dialysis
GFR= 30-50 in mild CRF Keep >10g%
GFR= 10-29 in moderate Do Fe studies (Fe, ferretin, transferring, TIBC)
GFR< 10 in severe rEPO if not Fe-deficient
GFR<5 in ESRF, requires renal replacement Hypertension ACE-inhibitor
therapy Ca++ blocker
Etiology Bloods Plasma glucose Neurological Electrolyte control
ASOT/ HBV/ ANA/ C3
Urine Urinalysis
Radiology Renal U/S cysts
IVU Stones
MCU if suspect anatomical abnormalities in
paeds
DMSA/ DTPA
Biopsy GN
Complications Bloods FBC Anemia
Serum Ca/ PO4/ ALP/ PTH

DGIM Last updated March 2005