RENAL DISEASES

”“ Review

Chronic Renal Failure

Mohamad.S.Rababah.MD
 Function of Kidneys
• Remove toxic waste products
• Remove excess water and salts
• Play a part in controlling blood pressure
• Produce erythropoetin (epo) which
stimulates red cell production
• Helps to keep calcium and phosphate in
balance for healthy bones
• Maintains proper pH for the blood
 Definitions
• Azotemia: Elevated blood urea nitrogen
– (BUN>28mg/dL) & 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 mos.
• Creatinine Clearance (CCr): rate of filtration of creatinine
by the kidney (marker for GFR)
• Glomerular Filtration Rate (GFR): the total rate of filtration
of blood by the kidney.
 Nephrons
• Nephrons are the units in the kidney that
transfer waste products from the blood to urine.
• A human kidney has approximately one million
nephrons.
• Glomeruli are the filtration units of the nephron.
– The Glomerulus (first structure of the nephron) is
a tuft of capillaries. Blood enters the glomerulus
by the afferent arteriole and exits by the efferent
arteriole
• Bowman’s capsule is a tough layer of epithelial
cells that surrounds the glomerulus ;there is a
small holding area for the initial filtrate in
between the capillary walls of the glomerulus
and the inner layer of Bowman’s capsule; this
area is called Bowman’s space. Fluid and
solutes filtered by the glomerulus collect in this
space. The space connects to the proximal
convoluted tubule, which is the first section of
the nephron’s tube system
 a network of tubules extends from Bowman’s
capsule:
 proximal convoluted tubule (PCT)
 Loop of Henle—has a descending and ascending
limb
 distal convoluted tubule
 Collecting duct
 Renal Failure
• Acute Renal Failure
– Prerenal azotemia
• An abnormally high level of
plasma nitrogen-type wastes . It
is caused by conditions that
reduce blood flow to the
kidneys.
– Postrenal azotemia
• An obstruction of some kind
(i.e., bladder cancer, uric acid
crystals, urethral stricture etc)
– Intrinsic Renal Disease
• Acute tubular necrosis ,the
most common glomerular
disease
• Might lead to End Stage Renal
Disease
 Chronic Renal Failure
• Diabetic Nephropathy
– Diabetes most common contributor to ESRD
– >35% of ESRD cases attributed to Diabetes
• Hypertension
– CFR with Hypertension causes 23% of ESRD annually
• Glomerulonephretis: 10%
• Polycystic Kidney Disease: 5-10%,;ch.pyelonephritis..
• Renal Vascular Disease (i.e., renal artery stenosis)
• Medications
• Analgesic Nephropathy (progression after many years)
• Pregnancy: high incidence of increased creatitine and HTN
during pregnancy associated with CRF
 Chronic Renal Failure
• CRF is defined as a permanent reduction in
glomerular filtration rate (GFR) sufficient to
produce detectable alterations in well-being and
organ function. This usually occurs at GFR below
25 ml/min.
• About 100 to 150 per million persons in the U.S.
develop CRF annually
• Average annual cost is $25,000 – 35,000 per
patient per year
Stages of Chronic Renal Failure
1. Silent – GFR up to 50 ml/min.
2. Renal insufficiency – GFR 25 to 50
ml/min.
3. Renal failure – GFR 5 to 25 ml/min
4. End-stage renal failure – GFR less than
5 ml/min.
 Diabetic Nephropathy
• What can be done to reduce the risk of
problems?
– Blood glucose control
– Blood pressure control
– Using ACE inhibitors and AT II antagonists
– Diet
– Controlling blood lipids and cholesterol
– Smoking
 Treatment for Diabetic
Stage Nephropathy
Assessment Treatment
No Proteinuria Monitor BP & Glucose Hypertension drugs if
Screen for needed (BP should be
micoalbumininuria 130/85 or lower). Dietary
advice for sugar and fat,
stop smoking

Microalbuminuria Close monitoring of BP, Add more Hypertension

Glucose and blood lipids, drugs if needed needed.
monitor urinary proteins Monitor cholesterol and
& CCr add ACE inhibitor if
needed
Proteinuria Close monitoring of BP, BP should be lower than
glucose and blood lipids, 125/75, low protein diet
monitor urinary protein
and 24 CCr
Declining kidney function Prepare for dialysis &/or
transplant
 Metabolic changes
• Na+ excretion initially increased
• Edema occurs when GFR continues to diminish.
• NH4+ excretion declines adding to metabolic
acidosis.
• Bone CaCO3 begins to act as a buffer for the
acidosis and leading to chronic bone loss and
bone lesions develop (renal osteodystrophy).
• Accumulations of normally secreted uremic
toxins
 Uremic Syndrome
• Uremia occurs in stage 3 & 4 of CRF. It
means literally “urine in the blood”
– Symptomatic azotemia
– Malaise
– Anorexia, Nausea
– Mild neural dysfunction
– Uremic pruritus (itching)
 Associated problems with
CFR
• Immunosuppression
– Increased risk of infection
– People with CFR should be vaccinated regularly
• Anemia
– Due to reduced erythropoietin production by kidney.
• Hyperuricemia (Gout)
– Increased uric acid in system
– Pain in joints, may contribute to renal dysfunction
• Hyperphosphatemia
– Increased parathyroid hormone levels
– Increased phosphate load from bone metabolism
• Hypertension
• Poor coagulation
• Proteinuria
 Chronic Renal Failure
• Chronic Renal Failure and
Its Progression

• Functional Adaptation to
Nephron Loss
– Increased amount of sodium
that escapes reabsorption
– Excessive amount of
potassium in blood
– Increased ammonia
concentration
– Calcium and phosphorus
metabolism are markedly
altered
 Treatment of Chronic Renal
Failure
Hypertension
• Metabolic Acidosis
• Anemia
• Renal Osteodystrophy
• Uremic Neuropathy
• Sexual Dysfunction
 Conservative
Treatment

Dialysis Transplant

Hemodialysis Peritoneal Related Donor Cadaver Donor

Home Center
 Treatment of End Stage Renal
Failure
• Hemodialysis
– Uses a mechanized filter to
remove impurities from the
blood system
– Essentially replaces kidney
with a machine
– Dialysis usually occurs a
couple times per week.
 Hemodialysis
• Vascular preparation
– Surgical procedures usually
completed weeks before beginning
hemodialysis
Treatment of End Stage Renal
Failure

• Peritoneal Dialysis
– Uses the abdominal
cavity as a filter
 Treatment of End Stage Renal
Failure
• Transplantation
 Treatment of End Stage Renal
Disease
• Survival of People with ESRD
– Data show a mean expected remaining life span of
just under 8 years for people 40-44 beginning dialysis
and just over 4 years for people 60-64

• Adequacy of Dialysis

• Nutrition
 Chronic Renal Failure
• Physical Rehabilitation – benefits of exercise
• Vocational Rehabilitation
– The goal should be to help the person with chronic renal failure
to resume all the duties, responsibilities and benefits he or she
enjoyed prior to the illness
– Gainful employment is extremely important for an adult in the
earning period of his or her life, to regain self-esteem and to
interact with society confidently
• Fear of losing financial benefits may deter some people
• Some research has shown that multidisciplinary predialysis
intervention leads to maintenance of job