OS214 20060306 Grp10a Chronic Renal Failure

CHRONIC RENAL FAILURE

OS 214 EXCRETORY

GROUP

dR. IRMINGARDA GUECO, MARCH 6, 2005

OUTLINE Discuss the pathophysiology of CRF/ESRD. Distinguish the pathophysiology of CRF from ESRD. Describe the clinical manifestations of CRF/ESRD. Correlate clinical history and physical examination findings with the pathophysiology of CRF/ESRD. 5. Discuss the laboratory findings in CRF/ESRD. 6. Discuss the supportive management of patients with CRF/ESRD. 7. Explain the principles and indications of renal replacement therapies, including renal transplantation. 8. Construct an algorithm on the approach to a patient with CRF/ESRD. We would like to acknowledge the KREMLINS for the soft copy of this trans  Notes taken during the lecture are in arial size 8 1. 2. 3. 4.

Why separate acute from chronic renal failure? - Management is different - Manifestations may be similar - Prognosis is different: Chronic Renal Failure – irreversible; Acute Renal Failure – reversible Functions of the Kidney Excretory function Maintenance of Acid – Base Balance Maintenance of Fluid and Electrolyte Balance Maintenance of Ca-Phosphate Balance (Mineral balance)

Vitamin D production Erythropoeitin Production

Measured using: BUN, creatinine pH, HCO3, pCO2 Osmolality, water, Na, K, Cl Ca, Phosphates (Mg) Calcium Hgb, hct for confirmation

Chronic Renal Failure (CRF) -Pathophysiologic process which is a result of varied conditions that leads to irreversible destruction of nephrons, ultimately leading to End Stage Kidney Disease (ESRD). -Sum of all processes that happen cause by various diseases such as DM, hpn, GN, lupus, secondary causes due to multiple myeloma, etc. - Slow deterioration of kidney function - Loss of nephrons  other nephrons try to compensate during CRF phase, you don’t see manifestations of ESRD - Normal GFR men:100ml/min; women:85ml/min - Just keep in mind that the key word in CRF is COMPENSATION - DO NOT MAKE THE MISTAKE OF DIALYSING A PATIENT WITH CRF! Spectrum of CRF: Normal kidney

CRF (>3mos)

ESRD

Pathophysiology -Long term reduction of renal mass / function which initially leads to compensatory hypertrophy and function. Eventually this leads to sclerosis of the remaining nephron, resulting to ESRD. Stages of Chronic Renal Disease Stage

Description

1

At increased risk of kidney damage with normal or increased GFR Kidney damage with mildly decreased GFR Moderately decreased GFR Severely decreased GFR

2 3 4

page 1/3

GFR, mL/min per 1.73 m2 90 (with CRD risk factors) 90 60-89 30-59 15-29

5

Renal Failure (ESRD)

< 15

GFR • CRF: 16-89 mL/min • ESRD: 60, accumulation of Na • Increased BP: CM, lupus, GN • No signs/symptoms, normal BP: may also have renal failure, creatinine worsening • Buko juice: causes hyperkalemia; so AVOID DRINKING BUKO JUICE WHEN YOU HAVE KIDNEY PROBLEMS UNLESS YOU HAVE LOW POTASSIUM • Buko juice, bananas  good fore people with diarrhea • Nephrologists should therefore identify patients are Na or K wasters. If this is the case then don’t let them avoid Na of K. Maintenance of Calcium-Phosphate Balance • >25% creatinine clearance is still normal Vitamin D Production • Calcitriol- only in lab research for now • (Please refer to table at last page) Why is there an increase in phosphates in ESRD?  because the poorly functioning kidney

OS 214 GROUP

CHRONIC RENAL FAILURE

EXCRETORY

can’t eliminate them all. The phosphate binds with calcium  leading to a decrease in ionized calcium  leading to secondary hypoparathyroidism Erythropoietin Production • In DM, anemia occurs early

Management of Chronic Renal Failure A. Comprehensive strategy for renoprotection in patients with chronic renal disease Intervention Therapeutic Goal Specific renoprotective therapy Proteinuria