Chronic Renal Failure for General Practice Robin Jeffrey Bradford Hospitals.
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Transcript of Chronic Renal Failure for General Practice Robin Jeffrey Bradford Hospitals.
Chronic Renal Failure for General Practice
Robin Jeffrey
Bradford Hospitals
Progressive and irreversible deterioration in glomerular +/- tubular function measured over
months and years
Pyramid of chronic renal disease
600/M
>5000/M
Measurement of renal function
• Glomerular function– Inulin clearance, radio-isotopic clearance– Creatinine clearance, Cockcroft-Gault– Serum creatinine, serum urea
• Tubular function– Serum K, PO4, urate, – Acid-base balance
• Endocrine function– Haemoglobin– Serum calcium, PO4, PTH
time
GFR
Cockcroft-Gault formula
• Calculated Crcl
= (140-age) x weight x 1.2
serum creatinine
example
• 70 year old woman• Weight 45kg• Crcl 25ml.min• Serum creatinine
132umol/l
• 25 year old male• Weight 85kg• Crcl 25ml/min• Serum creatinine
469umol/l
Urea as a marker of renal function
Elevated by• Dehydration• Increased dietary
protein inc. gut bleed• Catabolic states inc.
infection and steroids
Reduced by• Overhydration• Starvation• Liver disease• pregnancy
x x
xGFR
time
Who gets renal disease
• Elderly
• Males
• Ethnic minorities
Progression of CRF
• Continuation of primary disease process
• Factors associated with acute reversible deterioration
• Background irreversible progression
dehydrationand reduced renal perfusion obstruction
infection
toxins
hypercalcaemia
Acute insult
Background progression
• Adaptive hyperfiltration hypothesis
• Hypertension
• Proteinuria
• Tubulo-interstitial nephritis
• Hyperlipidaemia
• Cytokines
• Genetic factors
Glomerular maladaptation
Increased intraglomerular pressure
Glomerular hypertrophy
Glomerulosclerosis
Maintain GFR
GFR
time
Clinical factors associated with accelerated progression
• Hypertension
• Heavy proteinuria
• Type of renal disease
• Genetic markers
• ? Ethnic relationship
• Smokers
Management of chronic renal failure
• Reversal of underlying disease
• Avoid/treat acute insults
• Slow progression of nephropathy
• Minimise complications
• Prepare physically and mentally for renal replacement therapy
GFR
time
Slow disease progression
• Control of blood pressure
• Reduce proteinuria
• The special role of ACE inhibitors
• Low protein diet
Lewis slide from uptodate
METABOLICCOMPLICATIONS
Anaemia Left VentricularHypertrophy
AcceleratedAtherosclerosis
AcidosisRenal osteodystrophy
Catabolism
Hyperkalaemia
Management of complications
• Erythropoietin
• Sodium bicarbonate
• Calcium-based phosphate binders
• Vitamin D supplementation
• Statins
• Anti-hypertensives
Psychological and physical preparation for RRT
• Education about different forms of dialysis and transplantation
• Support and counselling of patient and family
• Surgical creation of dialysis access
• Discussion about potential living donor
CHRONICRENAL FAILURE
PRE-DIALYSIS
ESRF
RENALTRANSPLANT
LIVINGDONOR
CADAVERIC
Late referral to specialist care is associated with:
• Inferior biochemical control
• Malnourishment
• Poorer quality of life
• Longer hospitalisation
• Increased early morbidity and mortality
0
5
10
15
20
25
30
35
40
Early referral Late referral
Initiation of dialysis
• Ethics – ‘conservative care of CRF’
• Ideally smooth and programmed
• Emergency in 50%
• Absolute and relative indications