Chronic Renal Failure

History
Symptoms, Diagnosis, Aetiology
1) Earliest symptom usually
nocturia,lethargy, anorexia. 1
st

episode of oert failure may !e
further insult eg "SA#DS, iodine,
ACE$#, dehydration, anaemia
%) &lomerulonephritis as' a!out
proteinuria, haematuria, oliguria,
oedema, sore throat, sepsis, rash,
heamoptysis. As' a!out (iopsy
)) Analgesic nephropathy * as' a!out
type, duration, +,#, -,, -aematuria,
&# !lood loss, nocturia, reanl colic,
,CC. .Aspirin / 0henacetin)
1)0olycystic 2idney. F-x, Diagnosis,
haematuria, polyuria, loin pain, -,,
renal calculi, headache, SA-, isual
changes .intracranial aneurysm)
3) Reflux nephropathy * childhood
renal infections, cystoscopy,
operations, enuresis
4)Dia!etic nephropathy .other D5)
6)-ypertensie nephropathy * 7hen
diagnosed, medications, compliance,
angiography
8)C,D .S9E, Scleroderma)
:)A7are of long term prognosis. -as
dialysis !een discussed. Eligi!le for
dialysis or transplant
5anagement
1)Conseratie * Follo7 up,
medications, diet, salt / 7ater
allo7ance.
#nestigations * !iopsy
Effect on life
E0; for anaemia
0rotein restriction
%) Dialysis * -D or 0D. <here
performed, ho7 often, ho7 long,
relief of symptoms. Complications
Fistulas, other operations .renal tract,
parathyroidectomy)
)),ransplant * 7or'up /
management. <hen, ho7 many.
,ype * liing, cadaeric. 0ost
operatie course. #mproement since
transplant. 5edications, long term
follo7 up
1)(ladder management for reflux or
neurogenic !ladder
3) Social arrangements and AD9s.
Employment, family coping, trael,
sexual function, financial situation
Complications
1) Conseratiely treated patients. =
Symptoms of anaemia, !one disease,
secondary gout or pseudogout,
pericarditis, hypertension, cardiac
failure, peripheral neuropathy,
pruritis, peptic ulcers, impaired
cognitie function, poor nutrition.
Dose reduction in renally excreted
drugs .eg digoxin)
%) Dialysis patient * A>F !loc'ages,
access pro!lems, infection,
pericarditis, peritonitis
)) ,ransplant patient * recent
transplants as' a!out graft pain or
s7elling .failure of graft, re?ection),
infection, urine lea's, steroid side
effects
9ong term grafts * renal function
.Cre), proteinuria, recurrent
glomerulonephritis, aascular
necrosis, s'in cancer and reflux
nephropathy. Drug compliance,
preious re?ection episodes / tmt
Examination
1)&eneral inspection *
5ental state
-yperentilation .acidosis)
2ussmauls !reathing, hiccupping
-ydration .fluid status)
Feer
Cushingoid
%)-ands
"ails * 7hite transerse !ands or lines in hypoal!umin@
!ro7n arc near end of nails .,errys nails)
0almar crease pallor
>asculitis, 7rist A>F, Asterixis, 0eripheral neuropathy
)) Arms
(ruising
0igmentation
Scratch mar's
Su!cutaneous calcification
5yopathy
A>F
S'in cancers
1) Face
Eyes for anaemia, ?aundice, !and 'eratopathy
5outh * dry, fetor
Rash .asculitis, S9E)
Facial hair .cyclosporins)
Saddle nose .<egners)
3) Chest
Cardiac $ 0ericardial ru!, cardiac failure
9ungs * infection, pleural effusion, enous hum
4) A!domen
Scars * dialysis
2idneys * !alota!le, transplant 'idney, mass, !ruits
,enc'hoff catheter exit site infection
(ladder
9ier, Ascites
"odes .9ymphoma)
Femoral !ruits and pulses
Rectal exam * masses, prostatomegaly
6) 9egs
;edema .nephrotic syndrome, CCF)
(ruising, 0igmentation, A>F, Scratch mar's
&out
"europathyA5yopathy
8) (ac'
,enderness, sacral oedema
:)+A
Specific graity, !lood, protein, glucose, microscopy and
casts
1B);ther
(lood pressure lying / standing
Fundoscopy
Investigations/Diagnostic Criteria
1) Determine Renal Function *
a) &FR $ E+C .e&FR) .%1 hr creatinine clearance)
!) ,u!ular function * electrolytes, C50, uric acid, Al!,
urine specific graity, p-, glycosuria
c) +rine analysis and %1 hr protein excretion
d) ;thers * D,0A for renal artery stenosis or o!struction
%) Determine Renal Structure
a) +S * Renal siCe and symmetry, signs of o!struction.
Small 'idneys suggest chronic disease
!)2+(
c)C, 2+(
d)Cystoscopy and retrograde pyelogram
e)Renal artery duplex
))#nestigations trying to find underlying pathology
Renal !ipsy
A"A, A"CA
-ep ( / C serology
-#>
Complement
E0&, #E0&
+rine cytology
1) #nestigate to assess effects of renal failure
F(C .anaemia)
Fe studies
5S+
C50
A90
0,-
"ere conduction for peripheral neuropathy
Arterial Doppler studies
3) Chronic features are nocturia, polyuria, long standing
hypertension, renal osteodystrophy, peripheral
neuropathy, anaemia, hyperphosphataemia,
hyperuricaemia, 'idney siCe .usually small) except for
Early dia!etic nephropathy
0olycystic disease
;!structie uropathy
Acute renal ein throm!osis
Amyloidosis
;ther infiltrating disease
Treatment and complications
1) ,reat reersi!le causes of deterioriation including
a) hypertension
!) +,#
c) ;!struction
d) dehydration
e) cardiac failure
f) drugs ."SA#DS, cyclosporine, #odine, gent)
g) hypercalcaemia
h) hyperuricaemia 7ith urate o!struction
i) hypothyroidism or rarely hypoadrrenalin
%) 5onitor and treat hypertension
)) Carefully attend to salt, 7ater !alance and acidosis
1) "ormalise calcium and phosphate leels 7ith diet, phosphate !inders or calcitriol
3)Restrict dietary protein
4) Dialyse 7hen indicated
6) Consider transplant
Dialysis
1) +raemic symptoms despite conseratie management
%) olume oerload despite salt / 7ater restriction
)) hyper'alaemia unresponsie to conseratie measures
1) progressie deterioration of renal function
3) ARF