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OS 214 CHRONIC RENAL FAILURE 1/3

NEPHROLOGY dR. IRMINGARDA GUECO, December 6, 2005
KREMLINS

Why separate acute from chronic renal failure? Kidney Function

Chronic Renal End-Stage Renal
- Management is different Failure (CRF) Disease (ESRD)
Excretory No signs / symptoms Nausea / vomiting
- Manifestations may be similar Function ↑ BUN ↑↑ BUN
- Prognosis is different: Chronic Renal Failure ↑ Creatinine, ↑↑ Creatinine,
– irreversible; Acute Renal Failure – reversible ↑ Cystatin C ↑↑ Cystatin C
Maintenance of No Manifestations ↑ RR – Kussmaul
Acid-Base Normal acid-base breathing
Objectives Balance balance Metabolic Acidosis
1. Discuss the pathophysiology of CRF/ESRD. Maintenance of ↑ RR
2. Distinguish the pathophysiology of CRF from Fluid & ↑ BP Arrythmia
ESRD. Electrolyte NVE NVE
Balance Crackles Crackles
3. Describe the clinical manifestations of Edema Edema
CRF/ESRD. Na – Normal Na – Normal
4. Correlate clinical history and physical K – Normal or ↑ K–↑
examination findings with the pathophysiology Maintenance of No manifestations Osteitis fibrosa
Calcium- ↑ Phosphate cystica
of CRF/ESRD.
Phosphate ↓ Ca ↑↑ Phosphate
5. Discuss the laboratory findings in CRF/ESRD. Balance ↓↓ Ca
6. Discuss the supportive management of Vitamin D No manifestations Osteomalacia
patients with CRF/ESRD. Production ↓ Calcitriol ↓ Calcitriol
7. Explain the principles and indications of renal (see diagram below)
Erythropoietin Weakness Weakness
replacement therapies, including renal Production Dizziness Dizziness
transplantation. Pallor Pallor
8. Construct an algorithm on the approach to a Easy Fatigability Easy Fatigability
patient with CRF/ESRD. ↓ Hemoglobin ↓↓ Hemoglobin

Functions of the Kidney End Stage Renal Disease

1. Excretory function - Pathophysiology: fibrosis – no more
2. Maintenance of Acid – Base Balance compensation in whatever aspect of excretion
3. Maintenance of Fluid and Electrolyte Balance
4. Maintenance of Ca-Phosphate Balance Management of Chronic Renal Failure
5. Vitamin D production
6. Erythropoeitin Production A. Comprehensive strategy for renoprotection in
patients with chronic renal disease
Intervention Therapeutic Goal
Chronic Renal Failure (CRF)
Specific renoprotective
Pathophysiologic process which is a result of varied therapy
conditions that leads to irreversible destruction of ACE inhibitor or ARB Proteinuria <0.5 g/day
nephrons, ultimately leading to End Stage Kidney treatment GFR decline <2 ml/min/year
Disease (ESRD). Adjunctive cardiorenal
protective therapy
Additional <130/80 mm Hg
Pathophysiology antihypertensive therapy
Long term reduction of renal mass / function which Dietary protein restriction 0.6-0.8 g/kg/day
initially leads to compensatory hypertrophy and Dietary salt restriction 3-5 g/day
AIC < 6.05 %
function. Eventually this leads to sclerosis of the Tight glycemic control in
remaining nephron, resulting to ESRD. diabetes Normal values
Reduce elevated calcium-
Stages of Chronic Renal Disease phosporous
Stage Description GFR, mL/min per
1.73 m2 Lipid lowering therapy LDC-C <100mg/dl
1 At increased risk of kidney 90 (with CRD risk Anti-platelet therapy Thrombosis prophylaxis
damage with normal or factors) Smoking cessation Abstinence
increased GFR 90 Weight control Ideal body weight
2 Kidney damage with mildly 60-89
decreased GFR
B. Preparation for ESRD management
3 Moderately decreased GFR 30-59
4 Severely decreased GFR 15-29 • Psychological
5 Renal Failure (ESRD) < 15 • Renal Replacement Therapy, options
o Dialysis – Vascular Access
GFR o Transplant – Recipient Donor Work-Up
CRF: 16-89 mL/min * with a creatine clearance of 20 or 25, you can
ESRD: <15 mL/min start discussing dialysis with the patient
Difference between CRF & ESRD in terms of C. Management of ESRD
Pathophysiology (1) Supportive
CRF – there is hyperfiltration, some amount of a) Nutrition
compensation b) Control BP
ESRD – no more compensation; all other organ c) Maintain BP at 110-120 g/dl with
systems will end up with some kind of dysfunction Erythropoetin,
d) Maintain Ca and Phosphate balance
(2) Renal Replacement Therapy
a) Dialysis
o Hemodialysis
o Peritoneal Dialysis
b) Transplant
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OS 214 CHRONIC RENAL FAILURE 2/3
NEPHROLOGY dR. IRMINGARDA GUECO, December 6, 2005
KREMLINS
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OS 214 CHRONIC RENAL FAILURE 3/3
NEPHROLOGY dR. IRMINGARDA GUECO, December 6, 2005
KREMLINS

D. Renal Replacement Therapy in CRF

- indicated when metabolic abnormalities can no
longer be controlled with conservative
management or when signs and symptoms of
uremia developed
- No absolute value in terms of CR by which you
will start your RRT

Indications for Dialysis

- volume overload
- intractable metabolic acidosis
- hyperkalemia
- uremic state (encephalopathy, pericarditis)
- azotemia without uremic manifestations

Decreased Renal Function

Hyperphosphatemia Decreased 1.25 Accumulation of

(OH)2D3 AI3+ Intoxication
ß2 microglobulin

Decreased ionized
Ca2+
Decreased
expression
of calcium-
sensing Hyperparathyroidism
receptor

Hyperplasia
of the
parathyroid
glands

Osteitis fribrosa cystica Osteomalacia Adynamic bone Dialysis-related

(high-turnover bone disease) disease amyloidosis

Metabolic acidosis Excess Ca and vit D, PD, diabetes