Chronic renal failure (CRF) or end stage renal disease (ESRD) is an irreversible deterioration of renal function that results in uremia or azotemia. It is caused by a progressive reduction in kidney function such that the kidneys can no longer maintain homeostasis. This leads to decreased glomerular filtration rate, hypertrophy of remaining nephrons, inability to concentrate urine, further nephron loss, and loss of excretory and non-excretory renal functions. Management of CRF focuses on preserving renal function, alleviating extra-renal manifestations through medications and dialysis, and improving body chemistry through diet and medication.
3. DEFINITION
1.CRF OR ESRD IS A PROGRESSIVE, IRREVERSIBLE
DETERIORATION IN RENAL FUNCTION IN WHICH THE
BODYâS ABILITY TO MAINTAIN METABOLIC AND FLUID
AND ELECTROLYTE BALANCE FAILS RESULTING IN
UREMIA OR AZOTEMIA.
2.CHRONIC OR IRREVERSIBLE RENAL FAILURE IS A
PROGRESSIVE REDUCTION OF FUNCTIONING OF RENAL
TISSUE SUCH THAT THE REMAINING KIDNEY MASS CAN
NO LONGER MAINTAIN THE BODYâS INTERNAL
ENVIRONMENT.
5. ďś OBSTRUCTION OF THE URINARY TRACT
ďś HEREDITARY LESIONS
-POLYCYSTIC KIDNEY DISEASE
ďś INFECTIONS
ďś VASCULAR DISEASES
ďś MEDICATION OR TOXIC AGENTS
ďś ENVIRONMENTAL OR OCCUPATIONAL AGENTS
-LEAD
-CADMIUM
-MERCURY
-CHROMIUM
6. PATHPHYSIOLOGY
DUE TO ETIOLOGICAL FACTORS
DECREASED GFR
HYPERTROPHY OF REMAINING NEPHRONS
INABILITY TO CONCENTRATE URINE
FURTHER LOSS OF NEPHRON FUNCTION
LOSS OF NON-EXCRETORY AND EXCRETORY
FUNCTION
7. PATHOPHYSIOLOGY
Decreased renal
blood flow, primary
kidney disease,
damage from other
disease, urine outflow
obstruction
Decreased glomerular
filteration rate
Hypertrophy of
remaining nephrons
Inability to
concentrate urine
Further loss of
nephron function
Loss of excretory
renal function and
non excretoryrenal
function
9. STAGES OF CHRONIC KIDNEY DISEASE
STAGES 1 WITH NORMAL
OR HIGH GFR
>90 ml/min.
STAGE 2 MILD CKD 60-90 ml/min.
STAGE 3A
STAGE 3 B
MODERATE
CKD
45-59ml/min.
30-44ml/min.
STAGE 4 SEVERE CKD 15-29ml/min.
STAGE 5 END STAGE
CKD
<15ml/min.
10. STAGES OF CRF
1) Reduced Renal reserve
- BUN is high or normal
- Client has no C/M
- 40 to 75 % loss of nephron function
2) Renal Insufficiency
- 75 to 90 % loss of nephron function
- Impaired urine concentration
-Nocturia, mild anemia, increased
creatinine and
BUN
Edited by :-MR . ROMAN BAJRANG
11. 3) Renal failure
- Severe azotemia
- Impaired urine dilution
- Severe anemia
-Electrolyte Imbalances
Hypernatremia
Hyperkalemia
Hyperphosphatemia
4) End Stage Renal Disease
-10 percentage nephrons functioning
-Multisystem dysfunction
12. ⢠DECREASED LIBIDO
⢠INFERTILITY
⢠DELAYED HEALING
⢠INFECTION
⢠ANEMIA, PALLOR
DISTURBANCES IN
REPRODUCTION
IMMUNE DISTURBANCES
INCREASED PRODUCTION OF
LIPIDS
IMPAIRED INSULINACTION
FAILURE TO PRODUCE
ERYTHROPOIETIN
FAILURE TO CONVERT
INACTIVE FORMS OF
CALCIUM
⢠ADVANCEDATHEROSCLEROSIS
⢠ERRATIC BLOOD GLUCOSE LEVEL
⢠DECREASED CALCIUM ABSORPTION:-
OSTEODYSTROPHYANDHYPOCALCEMIA
LOSS OF EXCRETORY RENAL FUNCTIONS
19. ďś METABOLIC CHANGES
NORMAL RATIO OF BUN TO CREATININE IS 10:1
HYPOPROTEINURIA
INCREASED SERUM URIC ACID
CARBOHYDRATE INTOLERANCE
METABOLIC ACIDOSIS AS KIDNEYS FAIL TOEXCRETE
HYDROGEN IONS.
20. ďś CHANGES IN MEDICATION
TOXICITY
⢠MEDICATION TOXICITY
Edited by :-MR . ROMAN BAJRANG
32. ď Features of CNS involvement
-Forgetfulness
-Inability to concentrate
-Short attention span
-Impaired reasoning
⢠Musculoskeletal changes
-Osteomalacia
-Osteitis fibrosa
-Osteoporosis
-Oateosclerosis
33. ď Integumentary Changes
-Yellow grey discoloration of skin
-Pale
-Dry and scaly
-Pruritis
-Bruising ,Petechial and Purpura
-Hair is brittle
-Nails are thin and brittle
35. ď Endocrine Changes
-Hypothyroidism
-Increased GH and prolactin
ď Immunologic changes
-Depression of human antibody
formation
-Decreased function of leukocytes
- Depression of delayed
hypersensitivity
37. DIAGNOSTIC STUDIES
ď History and physical examination
ď Routine lab measurements
- BUN
- Serum Creatinine
- Serum Electrolytes
- Hematocrit and Hb levels
- Urine Analysis
- Urine Culture
38. ď Identification of Reversible Renal Disease
- Renal Ultrasound
- Renal Scan
- C T Scan
- Renal Biopsy
39. MANAGEMENT
1) Preserve the renal function and dialysis
- Controlling the disease process.
- Controlling BP by diet control,
weight control and medication.
- Reducing dietary protein intake.
2) Alleviate extra renal manifestations.
a) Pruritis
- Topical emollient and lotion.
- Antihistamine.
- IV Lidocaine
40. b) Neurological manifestations.
- Safety measures to protect From injury.
- Anticonvulsants.
- Sedatives
c) Hematologic changes:-
Therapy with epoetin alfaThree times a week
and
- supplemental iron, vitamin B12
folic acid.
41. 3) Improve body chemistry.
a) Dialysis
b) Medications
c) Diet
43. * Hypertension
- Sodium and fluid restriction
- Anti hypertensive
drugs Diuretics
Beta adrenergic blockers
Ca channel blockers
ACE inhibitors
44. Renal osteodystrophy
- Regulation of calcium,
ď Phosphorus and acidosis
1.Treatment of hyperparathyroidism
2. Calciferol
- Paricalcitol (Vitamin D analog)
- Calcium based phosphate binders
Calcium acetate Calcium
carbonate
45. * Anaemia
- Erythropoietin â I/V
subcutaneously
- Epogen ( Epoetin alfa)
- Parental iron
- Folic Acid 1 mg daily
* Diuretics
Given early to stimulate excretion of
water
46. * Vitamins
- Supplemental water soluble
vitamins
c) Diet
* Protein restriction
- 0.6 to 0.75 gm/kg of ideal body
weight/day
- 1.2 to 1.3 gm/kg of ideal body
weight/day once the patient
starts dialysis .
47. * Water restriction
Patient not receiving dialysis â 600ml +
an amount equal to the previous days
urine out put
Patients on dialysis â fluid intake is
adjusted so that weight gains are not
more than 1 to 3 kg between dialysis
49. * Sodium restriction
- 2 to 4 gm/day
(Sources are â pickled foods,
soups, soya sauce
canned
etc. )
* Calcium
If serum ca levels are low,
calcium intake isadequate
important.
* Magnesium
Mild Mg restriction may be
imposed
59. 1. FLUID VOLUME EXCESS
RELATED TO DECREASED URINE
OUTPUT, DIETARY EXCESS &
RETENSION OF SODIUM AND
WATER SECONDARY TO DISEASE
PROCESS.
60. 2. ALTERED NUTRITION LESS
THAN BODY REQUIREMENT
RELATED TO ANOREXIA, NAUSEA,
VOMITING, DIETARY RESTRICTION,
ALTERED ORAL MUCUS
MEMBRANES SECONDARY TO
DISEASE PROCESS.
61. 3. ACTIVITY INTOLERANCE
RELATED TO FATIGUE,
RETENTION OF WASTE
PRODUCT AND DIALYSIS
PROCEDURES SECONDARY
TO CHRONIC RENAL FAILURE.
62. 4. SELF-ESTEEM DISTURBANCE
RELATED TO DEPENDANCY,
ROLE CHANGE, CHANGE IN
BODY IMAGE AND CANGE IN
SEXUAL FUNCTION SECONDARY
TO DISEASE PROCESS.
63. 5. RISK FOR HYPERKALEMIA,
PERICARDITIS, PERICARDIAL
EFFUSION, PERICARDIAL
TEMPONATE, HYPERTENSION,
ANEMIA, BONE DISEASE,
METASTATIC CALCIFICATION
RELATED TO DISEASE PROCESS.