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Chronic Renal Failure for General Practice Robin Jeffrey Bradford Hospitals.

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Presentation on theme: "Chronic Renal Failure for General Practice Robin Jeffrey Bradford Hospitals."— Presentation transcript:

1 Chronic Renal Failure for General Practice Robin Jeffrey Bradford Hospitals

2 Progressive and irreversible deterioration in glomerular +/- tubular function measured over months and years

3 Pyramid of chronic renal disease 600/M >5000/M

4 Measurement of renal function Glomerular function –Inulin clearance, radio-isotopic clearance –Creatinine clearance, Cockcroft-Gault –Serum creatinine, serum urea

5 Tubular function –Serum K, PO4, urate, –Acid-base balance Endocrine function –Haemoglobin –Serum calcium, PO4, PTH

6 time GFR

7 Cockcroft-Gault formula Calculated Crcl = (140-age) x weight x 1.2 serum creatinine

8 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

9 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

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11 x x x GFR time

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19 Who gets renal disease Elderly Males Ethnic minorities

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21 Progression of CRF Continuation of primary disease process Factors associated with acute reversible deterioration Background irreversible progression

22 dehydration and reduced renal perfusion obstruction infection toxins hypercalcaemia Acute insult

23 Background progression Adaptive hyperfiltration hypothesis Hypertension Proteinuria Tubulo-interstitial nephritis Hyperlipidaemia Cytokines Genetic factors

24 Glomerular maladaptation Increased intraglomerular pressure Glomerular hypertrophy Glomerulosclerosis Maintain GFR

25 GFR time

26 Clinical factors associated with accelerated progression Hypertension Heavy proteinuria Type of renal disease Genetic markers ? Ethnic relationship Smokers

27 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

28 GFR time

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30 Slow disease progression Control of blood pressure Reduce proteinuria The special role of ACE inhibitors Low protein diet

31 Lewis slide from uptodate

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33 METABOLIC COMPLICATIONS AnaemiaLeft Ventricular Hypertrophy Accelerated Atherosclerosis Acidosis Renal osteodystrophy Catabolism Hyperkalaemia

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38 Management of complications Erythropoietin Sodium bicarbonate Calcium-based phosphate binders Vitamin D supplementation Statins Anti-hypertensives

39 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

40 CHRONIC RENAL FAILURE PRE-DIALYSIS ESRF RENAL TRANSPLANT LIVING DONOR CADAVERIC

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43 Late referral to specialist care is associated with: Inferior biochemical control Malnourishment Poorer quality of life Longer hospitalisation Increased early morbidity and mortality

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45 Initiation of dialysis Ethics – conservative care of CRF Ideally smooth and programmed Emergency in 50% Absolute and relative indications

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