1. CHRONIC RENAL FAILURE
R.Manoj Kumar

2. Definition
CRF refers to an irreversible deterioation in renal function which classically develops over a period of years.
CRF corresponds to CKD stages 3-5

4. CAUSES of CRF
Congenital and Inherited- Polycystic Kidney Disease, Alport’s syndrome
Renal artery stenosis
Hypertension
Glomerular diseases- IgA Nephropathy most common
Interstitial diseases
Systemic Inflammatory diseases- SLE, Vasculitis
Diabetes Mellitus
Unknown causes

5. PATHOGENESIS
Disturbances in water, electrolyte and Acid-Base balance contribute to the clinical picture in Patient with CRF;But the exact Pathogenesis of the clinical syndrome of Uremia is unknown.
Many substances present in Abnormal concentrations in the Plasma have been suspected as being Uremic toxins and uremia is probably caused by the accumulation of various intermediate products of metabolism like Nitrogenous excretory products such as Guanido compounds,Urates,Hippurates,products of nucleic acid metabolism,polyamines,Myoinositol,Phenols and Indoles.

6. CLINICAL FEATURES Fluid & Electrolyte disturbance –
Volume expansion
Hyponatremia
Hyperkalemia
Hyperphosphatemia
Endocrine-metabolic disturbance –
Sec hyperparathyroidism
Adynamic Bone
Carbohydrate resistance
Hyperuricemia
Decreased HDL levels
PEM
Impaired growth
Amenorrhea

7. Neuromuscular disturbances- Fatigue
Sleep disorders
Headache
Lethargy
Muscular irritability
Myoclonus
Seizures
Coma
Myopathy

8. CVS & Pulmonary disturbances-
Arterial Htn
CHF
Pulmonary edema
Pericarditis
Cardiomyopathy
Uremic Lung
Atherosclerosis
Hypotension
Arrhythmias
Vascular calcifications

9. Skin disturbances- GIT- Pallor Hyperpigmentation Pruritus Ecchymoses
Uremic frost
GIT-
Anorexia
Nausea & vomiting
Gastroenteritis
GI bleeding
Idiopathic ascites
Peritonitis

10. Hematologic & Immunologic disturbance-
Anemia
Lymphocytopenia
Bleeding diathesis
Inc susp to infection
Leucopenia
Thrombocytopenia

11. INVESTIGATIONS Hematology- Full blood count Hematinics Biochemistry
Urea,electrolytes,creatinine
Calcium,phosphate,albumin
Parathyroid hormone
Lipids, Glucose

12. Hepatitis and HIV serology Imaging- Renal Ultrasound Chest X-ray
Microbiology-
Hepatitis and HIV serology
Imaging-
Renal Ultrasound
Chest X-ray
Renal artery imaging
E.C.G
Immunology-
Grouping
Tissue typing
CMV,EBV,VZV

13. If diagnosis is not Known.
Consider
Immunoglobulin and Protein electrophoresis
Urinary BenceJones proteins
Compliment
Rheumatoid factor
ANCA
Anti-GBM
Cryoglobulins

14. TREATMENT

16. Renal replacement therapy

18. Problems with Haemodialysis
Hypotension during Dialysis
Cardiac Arrhythmias
Hemorrhage
Air Embolism
Dialyser Hypersensitivity
Emergencies between treatments-
Pulmonary edema
Systemic sepsis

19. Problems with Peritoneal dialysis
Peritonitis
Catheter exit site infection
Ultra filtration failure
Peritoneal membrane failure

20. Management after Transplantation
Immunosuppressive therapy-
Prednisolone,ciclosporine and
Azathioprine
Rejection is treated by short course of very high dose corticosteroids and more potent therapies such as anti-lymphocyte antibodies or plasma exchange
Immunosuppression leads to Increased incidence of infection such as CMV & Pneumocystis

21. PROGNOSIS Cadaver donors- 96% patient survival
92% graft survival at 1 year
84% patient survival
76% graft survival at 5 years
Living donors-
92% patient survival
86% graft survival at 5 years
Renal transplantation offers the best hope of complete rehabilitation and is the most cost effective treatment for end stage CRF

22. THANK YOU