Dr. Hamed Ezzat El-Eraky

Nephrology Specialist

Mansoura International Hospital

Approach ToA Patient With Renal Disease

• Some Terminology:• Oliguria: urine output less than 500 cc/24hr.

• Anuria: urine output less than 50 cc/24hr.

• Uremia: Before the advancement of modern medicine, renal

failure was often referred to as uremic poisoning,

Uremia was the term used to describe the

contamination of the blood with urine. Starting

around

1847, this term was used to describe reduced urine

output that was thought to be caused by the urine

mixing with the blood instead of being voided

through

the urethra.

Approach to a patient with renal failure

In the evaluation of patients with an elevated serum

urea and creatinine levels, it is important to establish the

following:

1- The acute or chronic nature of the renal function

impairment or presence of superimposed reversible

factor.

3- The causes of renal dysfunction.

Function Of The Kidney

1. Excretion

2. Regulation

3. Formation & Activation

• Excretion Of Waste Products & Toxins.

• Excretion Of Excess Body Fluid.

• Regulation Of Body Minerals As Sodium,

Potassium, Calcium.

• Acid Base Balance.

• Formation & Activation Of Hormones &

Vitamins As: Erythropoietin, Rennin &

Vitamin D.

It's Inability Of The Kidney To Do Its Normal Function.

Renal Failure

1- Acute Renal Failure (AKI) which is a syndrome defined by

a sudden loss of renal function over several hours to several

days.

2- Chronic Renal Failure (CKD) can be defined as a chronic

reduction of glomerular filtration rate. (i.e. a diminution in

creatinine clearance and corresponding increase in Serum

creatinine.

3- Acute On Top Of Chronic Renal Failure

Types Of Renal Failure

AKI (ARF)

ETIOLOGY

•Pre renal (70%): A sudden serious drop in blood flow to the

kidneys due to Heavy blood loss (injury) or sepsis, Decrease

body fluid (dehydration, burn).

•Renal (11%): Damage from some medicines, poisons, or

infections as.

1.Antibiotics, such as gentamicin and streptomycin.

2.Pain medicines, such as aspirin and ibuprofen.

3.Some blood pressure medicines, such as ACE inhibitors.

4.The dyes used in some X-ray tests.

•Post renal (17%): A sudden blockage that stops urine from

flowing out of the kidneys. Kidney stones, a tumor, an injury, or

an enlarged prostate.

•Idiopathic (2%).

CLASSIFICATION

CLINICAL PICTURE

1. Anuria or Oliguria.

2. Volume overload (edema lower limb, pleural

effusion, pericardial effusion).

3. Nausea and vomiting.

4. Restlessness, confusion, even deep coma.

5. Flank pain.

6. Symptoms of the etiology.

7. Asymptomatic

Diagnosis of AKI

• History of medication & other illness.

• Laboratory findings as calcium & hemoglobin.

• U/S: to determine the state of both kidney

& differentiate between anuria & retention.

• Accidental during hospital stay.

TREATMENT

• Treatment of the cause: the main line of treatment including

(fluid to restore blood volume, stop any medication that may

harm the kidney, bypass or remove any urinary tract

obstruction).

• Treatment of complication as antibiotics to prevent sepsis,

medication for volume overload and restore electrolyte

balance.

• Diet which may include sodium, potassium, phosphorus

restriction.

• Dialysis may be used to help patient to feel better and

prevent complication due to loss of kidney function on other

system as uremia, acidosis & volume overload.

CRF

Chronic Kidney Disease:

- Is a general term for heterogeneous disorders affecting

the structure and function of the kidney.

- Kidney failure is defined as GFR of less than 15 ml/min

per 1·73 M², or the need for treatment with dialysis or

transplantation.

- a complex syndrome consisting of anemia, neuropathy,

oesteodystrophy, and acidosis and accompanied by

hypertension, susceptibility to infection and

generalized deterioration in organ function.

ETIOLOGY

CLASSIFICATION

• Accumulation of waste products (uremia).

• Disturbance of extra cellular fluid balance

(volume over load & hypertension).

• Acid-base imbalance (acidosis).

• Electrolyte and mineral disorders

(hyperkalemia).

Clinical Manifestation Of Renal Failure

Symptoms include:

- General: fatigue, weakness, lethargy.

- Skin: itching, easy bruising, skin discoloration, pallor.

- Cardiovascular: Dyspnea, orthopnea or chest pain.

- Gastrointestinal: anorexia, nausea, vomiting or hiccups.

- Neuromuscular: decreased ability to concentrate,

restlessness, parathesia, muscle cramps and/or twitching.

Clinical Manifestation Of Renal Failure

Signs:

- Skin: pallor, hyperpigmentation, hyperkeratosis & echymosis

- Oral: oral ulcer and uremic breath.

- Cardiovascular: hypertension, ejection systolic murmur,

edema, pericardial friction rub.

- Neuromuscular: peripheral neuropathy, drowsiness,

confusion, seizures even coma.

Clinical Manifestation Of Renal Failure

Description Of Symptoms:

• High levels of urea in the blood, which can result in

Nausea, Vomiting and/or diarrhea, which may lead to

dehydration & Weight loss.

• Nocturnal urination: More frequent urination, or in greater

amounts than usual.

• Increased serum phosphorous in the blood that diseased

kidneys cannot filter out may cause Itching, Bone damage,

Nonunion in broken bones.

Description Of Symptoms

• Bone damage, Nonunion in broken bones also with Muscle cramps

(caused by low levels of Calcium (hypocalcaemia).

• Increased serum Potassium in the blood that diseased kidneys cannot

filter out (hyperkalemia) may cause Abnormal heart rhythms & Muscle

paralysis.

• Failure of kidneys to remove excess Fluid may cause: Swelling of the

legs, ankles, feet, face and/or hands & Shortness of breath due to extra

fluid on the lungs (may also be caused by Anemia).

• Polycystic kidney disease, which causes large, fluid-filled cysts on the

kidneys and sometimes the liver, can cause: Pain in the back or side

Description Of Symptoms

• Healthy kidneys produce Erythropoietin which stimulates

the bone marrow to make RBCs. As the kidneys fail, they

produce less erythropoietin, resulting in decreased

production of RBCs to replace the natural breakdown of

old RBCs. As a result Anemia is developed which result in

Feeling tired and/or weak Memory problems, Difficulty

concentrating, Dizziness & Low blood pressure.

• Proteins are usually too big to pass through the kidneys,

but they can pass through when the glomeruli are

damaged. This does not cause symptoms until extensive

kidney damage after which symptoms include Foamy or

bubbly urine, swelling in the hands, feet, abdomen or face

• Other symptoms include: Appetite loss, a bad taste in the

mouth, Difficulty sleeping, darkening of the skin related to

Uremia.

Description Of Symptoms

Laboratory Findings

- Elevated serum urea and creatinine.

- Metabolic acidosis.

- Anemia most commonly Normochromic Normocytic.

- Proteinuria.

- Granular casts in urine analysis.

Three interventions have been proved to

slow the progression of kidney disease

• Blood pressure control & glycemic control in patients with

hypertension & diabetes.

• Reduction of Proteinuria with an ACE inhibitor or ARB.

• Other interventions that may be beneficial include:

1. Lipid-lowering measures.

2. Correction of anemia.

3. Limiting dietary protein intake to 0.60 to 0.75 g per kg

of body weight per day in patients in stages 4 & 5.

Indication Of Dialysis:

1. acidosis (PH < 7.2)

2. hyperkalemia (K > 5.5 meq\L with ECG changes or

> 6.5 without ECG changes)

3. Pleural and pericardial effusion.

4. Severe Hypertension not responding to medication.

5. Uremic encephalopathy.

6. Vomiting not relieved by medical treatment.

ACUTE ON TOP OF CHRONIC

RRT

Thank You

Nephrology Department - Mansoura International Hospital