Renal failure

Dr Chamilka Jayasinghe

Acute Renal Failure

Clinical syndrome in which a sudden
deterioration in renal function results
in the inability of the kidneys to
maintain fluid & electrolyte
homeostasis.

classification
Pre renal
Intrinsic renal
Post renal

Pre renal failure

Diminished circulating volume

inadequate renal perfusion

GFR
Common causes:
Dehydration
Haemorrhage
Sepsis
Cardiac failure
*renal function returns to normal once renal
hypoperfusion reversed

Intrinsic renal failure

Renal parenchymal damage
Causes:
1. Hypoperfusion/ischaemia
2. Post infectious GN
3. Lupus nephritis
4. HSP nephritis
5. Membranoproliferative GN
Acute tubular necrosis:
Renal Vein Thrombosis

Post renal failure

Obstructive causes
PUV
Tumours
Urolithiasis

Differentiation of pre renal

& intrinsic renal failure
Criteria

Pre
Intrinsic
renal
renal
>1.020 <1.010

Specific
gravity
Urine
>500
osmolality
(mosm/l)
Urine
<20
Na(meq/L)
FE Na %
<1
BUN/Cr

>20

<350

>40
>2
<20

Principles of Treatment
1.

If hypovolaemic intravascular volume expansion

N.Saline 20 ml/kg
2. Diuretic therapy Frusemide
3. Insensible loss-400ml/m2/24 H
fluid restriction
4. Mx hyperkalaemia
5. Metabolic acidosis
6. Hypocalcaemia
7. Hyponatraemia
8. Hypertension
9. Anaemia
10.Mx Seizures
11.Attention to Nutrition-Na, K, Phosphorus restriction
,maximize caloric intake

Chronic renal failure

1.
2.
3.
4.

Definition -Irreversible reduction in GFR

Aetiology
Congenital
Acquired -GN
Inherited-Alport
Metabolic
cystinosis,hyperoxaluria,polycystic
kidney disease

Pathogenesis
Progressive renal injury despite
removal of original insult
Hyperfiltration injury
Persistent proteinuria
Systemic hypertension
Renal calcium,phosphate deposition
Hyperlipidaemia

Degree of renal dysfunction

Mild chronic renal insufficiency: GFR
50-75 ml/min/1.73 m2
Moderate chronic renal
insufficiency:25-50ml/min/1.73 m2
CRF 10-25 ml/min/1.73 m2
End stage renal disease <10
ml/min/1.73 m2

CLINICAL FEATURES
Congenital disorders-renal dysplasia
& obstructive uropathy
Presents commonly in neonatal period
with FTT, dehydration,UTI
Acquired conditions- Nephrotic
Xd,Glomerular nephritis
Presents in childhood/adolescence with
oedema, hypertension,haematuria &
proteinuria

Examination
Pallor
Sallow complexion
Short stature
Renal osteodystrophy
Oedema
Hypertension
Pruritis

Investigations

Blood urea nitrogen

S.creatinine
Hyperkalaemia
Hyponatraemia
Acidosis
Hypocalcaemia
Hyperphosphatemia
Uric acid
Hypoalbuminemia
S.cholesterol/TG
UFR-Haematuria,proteinuria

Treatment
Replacing absent/diminished renal
functions
Slowing the progression of renal
dysfunction

Management
Multidisciplinary services
medical,nursing,social services,
nutritionist,psychologist involvement
Close monitoring clinical& lab studies
Blood studies Hb,S.E,BUN,Cr,Ca,PO4,

Alkaline Phosphatase
PTH, X Rays of bone-renal osteodystrophy
Echo cardiac dysfunction, LVH
Fluid & electrolyte balance

Fluid & electrolyte Mx

Polyuric stage-significant sodium loss
high volume ,low caloric feeds with
sodium supplementation
Hypertension/oedema or heart
failure-sodium restriction & diuretic
therapy
Hyperkalaemia-restriction of dietary
potassium intake
Oral alkalinizing agents

Anaemia
Inadequate Erythropoetin
Deficiency of iron,folate, vit B12
Rx
Human Recombinant Erythropoetin
Vitamin/iron supplementation

Hypertension
Related to volume overload or
excessive Renin production related to
glomerular disease
Salt restricted diet
Frusemide, ACEI, CaCB, Beta
Blockers

Immunization
Withhold live vaccines while on
immunosuppressive therapy
Adjust drug dosage as many drugs
are excreted by kidney

Aim to slow progression of

renal dysfunction
Optimal control of hypertension
Maintain s.phosphate within normal
range to minimize renal Ca & PO4
deposition
Prompt treatment of infectious
complications & episodes of
dehydration
Correct anaemia
Avoid NSAIDS

NUTRITION & GROWTH

Restriction of phosphate, potassium,sodium
accordingly
Fluid balance
Recommended daily caloric intake for age
Protein 2.5 g/Kg/24 Hours
High biological value- egg,milk,meat
Help of dietician
Enhance caloric intake by-supplementing with
modular components of CHO, fat(MCT), Protein
Enteral tube feedings
Water soluble vitamins
Zinc, iron supplements

Growth
Apparent growth hormone resistant
state
Rx Recombinant Human Growth
Hormone

Renal osteodystrophy
GFR<50%

1 alpha hydoxylase

1,25 (OH)2D3

Intestinal calcium absorption

PTH activity

Bone resorption

GFR <20%
Compensatory mechanisms
inadequate
Hyperphosphatemia
Hypocalcaemia
PTH secretion results in increasing
bone resorption and osteitis fibrosa
cystica

Clinical features of renal

osteodystrophy
Muscle weakness
Bone pain
Fractures with minor trauma
Rachitic changes
Varus, valgus deformities of long
bones

Investigations
S.calcium
S.Phosphorus
Alkaline phosphatase

X Rays-widened metaphysis with

subperiosteal resorption

End stage renal disease

The state at which renal dysfunction
has progressed to the point at which
homeostasis & survival can no longer
be sustained with native kidney
function & maximum medical
management

Complications
Electrolyte abnormallities- dilutional
hyponatraemia,hyperkalaemia*,hypocalcemia,hyp
ermagnesemia
Seizures,arrhythmias,tetany,weakness,acidosis
Pericarditis /effusions,tamponade
Myocardial ischaemia
Mental state changes
Peritonitis/ pancreatitis
Infection at catheter exit sites
Vascular access problems- ischaemia of limbs

Renal replacement therapy

Dialysis peritoneal/ haemodialysis
Renal transplantation

Dialysis initiated when

GFR <10-15 ml/min/1.73 m2
Refractory fluid overload
Electrolyte imbalance
Acidosis
Growth failure
Uraemic symptoms-fatigue, nausea,
impaired school performance

Peritoneal dialysis
Peritoneal membrane is the dialyser
Excess body water is removed by
osmotic gradient created by high
dextrose [ ] in dialysate
Waste is removed by diffusion from
peritoneal capillaries into dialysate
Must be performed daily

Haemodialysis
In hospital setting
3-4 hour sessions/week
Fluid & solute wastes are removed
via indwelling subclavian, internal
jugular catheter

Advantages of peritoneal
dialysis
Can be done at home
Technically easier
Freedom to attend school & other
activities
Less restrictive diet
Less expensive than haemodialysis

Disadvantages
Catheter malfunction
Catheter related infectionsperitonitis,exit site infection
Impaired appetite
Negative body image
Caregiver burn out

Renal transplantation
To provide the most normal lifestyle
& possibility for rehabilitation for the
child & family
Optimal treatment for ESRD is early
renal transplant from a living related
donor

Renal transplant pre & post

management
Donor evaluation
Recipient evaluation
Looking out for post transplant
complications- rejection reaction,
technical defects, recurrence of
original disease, drug toxicity
,infection(CMV,HIV,HSV,PCP),
bleeding, bowel obstruction

END