Chronic renal injury Flashcards by lukas s

Chronic Renal Failure

Chronic renal failure

Definition: permanent reduction and progressive renal function

Irreversible damage of
renal parenchyma —–>>>

which leads to:

Reduction of the glomerular filtrate
Alteration of tubular functions
Deficit of endocrine and metabolic functions.

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Chronic renal failure etiology 1

Glomerular nephropathies

primary glomerulonefritis
Glomerulonefriti secondary
Nefropatia Diabetic

tubular-interstitial nephropathies:

da-infectious causes (pyelonephritis, TBC)
da causes toxic (drugs, metals, etc)
da chronic obstruction of the urinary tract (Prostatic hypertrophy, calculi renal malformations, etc)
Nefropatia gout
Nefro calcinosi

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chronic renal failure etiology 2

Vascular nephropathies

Nefroangiosclerosi
ipertensione blood malignant
vasculiti
necrosi bilateral cortical

Hereditary nephropathy

Malattia polycystic adult / child
Malattia medullary cystic-Nephronophthisis
Ossalosi; Cystinosis
Glomerulopatie hereditary (Syndrome Alport, nephrotic syndrome type Finnish, etc)

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Main factors of progression of chronic kidney disease

FACTORS progression of chronic kidney disease

Main:
Hypertension
Proteinuria

Secondary:

black race
male
advanced age
dyslipidemia
Recurrent UTI
chronic therapy with NSAIDs
AVP, PDGF, TGF
, AII, ET-1
Nitric Oxide

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Chronic Renal Failure
Clinical manifestations groups

Clinical manifestation groups:

Fluid and electrolyte abnormalities
Alterations neuromuscular
Endocrine and metabolic
Gastrointestinal disorders
Cardiovascular disorders
Pulmonary changes
Haematological disorders and immunological
Ocular complications

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Clinical manifestations of CRF

Fluid and electrolyte abnormalities

Clinical manifestations
Fluid and electrolyte abnormalities
espansione VEC
Iperpotassiemia
acidosi metabolic
iperfosfatemia
ipocalcemia

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Clinical manifestations of chronic renal failure

Endocrine and metabolic

Endocrine and metabolic
iperparatiroidismo secondary
osteodistrofia renal
intolleranza glucose
iperuricemia
dislipidemia
malnutrizione protein-calorie
infertilità and sexual dysfunction

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Clinical manifesttations of Chronic renal failure

neuromuscular alterations.

Alterations neuromuscular
astenia
disturbi sleep
neuropatia device
irritabilità muscle
miopatie

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Chronic renal failure clinical manifestations

Gastrointestinal disorders

nausea and vomiting
anorexia
alterazioni alvus
gastroenterite uremic
ulcera peptic

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Chronic renal failure. clinical manifestations. cardiovascular disorders

Cardiovascular disorders
Ipertensione arterial
Scompenso heart failure
edema acute pulmonary
pericardite
miocardiopatia uremic
aterosclerosi accelerated

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Chronic renal failure disorders. pulmonary and dermatological changes

Pulmonary changes
broncopolmoniti / pneumonia
Dermatological
iperpigmentazione (gray / ashen)
prurito
ecchimosi
uremidi (uremic frost)

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Chronic renal failure clinical manifestations. haematological disorders and immunological

Haematological disorders and
immunological
anemia normochromic normocytic
linfocitopenia


bleeding tendency


susceptibility to infection

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Chronic renal failure clinical manifestations. ocular complications and psychological changes

Ocular complications
Sindrome “red-eye”
Keratopatia bands
retinopatia hypertensive
Psychological changes
(Rare)
disturbi psychotic (delirium, etc)
sintomi manic
depressione

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Chronic Renal Failure

HYPERPARATHYROIDISM SECONDARY

decrease of nephrons
decrease of GFR
decrease of kalcitriol synthesis
hipocalcemia
hipophosphatemia
calcificatione metastatische
problems with bones

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Chronic Renal Failure
diagnosis steps

anamnesis
objective examination
laboratory tests
instrumental tests

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Chronic renal failure anamnesis, questions to ask the patient

Chronic renal failure anamnesis

questions to ask the patient
 micturition disorders? (Burning, frequent urination and poor, etc)
 emission of dark urine? (Color Coca-Cola, to “washing of meat”)
 episodes of renal colic?
 nocturia?
 high blood pressure?
 analgesic abuse?
 other patients with kidney disease in the family?

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Chronic renal failure diagnosis, objective examination steps and first step

Examination General Inspection

Skin color (ashen gray; yellowish; cyanosis)
Look for any bruising, purpuric spots
(Vasculitis); rash (erythema lupus); injuries
scratching (itch); ulcerations (diabetes mellitus,
calciphylaxis, venous insufficiency)
 edema (periorbital; parts slopes; anasarca)
 Research and evaluation of peripheral pulses
 BP Reading supine and standing positions (3 measurements)
 HR in supine and standing positions
 Assessment of body weight

annd chest and abdominal examination

Chronic renal failure diagnosis. second step of objective examination. chest examination and abdominal examination

Chest examination and abdominal
 search of wet lung sounds (rales, crackles)
 Search chafing pleural / pericardial
 search of possible renal masses (polycystic kidney disease)
 rating of any globe bladder

Chronic renal insufficiency

diagnosis, blood tests

Diagnosis

Blood tests

Diagnostic evaluation of:
Glomerular Filtrazione

• Azotemia /BUN increased
• Creatininemia increased
Clearance Creatinina Calcolata decreased

Anemia (ClCr < 70 ml/min)

G.R. decreased
Hb e Htc decreased
reticolociti decreased (%)
MCV, MCH, MCHC nella norma

DEFINITION OF THE SECOND CKD
GUIDELINES according to NFK / DOQI

The Chronic renal injury is defined by the presence of
at least 3 months of kidney damage
characterized by:

• structural or functional abnormalities of the
kidney with or without reduction in GFR
or
• by GFR <60 mL / min also
in the absence of renal damage.

CLASSIFICATION OF THE SECOND CKD
GUIDELINES NFK / DOQI

Stage

I -
GFR normal * >90

II - slight reduction
60-89

III - moderate reduction
30-59

IV - severe reduction
15-29

V - EGFR
<15

Chronic renal failure diagnosis

Blood tests (2)

serum sodium
serum calcium
serum potassium
phosphorus
phosphatase
glucose
triglycerides
total cholesterol
uricemia
also might be metabolic acidosis

Chronic renal failure diagnosis

urine examination

24 hour urine and review of

• Volume (1.5-2 L / day)
• creatininuria
• Electrolytes (Na
and K)
• azoturia
• Proteinuria
review of:
• Measured Creatinine Clearance ()
Intake g NaCl / day

Intake Protein g / da

Chronic renal failure diagnosis. urine 2. morning urine

morning urine
Color (pale, “like water”)
• Specific Gravity  1010 (Isosthenuria)
• pH
• Examination of the sediment
• FEN> 1%

Chronic renal failure diagnosis. renal ultrasonography.

Reduced dimention kidney ( Ø longitudinal and transverse) reduction the thickness parenchymal and poor cortico-medullary differentiation. Other possible findings:  * parenchymal echogenicity * cysts * cholelithiasis nuclei * dilatation of the urinary tract, etc \* Exceptions: polycystic kidney disease, amyloidosis, diabetes mellitus

Chronic renal failure diagnosis. renal scintygraphy.

Sequential renal scintigraphy with [ 99 mTc] DTPA Reni small with uneven uptake. The renogram highlights transit delay and excretion of radiotracer.

Chronic renal failure diagnosis. other imaging studies.

* Fund eyepiece * Holter (24 h) * ECG * Echocardiography * Ultrasound abdomen and pelvis * Eco-doppler TSA * Eco-doppler renal artery * chest X-ray * Rx skeletal *  MOC *  Direct abdomen *  Other (urography, CT scan, etc)

Chronic renal insufficienecy vs acute renal insufficiency

In chronic renal insufficiency and not in acute RI there is: * Hypertension long life * Anemia normochromic and normocytic * Hypocalcemia and hyperphosphatemia * Nocturia * reduced kidney size in ultrasound

Chronic renal failure therapy. conservative therapy vs replacement therapy

 CONSERVATIVE THERAPY Dietetics Pharmacological  REPLACEMENT THERAPY Hemodialysis Peritoneal Dialysis Transplant

Chronic renal failure therapy objectives

 Prevent and treat the clinical manifestations  Slowing the progression  Ensure a good nutritional status

Chronic renal failure conservative therapy

**Diet** Dietary therapy is essentially based on reducing NaCl and (Low value proteins of plant origin organic, that is poor in essential amino acids), and on the administration of an adequate share of calories

Conservative therapy for chronic renal failure. diet

CONSERVATIVE THERAPY * *Reduced supply of protein** - -\> * reduced nitrogen * reduced conc. of phosphorus * reduce of acidity * reduced rate of progression **Adequate caloric intake (30-35 kcal / kg / day)** Prevents catabolism of endogenous proteins for energy purposes

Sodium CRF conservative therapy

Sodium SODIUM (if not nephropathy with salt loss) Reduce to 5-6 g / day the amount of salt supplied by food.

CRF conservative therapy intake of liquids, potassium

INTAKE OF LIQUIDS- normal Reduce the daily intake of fruit fresh / dried fruit juices, vegetables ... Avoid using salt substitutes kitchen Assume per os, possibly, resins trade off Cation (Kayexalate)

CRF conservative therapy. calcium.

Integrating dietary intake with 1-1.5 g / day of Calcium Carbonate, recruited fasting. Administered orally, possibly, 0.25-0.50 microg / day of calcitriol

CRF conservative therapy. phosphorus, bicarbonate

**phosphorus** Contain dietary intake at 400- 600 mg / day (low protein diet) **BICARBONATE** Useful oral dosing of 2-5 g / day

Chronic Renal Failure. Drug therapy.

First choice drugs:  ACE inhibitors or ARBs (Anti-hypertensive, anti-proteinuric and slowing the progression of the disease kidney)  Loop diuretics (Correction hypervolemia) Second choice drugs:  Calcium channel blockers  beta-blockers  Peripheral vasodilators  centraal alfa2-agonists

Chronic renal failure. Drug therapy.2

**Glycemic control** * *Gly \<= 110-120 mg / d** * *HbA1c \< 7%** sulphonylureas, Insulin sulphonylureas, Insulin, **Lipid control** LDL-cholesterol \<= 100 mg / dl statins **anemia control** Statins recombinant human erythropoietin Darbopoietina  Iron gluconate, sulfate, etc  Folic Acid  Vitamin B12

Chronic renal failure replacement therapy. **absolute** Indications for the start of dialysis

REPLACEMENT THERAPY INDICATIONS FOR THE START OF dialysis **Absolute** * pericarditis * Fluid overload and pulmonary edema not responsive to diuretics * Hypertension unresponsive to medication * Hyperkalemia not responsive to drug treatment * Motor neuropathy and encephalopathy * Bleeding diathesis * Persistent nausea and vomiting * Malnutrition

Chronic renal failure, replacement therapy. **Relative** indications for the start of dialysis

* Creatinine clearance \<10-15 ml / min * Azotemia with anorexia, nausea and vomiting morning * Tiredness and fatigue * Anemia resistant al'eritropoietina * Persistent itching and severe