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CPR97: Acute and chronic renal failure


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Kidney dysfunction
A frequent consequence of urinary tract diseases
GFR
Standard measurement of renal function, Normal GFR ~ 100-125 ml/min/1.73 m2, Declines by 1 ml/min/1.73m2per year
AKI vs CKD
Disease course & Associated features (anemia, bone profile abnormalities)
Renal disease causes category
Pre-renal, Intra-renal, Post-renal
AKI epidemiology
common among hospitalized patients (~ 3-7%); can be up to 25-30% in ICU patients
AKI significance
Without prompt Dx& proper Mx, can progress to CKD/ESRD
AKI Dx
↑SCr by ≥0.3 mg/dL( ≥ 26.5 μmol/L) within 48 hrs OR ↑SCrby 1.5 x baseline, which has occurred within the prior 7 days; OR Urine volume <0.5 ml/kg/hr for 6 hrs
RIFLE criteria for AKI
Risk, Injury, Failure, Loss, ESKD
Risk
1.5x ↑ SCr, or GFR ↓by 25%, or UO <0.5 mL/kg/hr for 6 hrs
Injury
2x ↑ SCr, or GFR ↓ by 50%, or UO <0.5 mL/kg/hr for 12 hrs
Failure
3x ↑ SCr, or GFR ↓ by 75%, or UO <0.3 mL/kg/hrfor 24 hrs or anuria for 12 hrs
Loss
Complete loss of kidney function for > 4 wks
ESKD
Complete loss of kidney function for >3 months
CKD
is defined as either kidney damage or GFR <60/min/1.73m2for ≥ 3 months
Kidney damage
is defined as pathologic abnormalities or markers of damage (including abnormalities in blood or urine tests or imaging studies)
NKF KDOQI Classification of CKD
5 stages
Stage 1
Kidney damage with normal or↑ in GFR (≥90 ml/min/1.73m2)
Stage 2
Kidney damage with mild ↓ in GFR (60-89 ml/min/1.73m2)
Stage 3
Moderate↓in GFR (30-59 ml/min/1.73m2)
Stage 4
Severe in ↓ GFR (15-29 ml/min/1.73m2)
Stage 5
Kidney Failure (<15 or dialysis)
Pre-renal causes of kidney dysfunction
Hypoperfusion (Hypovolaemia(GIB/dehydration), Septic shock, Cardiogenic shock), OR Renovascular diseases (Renal artery stenosis, Renal art/vein thrombosis)
Intrarenal causes
Drugs, Glomerulonephritis (GN), Acute tubular necrosis (ATN), Metabolic diseases, Infection, Acute or chronic interstitial nephritis, Intra-tubular obstruction
Drug-induced nephrotoxicity
One of the commonest causes of renal impairment, Direct vs indirect (often idiosyncratic/immunological) effects
Drug-induced nephrotoxicity drugs
NSAIDs, Antimicrobials (Aminoglycoside/foscarnet/amphoB(direct), Adefovir/tenofovir(direct), Penicillin/rifampicin (AIN)), Iodine contrast
Glomerular diseases
DM nephropathy, HT nephrosclerosis, Hereditary nephropathies (usually with positive FHx)
DM nephropathy
Most common cause of ESRD (up to 50% cases), Associated with other microvascular complications, Type I vs. Type 2, Glycemic/hypertensive control
Hereditary nephropathies
Alports’ syndrome (ass. Hearing impairment), APKD (ass. ICH)
Secondary GN
Autoimmune disorders (e.g. SLE, RA, Sjogren), Infection (e.g. HBV/HCV/HIV/malaria/syphilis), Malignancy (lymphoma, solid organ malignancy), Occasionally drugs (e.g. NSAIDs)
GN Ix
Autoimmune markers (e.g. ANA, Anti-dsDNA, C3/4, ANCA, Anti-GBM, CRP), infection (e.g. HBV/HCV/HIV/VDRL/malaria) & malignancy (e.g. tumor markers) screen might give clue to diagnosis
GN Ix renal biopsy
LM/IF/EM findings
GN General Rx
ACEI/ARB
GN Specific Rx
Specific treatment: Depending on Dx; may require immunosuppressive Rx
Acute/Chronic interstitial nephritis
Interstitial infiltrates (usually mononuclear cells with occ. eosinophils)
Acute/Chronic interstitial nephritis common etiology
Commonly related to drugs(e.g. rifampicin, allopurinol, NSAIDs, PPI, check-point inhibitors), Drug-related AIN usually resolved with withdrawal of offending drugs; use of corticosteroids controversial
Acute/Chronic interstitial nephritis Other etiology
Infection (e.g. hanta virus, leptospirosis) or Autoimmune disease (e.g. SLE, Sjogren)
Intra-renal tubular obstruction
Cast nephropathy (myeloma light chains), Rhabdomylosis(myoglobin) (E.g. limb ischemic, crush syndrome), Crystallization (e.g. acyclovir)
Acute tubular necrosis (ATN)
Most common cause of AKI, Usually due to acute ischemic/toxic event
ATN 3 phases
Initiation (acute↓GFR; sudden↑serum urea & Cr) -> maintenance (oliguric/non-oliguric) -> recovery (polyuricphase)
ATN prognosis
Usually recovers within 1-2 wks; can be up to 4-6 wkss
Post-renal causes
Renal impairment is usually associated with bilateral obstruction e.g. prostate problem in men (Prostate/urethra, Urinary bladder, Ureter)
Prostate pathology
Benign prostatic hyperplasia (BPH), CA prostate
Benign prostatic hyperplasia (BPH)
commonest cause of bilateral hydronephrosis in men, Hesitancy/ frequency/ weak stream, Can be precipitated by UTI/anti-muscarinic drugs
CA prostate
Prostatism/back pain (bone metastasis)
Urethral problems
Urethral stenosis/stricture (Previous trauma or prolonged catheterization), Lower UTI seldom results in renal impairment
UB problem
Ca bladder (Painless gross hematuria, Can cause bilateral ureteric obstruction)l Bladder stones (Dysuria/hematuria/recurrent UTI)
Ureteric problem
Extramural (LN Met, Post-radiation fibrosis, Idiopathic retroperitoneal fibrosis rare), Intramural (CA ureter)
Renal failure General symptoms
Malaise, Pruritus, Anorexia, Nausea, Vomiting
Renal failure Urinary symptoms
Early stage: polyuria/nocturia, Late stage: oliguria/anuria
Renal failure Cardiovascular symptoms
Ankle edema; pulmonary edema, Hypertension, cardiomegaly, Accelerated atherosclerosis & CAD, Uremic pericarditis
Renal failure Neurological symptoms
Restless legs, Hiccups, Confusion and seizure (uremic encephalopathy), Carpel tunnel syndrome (β2-microglobulin amyloidosis)
Renal failure Hematological symptoms
NcNcanemia (reduced erythropoietin production), Bleeding tendency (platelet dysfunction)
Renal failure endocrine symptoms
Infertility, amenorrhea, Sexual dysfunction, Growth retardation in children, Secondary/ tertiary hyperparathyroidism, Renal osteodystrophy
Renal failure Electrolyte and acid-base disturbance
Hyponatremia, Hyperkalemia, Hypocalcemia, Hyperphosphatemia, Metabolic acidosis (usually ↑AG)
CKD Mx
Treatment of underlying causes (e.g. DM, GN), Dietary & lifestyle modifications, Blood pressure control & RAS blockade, Avoid nephrotoxic agents/drugsESRF
ESRD Mx
Renal Replacement Therapy (PD ~80%, HD~20%, kidney transplant), Palliative Renal Care