Chronic Renal Failure
History
Symptoms, Diagnosis, Aetiology
Management
Complications
1) Earliest symptom usually
1)Conservative – Follow up,
1) Conservatively treated patients. _
nocturia,lethargy, anorexia. 1st
medications, diet, salt & water
Symptoms of anaemia, bone disease,
episode of overt failure may be
allowance.
secondary gout or pseudogout,
further insult eg NSAIDS, iodine,
Investigations – biopsy
pericarditis, hypertension, cardiac
ACE-I, dehydration, anaemia
Effect on life
failure, peripheral neuropathy,
2) Glomerulonephritis ask about
EPO for anaemia
pruritis, peptic ulcers, impaired
proteinuria, haematuria, oliguria,
Protein restriction
cognitive function, poor nutrition.
oedema, sore throat, sepsis, rash,
2) Dialysis – HD or PD. Where
Dose reduction in renally excreted
heamoptysis. Ask about Biopsy
performed, how often, how long,
drugs (eg digoxin)
3) Analgesic nephropathy – ask about relief of symptoms. Complications
2) Dialysis patient – AVF blockages,
type, duration, UTI, HT, Haematuria,
Fistulas, other operations (renal tract,
access problems, infection,
GI blood loss, nocturia, reanl colic,
parathyroidectomy)
pericarditis, peritonitis
TCC. (Aspirin & Phenacetin)
3)Transplant – workup &
3) Transplant patient – recent
4)Polycystic Kidney. FHx, Diagnosis, management. When, how many.
transplants ask about graft pain or
haematuria, polyuria, loin pain, HT,
Type – living, cadaveric. Post
swelling (failure of graft, rejection),
renal calculi, headache, SAH, visual
operative course. Improvement since
infection, urine leaks, steroid side
changes (intracranial aneurysm)
transplant. Medications, long term
effects
5) Reflux nephropathy – childhood
follow up
Long term grafts – renal function
renal infections, cystoscopy,
4)Bladder management for reflux or
(Cre), proteinuria, recurrent
operations, enuresis
neurogenic bladder
glomerulonephritis, avascular
6)Diabetic nephropathy (other DM)
5) Social arrangements and ADLs.
necrosis, skin cancer and reflux
7)Hypertensive nephropathy – when
Employment, family coping, travel,
nephropathy. Drug compliance,
diagnosed, medications, compliance,
sexual function, financial situation
previous rejection episodes & tmt
angiography
8)CTD (SLE, Scleroderma)
9)Aware of long term prognosis. Has
dialysis been discussed. Eligible for
dialysis or transplant
4) Investigate to assess effects of renal failure
Investigations/Diagnostic Criteria
1) Determine Renal Function –
FBC (anaemia)
a) GFR - EUC (eGFR) (24 hr creatinine clearance)
Fe studies
b) Tubular function – electrolytes, CMP, uric acid, Alb,
MSU
urine specific gravity, pH, glycosuria
CMP
c) Urine analysis and 24 hr protein excretion
ALP
d) Others – DTPA for renal artery stenosis or obstruction
PTH
Nerve conduction for peripheral neuropathy
2) Determine Renal Structure
Arterial Doppler studies
a) US – Renal size and symmetry, signs of obstruction.
Small kidneys suggest chronic disease
5) Chronic features are nocturia, polyuria, long standing
b)KUB
hypertension, renal osteodystrophy, peripheral
c)CT KUB
neuropathy, anaemia, hyperphosphataemia,
d)Cystoscopy and retrograde pyelogram
hyperuricaemia, kidney size (usually small) except for
e)Renal artery duplex
Early diabetic nephropathy
Polycystic disease
3)Investigations trying to find underlying pathology
Obstructive uropathy
Renal bipsy
Acute renal vein thrombosis
ANA, ANCA
Amyloidosis
Hep B & C serology
Other infiltrating disease
HIV
Complement
EPG, IEPG
Urine cytology
Examination
1)General inspection –
Mental state
Hyperventilation (acidosis)
Kussmauls breathing, hiccupping
Hydration (fluid status)
Fever
Cushingoid
2)Hands
Nails – white transverse bands or lines in hypoalbumin;
brown arc near end of nails (Terrys nails)
Palmar crease pallor
Vasculitis, wrist AVF, Asterixis, Peripheral neuropathy
3) Arms
Bruising
Pigmentation
Scratch marks
Subcutaneous calcification
Myopathy
AVF
Skin cancers
4) Face
Eyes for anaemia, jaundice, band keratopathy
Mouth – dry, fetor
Rash (vasculitis, SLE)
Facial hair (cyclosporins)
Saddle nose (Wegners)
Treatment and complications
1) Treat reversible causes of deterioriation including
a) hypertension
b) UTI
c) Obstruction
d) dehydration
e) cardiac failure
f) drugs (NSAIDS, cyclosporine, Iodine, gent)
g) hypercalcaemia
h) hyperuricaemia with urate obstruction
i) hypothyroidism or rarely hypoadrrenalin
5) Chest
Cardiac - Pericardial rub, cardiac failure
Lungs – infection, pleural effusion, venous hum
6) Abdomen
Scars – dialysis
Kidneys – balotable, transplant kidney, mass, bruits
Tenckhoff catheter exit site infection
Bladder
Liver, Ascites
Nodes (Lymphoma)
Femoral bruits and pulses
Rectal exam – masses, prostatomegaly
7) Legs
Oedema (nephrotic syndrome, CCF)
Bruising, Pigmentation, AVF, Scratch marks
Gout
Neuropathy/Myopathy
8) Back
Tenderness, sacral oedema
9)UA
Specific gravity, blood, protein, glucose, microscopy and
casts
10)Other
Blood pressure lying & standing
Fundoscopy
2) Monitor and treat hypertension
3) Carefully attend to salt, water balance and acidosis
4) Normalise calcium and phosphate levels with diet, phosphate binders or calcitriol
5)Restrict dietary protein
6) Dialyse when indicated
7) Consider transplant
Dialysis
1) Uraemic symptoms despite conservative management
2) volume overload despite salt & water restriction
3) hyperkalaemia unresponsive to conservative measures
4) progressive deterioration of renal function
5) ARF