DR.

UROOBA HASAN
Click to edit Master title style Medical Conditions -II
Reference: Davidson’s Essentials of Medicine

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RENAL FUNCTIONS
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• Excretion of nitrogenous waste products e.g. urea.

• Maintenance of fluid and electrolyte balance.
• Maintenance of acid-base balance.
• Synthesis of vitamin D.
• Produces erythropoietin.

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RENAL FAILURE
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• Loss of renal functions

• TYPES OF RENAL FAILURE:

• Acute renal failure (ARF) or acute kidney injury (AKI): sudden and
usually reversible loss of functions, duration < 3 months.

• Chronic renal failure (CRF) or chronic renal injury (CKI): gradual and
usually irreversible loss of function, duration >3 months.

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ACUTE
Click to RENAL FAILURE/
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INJURY (AKI) :
SUDDEN and usually REVERSIBLE loss of renal function
which develops over a period of DAYS or rarely WEEKS
and results in URAEMIA.

URAEMIA: clinical sign and symptoms of renal failure:

-metabolic acidosis
-fluid overload
-hyperkalemia
-uremic encephalopathy
-uremic pericarditis 4
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symptoms
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• Oligouria (urine volume <400ml/ day)
(Can be non oligouric also)
• Inc plasma urea and creatinine
• with advancing uremia: anorexia, nausea and vomiting
followed by drowsiness, apathy, confusion, muscle twiching,
hicoughs, fits and coma.
• Acidotic breathing
• Anemia
• Bleeding tendency
• Infections
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CAUSES OFMaster
ACUTEtitle
RENAL
style FAILURE

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PRE-RENAL FAILURE
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• Causes:
• DECREASED EFFECTIVE ARTERIAL VOLUME:
• hypovolemia due to fluid or blood loss
• heart failure
• Sepsis
• LOCAL CAUSES:
• renal artery stenosis,
• renal arteriolar disease,
• nephrotoxic drugs (NSAIDs , ACEIs) etc.

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ClickRENAL
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FAILURE
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Examination: marked dehydration or hypotension,

delayed capillary return, postural hypotension, etc.
Diagnosis:
Complete hx
Clinical findings
Progressive inc in urea and creatinine
BUN:Creatinine ratio: > 20:1
Urine sodium: < 20mmol/L
Urine osmolality: >500 mOsm/kg
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PRE-RENAL FAILURE
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• Management:
• Identify and correct underlying cause
• Restore blood volume if hypovolemia or hemorrhage
• IV fluids
• Blood transfusion
• Manage acidosis and electrolyte abnormalities
• Avoid nephrotoxic drugs

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INTRINSIC RENALtitle
FAILURE
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• Aka established acute renal failure
• Causes:
• 1) GLOMERULONEPHRITIS
• 2) TUBULAR DISEASE
• Acute tubular necrosis (ATN) – MOST COMMON CAUSE
3) INTERSTITIAL DISEASE
• Acute interstitial nephritis (AIN)
4)VASCULAR DISEASE:
• Small vessel disease (cholesterol emboli, thrombotic microangiopathy)
• Contrast induced kidney injury
• Rhabdomyolysis

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INTRINSIC
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MasterFAILURE
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ACUTE TUBULAR NECROSIS

• Acute necrosis of tubular cells

• Kidney Injury from ischemia and toxins resulting in

sloughing off of tubular cells into urine.

• Cause:
• ischemia - progression of pre renal disease.
• toxins (bacterial toxins or chemicals e.g. gentamicin, cisplatin,
amphotericin B), hemoglobin, myoglobin.

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INTRINSIC RENALtitle
FAILURE
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ACUTE TUBULAR NECROSIS

• Features:
• Oliguria or anuria (80%)
• Non-oliguric (20%)
• Uremia  nausea, vomiting, hiccups, myoclonus, bleeding,
confusion, pericarditis, fits, coma.
• Increased respiratory rate
• Fluid overload, pulmonary edema
• Anemia
• Infections

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INTRINSIC RENALtitle
FAILURE
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ACUTE TUBULAR NECROSIS

• Management:
• IV fluids
• Diuretics FUROSEMIDE if overloaded
• Correct hyperkalemia
• Correct acidosis
• Maintain fluid and electrolyte balance
• Good energy intake.
• Avoid nephrotoxic drugs
• If pt is septic, obtain blood cultures and start axb.
• Hemodialysis (when condition is refractory to conventional therapy.
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INTRINSIC RENALtitle
FAILURE
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ACUTE INTERSTITIAL NEPHRITIS
• In this disease antibodies and easinophils attacks tubular cells.
• Mostly idiopathic
• Causes:
• Drugs: (most common) penicillin, cephalosporins, furosemide,
phenytoin, rifampicin
• Infections: pyelonephritis
• Autoimmune: SLE, sjogren's
• Infiltrative: sarcoisdosis, lymphoma, leukemia

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Sign and symptoms:

Rising BUN and creatinine with
• Fever
• Rash
• Arthralgias
• Eosinophilia and eosinophiluria

Lab findings:
BUN: creatinine ratio: < 20:1 15
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INTRINSIC RENALtitle
FAILURE
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ACUTE GLOMERULONEPHRITIS

• MANAGMENT:
• Withdrawl of offending drug or agent.
• Corticosteroid eg prednisolone 1mg/kg/day
• Dialysis

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POST-RENAL FAILURE
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• Caused by obstruction to pathway of urine.
• Causes:
• Ureteric obstruction: ureteric stones, compression by adjacent malignancy or lymph
nodes
• Bladder neck obstruction: BPH, prostatic carcinoma, bladder stones, neurogenic
bladder, malignancy
• Urethral obstruction: urethral stricture, tumors
• Diagnosis: distended bladder, massive diuresis with catheter placement, bilateral or
unilateral hydronephrosis on U/S
• Treatment: according to cause, relieve obstruction. Urinary catheter
placement to decompress the bladder.

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Click to editKIDNEY
CHRONIC Master title
INJURY
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Irreversible deterioration in renal function that

develops over a period of years.

END STAGE RENAL DISEASE (ESRD): CKD

that is so severe in which death is likely without
renal replacement therapy.
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Click to editKIDNEY
CHRONIC Master title
INJURY
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• STAGES ACCORDING TO GFR

GFR CATEGORY GFR in ml/min/ 1.73 m2

G1 ≥90
G2 60 – 89
G3a 45 – 59
G3b 30 – 44
G4 15 – 29
G5 <15 19
Click to editKIDNEY
CHRONIC Master title
INJURY
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CAUSES:
• Diabetes mellitus
• hypertension
• glomerular diseases
• interstitial kidney disease
• systemic inflammatory diseases example SLE
• Renal artery stenosis
• congenital and inherited diseases
• idiopathic 20
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•Asymptomatic in early stages, symptoms develop when GFR drops below
30 ml per minute.

1) GENERAL SYMPTOMS:
• ill looking
• Nausea, vomitting
• Loss of appetite
• Fatigue weakness
• Sleep problems
• Changes in how much you urinate
• Nocturia
• Decreased mental sharpness
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• Persistent itching (pruritis)

• Shortness of breath
• If metabolic acidosis, Kussmal's breathing
• Later hiccoughs, breathing, fits, drowsiness, coma.
• 2) HEMATOLOGICAL:
• Anemia - dec erythropoetin
• Bleeding tendency - platelet dysfunction
• 3) FLUID AND ELECTROLYTES: Disproportionate
fluid and electrolyte retention can cause volume overload
hypertension and edema formation. 22
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4) CARDIOVASCULAR:
most common cause of death in CKD.
Cardiovascular disease can manifest in the form of:
Pericarditis
accelerated atherosclerosis
Hypertension
hyperlipidemia
volume overload
CHF
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5) IMMUNE DYSFUNCTION: cellular and humoral immunity are

impaired in chronic kidney disease leading to infections - second
most common cause of death in dialysis patients.
6) ENDOCRINE FUNCTIONS:
Hyperprolactinemia - loss of libido
Half life of insulin prolonged - insulin requiremtns may decline in
diabetic pt.
Can produce insulin resistance
Secondary hyperparathyroidism:due to hypocalcemia
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7) HYPOCALCEMIA AND METABOLIC BONE
DISEASE: kidney transform vitamin D into its activated form
1-25 dihydroxycholecalciferol which absorbs calcium from gut.
Dec calcium causes:
Osteomalacia,
osteoporosis,
Hyperparathyroid bone disease (osteitis fibrosa)
8) MYOPATHY AND NEUROPATHY can also develop.

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CHRONIC KIDNEY
Click to edit MasterINJURY
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PRESENTATION

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INVESTIGATION:
• CBC, UCE
• BUN
• Urinanalysis and quantification of proteinuria
• PTH , calcium and phosphate
• Blood sugar , hba1c
• ECG (if pt is >40yr or hyperkalemic)
• Renal u/s: small kidneys, assymetrical kidneys, chronic
diease, renovascular or developmental disease
• Renal biopsy
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MANAGMENT

1) Dietary modifications
2) Treatment of complcations
3) Renal Replacement Therapy

DIETARY MODIFICATIONS:
Protein restriction
Potassium restriction
Salt and water restriction
Carbs and fat should be adequate to provide energy to body.
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MANAGEMENT:

TREATMENT OF COMPLCATIONS:
• Anemia: Erythropoetin replacement and iron
supplementation.
• Bleeding tendency: desmopressin (DDAVP) increases
plated function, use only when bleeding.
• Hypertension: ACEI, ARBs
• Hypocalcemia + osteomalacia: vit D + calcium
replacement.

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MANAGEMENT:
• Endocrinopathy: Dialysis, estrogen and progesterone
replacement.
• Metabolic acidosis: sodium bicarbonate.
• Reduction of proteinuria: ACEis ARBs
• Hyperlipidemia: statins

• RENAL REPLACEMENT THERAPY:

• Hemodialysis (most common)
• Hemofiltration
• Peritoneal dialysis
• Renal transplantation 30
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DIFFERENCES IN AKI
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AND CKI
AKI CKI
Duration <3 months Duration >3 months
Symptoms are usually more pronounced Symptoms are less pronounced

Kidney size is usually normal Kidney size is usually shrunken except in

few conditions like diabetes, amyloidosis,
polycystic kidneys

Usually do not have anemia Usually have anemia

Usually no hypocalcemia, There is hypocalcemia, hypovitaminosis
hypovitaminosis or hyperparathyroidism or hyperparathyroidism
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INDICATIONS
Click OF HEMODIALYSIS
to edit Master title style IN ACUTE
RENAL FAILURE
• severe acidosis refractory to medical therapy
• Hyperkalemia refractory to medical therapy
• Electrolyte imbalances e.g. sodium, potassium, calcium
• intoxications e.g. methanol, ethylene glycol, lithium, aspirin
• Uremic complications e.g. pericarditis, encephalopathy, seizures, severe
gastrointestinal symptoms, gastrointestinal bleeding
• Urea >180 mg/dL or creatinine >6.8 mg/dL
• Anuria or oliguria
• Volume overload refractory to diuretics

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INDICATIONS
Click OF HEMODIALYSIS
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RENAL FAILURE
• Severe symptomatic renal failure
• Low GFR in diabetes
• Difficulty in medial control of hyperkalemia, acidosis,
hyperphosphatemia

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•Thank you

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