Acute and Chronic Renal Failure

- Glomerulonephritis and acute tubular necrosis are of the most important causes of renal failure. - Glomerulonephritis is an immunological issue that occurs due to deposition of antigen-antibody complexes in the basement membrane of the glomerulus. - The glomerulus is a network of capillaries which are encapsulated in the Bowman's capsule. - The filtration occurs through the glomerulus through three layers which are : the cells of the glomerulus ( one layer of cells ) , the basement membrane and the inner layer of the Bowman's capsule. - The structures of the kidney that might be involved in the occurrence of renal failure : 1- The glomerulus ( comes from the renal artery ) , if there's any problem in the renal artery such as stenosis, atherosclerosis, constriction (for example, one of the most important causes that might lead to renal failure is diabetes mellitus, the effect of diabetes milletus is general and leads to microangiopathy, and the renal artery is one of those blood vessels that might be affected by microangiopathy) 2- The efferent arterioles (later form the peri-tubular capillaries) 3- The tubules
The exchange and secretion occur between the tubules and the peri-

tubular capillaries.

- Necrosis of the tubules due to ischemia (which is called acute nephrotic necrosis) might lead to acute renal failure.

- Tubular cells death is caused by reduced renal blood flow (ischemia) or toxins.

Acute tubular necrosis Necrosis of cells of kidney tubules and it's the most common cause of acute renal failure

- Glmerulonephritis mostly seen after streptococcal infection.

Signs & Symptoms

1- Sodium retention. 2- Edema. 3- Hypertension. 4- Proteinuria. 5- Hematuria (which is not existed in nephrotic syndrome)

- The functions of the kidney that will be disturbed due to renal failure : 1- Getting rid of waste products, so accumulation of waste products (urea, creatinine and uric acid, which are nitrogenous products) reflects the presence of renal failure, if this will continue over hours or days it's acute but longer it might be converted to be chronic.
If a person has any problem or post operation (post-operative surgery)

it's routine to do what's called kidney function test so as to check the functions of the kidneys, and the urea, uric acid and creatinie reflect the wellness of the kidneys.

2- The maintenance of homeostasis, acid-base balance and to get rid of excessive fluid and electrolytes, so if we have for example water retention, sodium retention, presence of edema they reflect a state of renal failure.

3- Secretion of rennin & erythropoietin, so those people with renal failure will develop anemia (Hb doesn't exceed 6-7 and the PCV is about 20%)

Erythropoietin stimulates or enhances the process of erythropoeisis in the bone marrow. Erythropoietin secretion is stimulated due to hopoxia.

Acid Base Balance To get rid of H+ ions and reabsoption of bicarbonate or sodium between kidney tubules and the peritubular capillaries so as to maintain a state of equilibrium.

- The indicators of the presence of renal failure: 1- One of the most biochemical markers is creatinine, creatinine of more than 200 mol/liter reflects the presence of renal failure (normal creatinine is 55-120) 2- Urea (normal 2.5-6.5 mmol/liter) 3- Potassium (normal 3.5-5 mmol/liter) , in renal failure the patient might develop hyperkalemia which leads to the flaccidity of the heart and might lead to cardiac arrest (the vital organ whose function is affected by potassium is the heart)

Be aware ! If you work in the ICU department note that the ampoule of potassium chloride is placed on the same trolley that has distilled water (the ampoule of potassium chloride and the ampoule of the distilled water look the same) and unless you read you won't be able to differentiate, so if you give the patient potassium chloride (10cc potassium chloride intravenously) instead of distilled water, it means that you killed the patient.

- Acute renal failure is usually reversible (renal function usually returns) - If renal function is not restored rapidly, replacement therapy may be required. (if a person had bleeding, if we do resuscitation & replacement therapy -to give him blood and IV fluid- he might be OK and the functions will be restored), I think the doctor here was talking about heart failure.

Causes of acute renal failure

Pre-renal
- Before kidney. - Results in a decreased renal blood flow. - Usually due to circulatory failure or something that affects the renal artery (diabetes milletus, hypertension) - Systemic >> circulatory shock - Local >> local renal stenosis (as in diabetes milletus)

Intrinsic (Renal)
- Glomeruli >> glomerular disease (e.g. glomerulonephritis) - Blood vesssels - Renal tubules >> mainly acute tubular necrosis. - Interstitial disease.

Post- renal
- After the kidney. - Due to obstruction in the renal pelvis, ureter, urinary bladder or urethra (the causes are stones, tumors or inflammatory process), if there's urethric stone closing the ureter it leads to hydronephrosis due to accumulation of fluid and urine and if it's not treated it might lead to renal failure that's why for those patients who are complaining of presence of stone closing the ureter, this stone have to be removed, otherwise it might lead to renal failure. - Prostatic hypertrophy, might cause total block for the urine flow. - Malignancies (e.g. tumor in the urinary bladder)

 The doctor here said about reversible pre-renal, if there's a problem in the circulation, when we say reversible it's easy to restore the function of the kidney, we do resuscitation to give the patient either blood or fluids.

- The minimum output of urine daily is half liter (500 ml) - Anuria : if the amount of urine is less than 100 ml. - Anuria is fatal Why? - since to get rid of waste products there should be a minimum of 500 ml of urine, because the waste products should be diluted in urine (they are not excreted as powder or dry) - Sometimes urine volume is normal or increased (seen in 20% of patients), this is due to low glomerular filtration rate (GFR), GFR reflects the intake. - (the doctor here was talking about the clinical features of established acute renal failure, especially about hypekalemia - mentioned before) - The chronic renal failure is irreversible (such as in a patient have uncontrolled diabetes milletus or hypertension over 20 years, if the patient developed renal failure, it's too late to do anything for him) -Some times the chronic renal failure is described as uremia (urine in the blood) - (the doctor here talked about the causes any factor or condition which destroys the normal function and structure of the kidney) - in most cases, serious symptoms don't occur until the number of normal functioning nephrons decreased below 20-30% of normal. - (hypocalcimia, acid-base disturbances, respiratory rate is increased because of acidosis and accumulation of H+ ions,anemia, bleeding tendency, immunity depression & infection)

 Please refer to the slides concerning the last few sentences because I

think the doctor was going in the slides backwards instead of forwards to make sure whether these sentences are about acute or chronic renal failure. Here are some Physical signs in CRF

- In late stages of chronic renal failure the patient looks ill, anemic, respiration is deep, anorexia, nausea, hiccups, vomiting - Osteomalatia due to failure of bone mineralization. - Osteoporosis - decreased mass of the bone - Osteosclerosis due to increased bone density.
Again here the doctors mentioned that there are details in the slides about the relationship of hypertension with the chronic renal failure and how the edema will develop (renin-angiotensin-aldosterone system)

- The treatment or management for chronic renal failure is hemodialysis or peritoneal dialysis.
At last here a student asked a question and the doctor answered it

that it's neuropathy, you can listen the record if you want if you can understand it because I did not.

Useful Appendix :
- Pathology
Azotemia refers to an elevation of blood urea nitrogen and creatinine levels and is largely related to a decreased glomerular filtration rate (GFR).
Robbins Basic Pathology, 8th edition.

Acute renal failure is dominated by oliguria or anuria (no urine flow), with recent onset of azotemia. It can result from glomerular ingury (such as crescentic glomerulonephritis), interstitial injury, vascular injury (such as thrombotic microangiopathy), or acute tubular necrosis.
Robbins Basic Pathology, 8th edition.

Chronic renal failure, characterized by prolonged symptoms and signs of uremia, is the end result all chronic renal diseases.
Robbins Basic Pathology, 8th edition.

Done by : Muad Al-Zou'bi and Suliman garaleh

- Sorry if I committed any mistake without knowing. - I ignored to write the first very few minutes of the lecture because the doctor went over a previous issues like nephrotic syndrome- and when he talked about previous subjects like heart failure.

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