LEC-6 Chronic renal failure.pptx renal failure chronic

Chroni failure

1. CHRONIC RENAL FAILURE

2. DEFINITION Chronic kidney disease (CKD) is marked by the presence of kidney damage (usually defined as estimated GFR < 60 mL/min/1.73 m2) for 3 or more months

3. Glomerulopathies Primary glomerular disease Focal glomerulosclerosis Membranoproliferative g lomerulonephritis Membranous nephropathy Immunoglobulin A nephropathy Diabetes mellitus Amyloidosis Post infective glomerulonephritis Systemic lupus erythematous Wegener granulomatosis Tubulointerstitial diseases Analgesic nephropathy Reflux nephropathy with pyelonephritis Myeloma Sarcoidosis Hereditary diseases Polycystic kidney disease Alport syndrome Medullary cystic disease Systemic hypertension Renal vascular disease Obstructive uropathy HIV infection Hypertension Causes of Chronic Kidney Disease

4. STAGES OF CHRONIC KIDNEY DISEASE STAGE 1 WITH NORMAL OR HIGH GFR GFR > 90 ml/min. STAGE 2 MILD CKD GFR 60- 8 9 ml/min. STAGE 3 A STAGE 3 B MOD E R A TE CKD 45- 59ml/mi n . 30- 44ml/mi n . STAGE 4 SEVERE CKD GFR 1 6 -29ml/min . STAGE 5 END STAGE GFR < 15ml/min. Albuminuria Stages Albumin Excretion Rate (mg per 24 hours) Description A1 <30 mg Normal to mildly increased A2 30–300 mg Moderately increased A3 >300 mg Severely increased GFR stages Albumin stages

5. PATHOPHYSIOLOGY Decreased renal blood flow, primary kidney disease, damage from other disease, urine outflow obstruction Decreased glomerular filteration rate Hypertrophy of remaining nephrons Inability to concentrate urine Further loss of nephron function Loss of renal function

6. LOSS OF RENAL FUNCTIONS DECREASED LIBIDO INFERTILITY DELAYED HEALING INFECTION ADVANCED ATHEROSCLEROSIS ERRATIC BLOOD GLUCOSE LEVEL ANEMIA, PALLOR DECREASED CALCIUM ABSORPTION:- OSTEODYSTROPHY AND HYPOCALCEMIA DISTURBANCES IN REPRODUCTION IMMUNE DISTURBANCES INCREASED PRODUCTION OF LIPIDS (TG, LDL) IMPAIRED INSULIN ACTION FAILURE TO PRODUCE ERYTHROPOIETIN FAILURE TO CONVERT INACTIVE FORMS OF CALCIUM

7. LOSS OF RENAL FUNCTIONS METABOLIC ACIDOSIS DECREASED HYDROGEN SECRETION AND BICARBONATE REABSORPTION HYPERPHOSPHATEMIA→DECREASED CALCIUM ABSORPTION→ HYPOCALCEMIA→ HYPER-PARATHYROIDISM→ DECREASED POTASSIUM EXCRETION → HYPERLKALEMIA DECREASED PHOSPHATE EXCRETION HYPE R KALEMIA DECREASED POTASSIUM EXCRETION WATER RETENTION CAUSING HYPERTENSION , HEART FAILURE, EDEMA DECREASED SODIUM REABSORPTION IN TUBULE UREMIA CAUSING INCREASED BUN, CREATININE, URIC ACID, PROTEINURA, PERIPHERAL NERVE CHANGES, PERICARDITIS, PRURITIS, CNS CHANGES, BLEEDING TENDENCIES DECREASED EXCRETION OF NITROGENOUS WASTE

8. CLINICAL MANIFESTATION OF CHRONIC RENAL FAILURE

9. INTEGUMENTORY CHANGES:- SKIN-VERY DRY BECAUSE OF ATROPHY OF SWEAT GLAND . PRURITIS-EXCORIATED SKIN. SKIN COLOR-UROCHROMS PIGMENTS. MUEHRCKE’S LINE UREMIC FROST

10. MUSCULOSKELETAL CHANGES RENAL OSTEODYSTROPHY OSTEOPOROSIS OSTEOMALACIA

11. HEMATOLOGIC CHANGES ANEMIA, FATIGUE, WEAKNESS , AS KIDNEYS ARE TO PRODUCE ERYTHROPOIETIN. HEMOLYSIS, CLOTTING ABNORMALITIES. BLEEDING TENDENCIES AS ACCUMULATION OF UREMIC INTERFERE WITH PLATLET ADHESIVENESS.

12. METABOLIC CHANGES NORMAL RATIO OF BUN TO CREATININE IS 10:1 -20:1 HYPOPROTEIN EMIA INCREASED SERUM URIC ACID CARBOHYDRATE INTOLERANCE METABOLIC ACIDOSIS AS KIDNEYS FAIL TO EXCRETE H IONS.

13. HYPERTENSION; CAD, CVD, HF SILENT MI CARDIO-VASCULAR CHANGES DYSLIPIDEMIA; ATHEROSCLEROSIS LEFT VENTRICULAR DYSTROPHY AND HEART FAILURE DUE TO VOLUME OVERLOAD. ACCELERATED DUE TO ABNORMAL LIPID METABOLISM, ARTERIAL CALCIFICATION.

14. RESPIRATORY CHANGES PULMONARY EDEMA. UREMIC LUNG METABOLIC ACIDOSIS AS A RESULT OF RESPIRATORY CHANGES TO HYDROGEN IONS.

15. GASTROINTESTINAL CHANGES ANOREXIA, NAUSEA, VOMITING CONSTANT BITTER, METALLIC OR SALTY TASTE BREATH- UREMIC FETOR, AMMONIA, FISHY LIKE SMELL . CONSTIPATION, ULCER.

16. REPRODUCTIVE CHANGES DECREASED LIBIDO MENSTURAL IRREGULARITY AMENORRORHEA , IMPOTENCE. ENDOCRINE CHANGES HYPERPARATHYROIDISM

17. NEUROLOGIC CHANGES MILD; PERIPHERAL NEUROPATHY (Sensory and motor), PARAPLEGIA , IMPAIRED COGNITIVE FUNCTION . SEVERE; seizures, obtundation, uremic encephalopathy, coma PSYCHOLOGICAL CHANGES FINANCIAL STRESS LIFE-STYLE CHANGES

18. DIAGNOSTIC TEST FOR CHRONIC RENAL FAILURE

19. Signs of CKD are often diverse and undetected . When symptoms do appear, complaints are nonspecific, such as fatigue, malaise , and anorexia. In most patients the diagnosis is made during routine testing.

20. Lab investigations BUN Serum creatinine GFR CBC Electrolytes; Serum proteins Urine RE, Proteins Coagulation profile USG of kidneys

21. MEDICAL MANAGEMENT OF CHRONIC RENAL FAILURE

22. Management of patients with CKD includes aggressive treatment of the underlying cause , pharmacologic therapy to delay disease progression and prevent complications, and preparation for renal replacement therapy as ESRD ensues

23. MEDICAL MANAGEMENT OF CRF HYPERKALEMIA PERICARDITIS HYPE R TENSION ANEMIA PREVENT C O MPL I C A TI O N S -

24. DIETARY INTERVENTIONS:- Fluid allowance 500-600ml > than previous 24hrs urine output CARBOHYDRATE & FAT INTAKE 40- 50kcal/kg/day . Proteins 0.6 g/kg. VITAMIN SUPPLEMENTS. Dietary phosphorus should be restricted to 600–800 mg/ day Sodium intake should be restricted to less than 1.5–2 g/day Potassium diet restriction Calcium rich diet

25. ADMINISTRATION OF:- ANTI-HYPERTENSIVES ERYTHROPOIETIN ( RECOMBINANT HUMAN ERYTHROPOIETIN ) IRON SUPPLEMENTS PHOSPHATE BINDING AGENTS CALCIUM SUPPLEMENTS ADEQUATE DIALYSIS

26. HYPERKALEMIA :- DIALYSIS T H E R AP Y P O T ASS I U M REMOVAL POTASSIUM R EST R IC T E D DIET

27. HEMODIALYSIS / PERITONEAL DIALYSIS

28. S URGIC A L M A N A G E M E N T

29. MANAGEMENT OF ANESTHESIA Management of anesthesia in patients with CKD requires an understanding of the pathologic changes that accompany renal disease, co-existing medical conditions, and the impact of reduced renal function on drug pharmacokinetics Optimal management of modifiable risk factors is imperative .

30. Drugs Used in Anesthesia Practice That Depend Significantly on Renal Elimination SNO CLASS DRUGS 1 Induction agents Phenobarbital Thiopental 2 Muscle relaxants Metocurine Pancuronium Vecuronium 3 Cholinesterase inhibitors Edrophonium Neostigmine 4 Cardiovascular drugs Atropine Digoxin Glycopyrrolate Hydralazine Milrinone 5 Analgesics Codeine Meperidine Morphine

31. PREOPERATIVE EVALUATION Preoperative evaluation of patients with CKD includes consideration of renal function, underlying pathologic processes, and comorbid conditions CBC RFTS; creatinine ELECTROLYES, PLASMA PROTEINS GLUCOSE PT,APTT,INR FLUID STATUS; body weight

32. PRE-OP MANAGEMENT AND PRE-MEDICATION HEMODIALYSIS ANTIHYPERTENSIVE BLOOD TXN (+,-) HEMATOCRET > 30 DESMOPRESSIN FOR COAGULOPATHY GASTRIC PROPHYLAXIS IV INSULIN; IN CASE OF DIABETES

33. INDUCTION IV INDUCTION BY PROPOFOL, ETOMIDATE, THIOPENTAL RSI BY SUCCINYLCHOLINE IF POTASIUM < 5.5mg/dl or Rocuronium RISK OF EXAGERATED HYPOTENSION

34. MAINTAINANCE BALANCED ANESTHESIA BY inhalational, muscle relaxant, opoids AVOID SEVOFLURANE TIVA MUSCLE RELAXANR ; mivacurium, atracurium, and cistracurium OPOIDS ; Alfentanil, fentanyl, remifentanil, and sufentanil FLUID MANAGEMENT NON-HEMODIALYSIS PATIENTS; generally contracted extracellular volume  pre-op hydration to restore urine output of 0.5ml/kg/hr ON HEMODIALYSIS PATIENT ; narrow margin of fluid balance, Non-invasive surgeries.. Replace only insensible losses, Major surgeries; BSS, colloids or blood txn

35. Monitoring PRESERVE VESSELS ON NON-DOMINANT HAND AND ARM CENTRAL VENOUS PRESSURE MONITORING IBP MONITORING INTR-OP FLUID BALANCE ARRHYTHMIAS PATIENT POSITIONING FISTULA PROTECTION

36. REGIONAL ANESHESIA SHOULD BE CONSIDERED IN CKD SYMPATHETIC BLOCK T4-T10 IMPROVES RENAL PERFUSION CHECK INR POST OPERATIVE REVERSAL ANALGESIA ECG; ARRHYTHMIAS

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