Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases.
Pathophysiology of Chronic renal failure
End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure
Stages of renal failure
Chronic kidney disease CKD stages correspond to the degree of nephron loss:
- Decreased renal reserve, Glomerular Filtration Rate GFR may be normal; slightly higher than normal, stage I: greater than or equal to 90 mL/min/1.73 m2; or somewhat less than normal, stage II: 60 to 89 mL/min/1.73 m2. Kidney dysfunction is present, however, it may be undiagnosed due to lack of symptoms blood urea nitrogen/creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%.
- Renal insufficiency, Nephron loss at 75% to 90%; GFR is moderately (stage III: 30 to 59 mL/min/1.73 m2) to severely (stage IV: 15 to 29 mL/min/1.73 m2) reduced. Slight elevation in BUN/Cr. Polyuria and nocturia present high output failure
- Renal Failure (GFR 20% to 25% of normal)
- End Stage Renal Disease (ESRD). Nephron loss at greater than 90% with a GFR of only 10% to 15% (stage V: less than 15 mL/min/1.73 m2). Fluid and electrolyte abnormalities, Azotemia and uremia present Dialysis required
Clinical Manifestations of Chronic renal failure
- Gastrointestinal GI anorexia, nausea, vomiting, hiccups, ulceration of Gastrointestinal GI tract, and hemorrhage
- Cardiovascular hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade
- Respiratory pulmonary edema, pleural effusions, pleural rub
- Neuromuscular fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma
- Metabolic and endocrine glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea
- Fluid, electrolyte, acid base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia
- Dermatologic pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost
- Skeletal abnormalities renal osteodystrophy resulting in osteomalacia
- Hematologic anemia, defect in quality of platelets, increased bleeding tendencies
- Psychosocial functions personality and behavior changes, alteration in cognitive processes
Etiology Causes Renal Failure Chronic CRF
- Acute tubular necrosis (ATN) from unresolved acute renal failure (ARF)
- Chronic infections: glomerulonephritis, pyelonephritis, beta hemolytic streptococci infection
- Vascular diseases: hypertensive nephrosclerosis, renal artery stenosis, renal vein thrombosis, vasculitis
- Obstructive processes: long-standing renal calculi, Benign Prostatic Hyperplasia (BPH)
- Cystic disorders: polycystic or medullary kidney disease
- Collagen diseases: systemic lupus erythematosus (SLE) and collagen vascular disease
- Tumors: malignant (multiple myeloma) or benign
- Nephrotoxic agents: drugs, such as aminoglycosides, tetracyclines, contrast dyes, heavy metals
- Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism
- Long-standing systemic hypertension
Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older
If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:
- Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids)
- Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis
- Hypertension due to sodium and water retention and malfunction of the rennin angiotensin aldosterone system
- Anemia due to decreased erythropoietin production, decreased Red Blood Cell RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis
- Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels
- Peripheral neuropathy, Restless leg syndrome, one of the first symptoms of peripheral neuropathy, causes pain, burning, and itching in the legs and feet. Eventually, this condition progresses to paresthesia and motor nerve dysfunction unless dialysis is initiated
- Sexual dysfunction
Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.
Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD
- Detection and treatment of reversible causes of renal failure (e.g. bring Diabetes Mellitus under control, treat hypertension)
- Dietary regulation low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition
- Fluid status maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume. Loop diuretics, such as furosemide only if some renal function remains, and fluid restriction can reduce fluid retention.
- A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema.
- Treatment of associated conditions to improve renal dynamics
- Anemia recombinant human erythropoietin (Epo-gen), a synthetic hormone. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells.
- Acidosis replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate
- Hyperkalemia restriction of dietary potassium; administration of cation exchange resin
- Phosphate retention decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract
- Drug therapy, surgery, and dialysis Maintenance renal dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management. Antiemetic taken before meals may relieve nausea and vomiting, and cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.
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