Chronic Renal Failure Transplant/ waiting list?

Concise Long Case Approach

Disease progression and Complications of disease

History DO YOU STILL PASS URINE NOW? (GIVES AN ESTIMATION OF SEVERITY OF RENAL
FAILURE)
Presenting complaint GONAH + skin + neuro + GIT
I have renal failure
complications Growth (paeds) Height/ weight
unrelated problem Osteodystrophy Bone pain
Fractures
Past history Arthritis
first diagnosis when Proximal myopathy
presenting complaint Nutrition Protein intake
o enquire about urinary symptoms Water restriction (glomerular) or excess (interstitial)
frothy urine Electrolytes
hematuria Anemia Pallor, lethargy, fatigue
SOB
oliguria/anuria/polyuria/nocturia
Hypertension treatment
Skin Sallow
etiology:
Pruritis
GIT NVD
Commonest Other
Neuro Seizures 20 electrolyte disturbances
DM Renal
Encephalopathy
ask for past history Renovascular
Peripheral neuropathy
ask for polyuria/polydipsia/polyphagia Interstitial nephritis e.g. drugs
HTN Cystic kidney diseases family history
ask Complications of treatment
NSAIDsanalgesic nephropathy
Dialysis bleeding/ infections/ occlusion
GN Pyelonephritis e.g. told of kidney
VITAMIN Immunosuppressive drugs cyclosporine/ azothioprine/ prednisolone
infection? Fever?
Vascular HSP rashes/joint/abdpain Stones loin to groin pain, previous
Infectious strep sore throat/ HBV Functional days off work/school, change of job, financial
stones
Toxin gold/ penicillamine The standard remaining history
Anatomical e.g. VUR, BPH
Autoimmune SLE symptoms
Metabolic DM Extrarenal
10 causes SLE
systemic sclerosis
myeloma

Investigations done
U/S anatomical malformations
Biopsy - GN

Management
medications
dialysis
AV grafts
Physical examination Investigations
to confirm diagnosis of CRF
General Ht/Wt to determine etiology of CRF
Cachexia to look for complications of CRF
Myoclonus 2o uremia
Cusingoid appearance 2o steroids Diagnosis U/E/Cr Creatinine to estimate GFR
Skin Sallow By Cockcroft-Gault formula
Scratch marks by Schwartz formula
Hands/ Arms Asterixis GFR= k x Height(cm)/plasma creatinine
Leuconychia k=48.6 (children >3y)
Lindsays and nails (proximal white distal brown) k=61 in males >13y
Palmar crease pallor It tends to overestimate CRF
AV fistula thrill present is important sign of patency GFR = 100-120ml/min/1.73m2
Myopathy GFR= 30-50 in mild CRF
Face/ chest Fundoscopy HTN/DM changes GFR= 10-29 in moderate
Anemia GFR< 10 in severe
Central line GFR<5 in ESRF, requires renal replacement
Tanner Staging therapy
Rickety rosary ribs Etiology Bloods Plasma glucose
Heart Pericardial rub ASOT/ HBV/ ANA/ C3
CCF Urine Urinalysis
Bruit suggest vascular cause of CRF
Radiology Renal U/S cysts
Lungs Creps IVU Stones
Abdomen Nephrectomy scar usu. postero-lateral MCU if suspect anatomical abnormalities in
Transplant scar (usu iliac fossa) and transplant kidney paeds
Kidneys ballotable, bruit DMSA/ DTPA
Bladder Biopsy GN
Enlarged prostate
Complications Bloods FBC Anemia
Legs Edema Serum Ca/ PO4/ ALP/ PTH
Neuropathy U/E/Cr electrolyte imbalance
PVD
Radiology CXR heart/lungs
Genu varum
Bone Xrays
Other Bone and joint tenderness
BP

Manifestations of DM, HTN, SLE

Management

Growth failure Treat all contributors to growth failure

Malnutrition inadequate protein
Anemia
Osteodystrophy
GH resistance

If ht<3%, velocity<50%, give rHGH tx

Osteodystrophy Phosphate binders (CaCO3)
Calcium supplements (CaCO3)
Vitamin D supplementation
Nutritional If HD/PD, give recommended daily allowance + additional
protein to compensate for losses from dialysis
Fluid fluid restriction in ESRF and fluid overload type CRF, if
salt-losing type CRF, encourage H20 intake
Na 2g/d
K usu well maintained, treat as emergency if hyperK
Ca gluconate
Insulin + dextrose
Salbutamol
Resin (Ca Resonium)
Dialysis
Anemia Causes of Anemia
Decreased EPO synthesis
Shortened RBC survival due to uremia
Management
Adequate dialysis
Keep >10g%
Do Fe studies (Fe, ferretin, transferring, TIBC)
rEPO if not Fe-deficient
Hypertension ACE-inhibitor
Ca++ blocker
Neurological Electrolyte control

DGIM Last updated March 2005

DGIM Last updated March 2005