RENAL FAILURE

The Miracle

Water Regulation Acid-Base Balance Excretion of Waste Produ

INTRO.
renal failure refers to a state of sudden

or progressive and irreversible or reversible loss of renal function

ACUTE RENAL FAILURE (INJURY) CHRONIC RENAL FAILURE ACUTE RENAL FAILURE ON CHRONIC

RENAL FAILURE

ACUTE RENAL FAILURE (INJURY)

ACUTE RENAL FAILURE (INJURY)

ARF is defined as a rapid

deterioration of renal function resulting in retention of nitrogenous wastes and biochemical derangement

ACUTE RENAL FAILURE (INJURY)

Oliguria (urine Volume < 0.5ml

/kg/h) or anuria is the most prominent feature. Although urine output may be normal or only slightly reduced (non-oliguric ARF)

EG. ARF associated with nephrotoxic drugs. Increase blood level of urea and creatinine suggest the diagnosis in such case

ACUTE RENAL FAILURE (INJURY)

When it occurs in a pre-existing

renal disease is called Acute-ohchum renal failure. ARF comprises of 1.5 2% of all paediatric in-pt at major hospitals and 20% percent of paediatric intensive care unit

CAUSES OF ARF

pre-renal Intrinsic ( renal) post-renal

CAUSES OF ARF

Pre-renal failure is renal insufficiency due to inadequate renal blood flow. Hypovolemic pre-renal failure, if treated early, responds to a fluid challenge with resumption of normal urine output and resolution of azotemia

CAUSES
CAUSES OF PRE- RENAL ARF 1) Acute gastroenteritis with dehydration and shock is a frequent cause of ARF in the part of the world 2) Burns. 3) Blood loss 4) Shock 5) Fulminant hepatitis

CAUSES
6) Congestive heart failure 7) Hepato-renal syndrome 8) Reye syndrome CUSESE OF INTRINSIC. Intrinsic Renal Disease Glomerular 1) Acute GN (APSGN) other infection 2) Cresentic GN

CAUSES OF ARF
3) Acute tubulointerstitial Nephritis 4) Acute tubular Necrosis 5) other Prolonged pre renal insult - Intravascular haemolysis( G 6PD), -Sepsis with multiorgan failure, -Nephrotoxic agent, -Snake bite, other envenomation, - P faciparum malaria, - leptospirosis

CAUSES OF ARF
CAUSES OF POST RENAL -Post-renal ARF occurs from obstruction in the urinary collecting system in the absence of renal parenchymal disease. -It is potentially reversible when the urinary tract obstruction is alleviated. -NB: Both pre and post renal condition can, if prolonged,
lead to parenchymal injury to the kidneys (intrinsic)

CAUSES Bilateral obstruction at pelvi ureteric junction, Both ureteric Obstruction, bladder outlet and urethral Obstruction by calculi, blood clots and pus debris .

INDICES FOR DIFFERENTIATING PRE-RENAL FROM INTRINSIC Pre-renal Intrinsic Urinary Na MEq/l < 20 > 40 Urinary Osmolality (mosm/kg) > 500 < 300 Blood Urea/cr. ratio > 20:1 < 20:1 Urine to plasma osmolality > 1.5 < 0.8 1.2 Fractional excretion of Na <1 >1

FeNa% = Urine Sodium x Semi Cr x 100 Semi Sodium x Urine Cr

CLINICAL FEATURE Symptoms: 1) Oliguria

2) Generalized weakness and dizziness 3) Ureamic symptoms- Anorexia, nausea, vomiting, pruritus, drowsiness, apathy, hiccup, convulsion, coma 4) There may be epigastic pain, body swelling

SIGNS
Pallor Dehydration Tachypnoea Hypotension/hypertension Mental clouding and confusion Asterixis Pericardial rub

MANAGEMENT
A)Urine Tests - Urinalysis with SG, urine m/c/s - Urine Osmolality, Na, Fractional Excretion of Na B) Blood Test - Serum e/u/cr, FBC, Blood culture, Blood gases, Peripheral Blood smear feature of micro angiopathy haemolysis, thrombocytopenia,and reticulocytosis indicate HUS. - Other test like ASO and C3 level as indicated.

MANAGEMENT (C) RADIOLOGY - Plan abdominal x-ray

- CXR - Abd uss - CT scan - IVU - Pylograph, renal arterograph and venograph.

(D) OTHERS
- Electricardigraphy (ECG) - Immunlogical study - Antinuclear antibody - Anti neutrophil cytoplasma antibody - Anti streptolysin o ASO titer

TX
Removal and treatment of offending agents (causes)

- History evaluation - Treatment of infection - Blood transfusion - Fluid replacement -Treatment of Hypertension - Correction of renal artery stenosis - Surgical relief of obstructive uropathy

MX of Common Conditions causing ARF

(1) Pre-Renal ARF - Administer crystalloid, Colloid infusion;

- STOP - diuretic, NASIDS, ACE inhibition, - Inotropic for (cardiac failure) - Pressor agents, and antibody for sepsis. (2) Acute Tubular Necrosis Rx: supporting care, discontinue drugs or toxin, treat cause of circulatory failure. (3) GN Rx: supporting care if post infectious, antibody if associating with shunt infection or endocarditis, consider immune suppressive medication.

MX of Common Conditions causing ARF

(4) Hemolytic Ureamic Syndrome

Rx: supporting care, limited role for plasma infusion or plasma exchange (5) Vasculitis: Immuno suppressive medication. ( (6) Acute interstitial Nephritis Rx: Discontinue offending drugs and consider steroid therapy (7) Renal artery or venous occlusion Rx: Anticoagulant, consider thrombolysis or surgical Arterial occlusion. (8) Intrarenal Obstruction-Rx: Discontinue offending drugs, Alkalin diuresn for rhasdonyolghi, hemoglobinum, or urate Nephropathy ( (9) Urinary Tract Obstruction -Bladder catheter or nephrostomy Radiologic/surgical treatment of obstruction

SUPPORTIVE OR NON PHARMACOLOGICAL TREATMENT

(1) Dietary advice
- Protein intake - Salt intake restriction - Caloric intake - Dietary Vitamin D supplement - Avoid food and drinks with high K+. (2) Daily weighing of pt (3) Daily Serum E/U/Cr (4) Fluid intake restriction with fluid input and output chart, strict in the olguric phase

PHARMACOLOGICAL TREATMENT
(1) Diuretics- If urine output is less than 0.5ml/kg/hr in pre-renal after two hours and there is no sign of intravascular volume deficit , 2 3mg/kg of frusemide is administration. - If no urine output occur in the following hour, intrinsic renal failure is strong suspected. ( (2) Dopamine Infusion, in low dosage 1-3micg/kg/min/ cause renal vasodilation and increase renal perfusion and has been used in pt with incipient ARF, not routinely recommendation. (3) Others- - H2 blocker in stress gastritis - Anti BP drugs if HBP - Antibiotics - Heamatinics in blood loss

COMPLICATION
(1) Fluid Overload -Rx Fluid restriction (2) Pulmonary oedema /pericardial effusion Rx: Oxygen, dopamine 5 10mg/kg/min with Minimum fluid, frusemide 2 4mg/kg and monitor by CVP line, dialysis with hypertoni glucose. (3) Hypertension: symptomatic - Nitropruside, 0.5 8mg/kg/min infusion , frusemide 2-4mg/kg Asymptomatic Nifedipine 0.3 0.5mg/kg oral. Maintenance t with oral- Nifedipine, hydralizin or atenolol.

COMPLICATION
(4) Metabolic Acidosis (5) Hyper Kalaemia Acute emergency- Rx: Calcium gluconate 10% 0.51ml/kg (5 10 mins) OR Salbutamol 5 10mg nebulizer less emergency-a) NaCo3 (8.4%) 1 2ml/kg (5-20mins) (b) Glucose 50%, 0.5 1/kg with 0.1 0.2IU/kg insulin (c) Ca resonium 1g/kg/day (d) Heamodialysis (5) Hyponatremia: Fluid restriction if sensorum alteration or seizure - 3% saline 6-12m/kg over 30-90 mins

COMPLICATION CONT.
(5) Hyponatremia: Fluid restriction, if sensorial alteration or seizure Rx- 3% saline 6-12ml/kg over 30-90 mins (6) Anaemia pack red cell 10ml/kg or consider EBT (7) High serum phosphate: phosphate binders (calcium carbonate, acetate and Dietary Phosphate restriction)

INDICATION FOR DIALYSIS IN ARF

(1) Ureamia Altered senserum, abnormal behavior, seizure, nausea peri- carditis. (2) Hyper Kalaemia K > 6.5 m Eq/L , K 5.5 6.5 m Eq/L with ECG change (3) Hyponatrema Na < 120 125 m Eq/L esp if symptomatic

INDICATION FOR DIALYSIS IN ARF

(4) Metabolic acidosis PH < 7.2 despite NaHCO3 therapy, or NaHCO3 administration not feasible because of fluid overload. (5) Hypercatabolic state marked tissue injury, crush-syndromes, burns, sepsis, tumor lysis syndrome.

PROGNOSIS/FOLLOW

Urinalysis - protein Persisitance Hypertension 3 Months check, 6 months, l year

as the case may be Abd U/s Serum E/C/U Other infection

CHRONIC RENAL FAILURE

CHRONIC RENAL FAILURE

Chronic Renal Failure (CRF)

is defined as irreversible deterioration of renal function, which gradually progress to end stage renal disease ESRD.

CHRONIC RENAL FAILURE

It is characterized by a fall in

glomerular filtration rate GFR below 80mls/min/1.75m3 (100ml) for over 3 months and often accompanied by other biochemical abnormality.

CHRONIC RENAL FAILURE

In Nigeria, about 2.5 children

per million of the population develop CRF per years. There are studies suggesting an increase in the incidence of CRF in Nigeria.

CHRONIC RENAL FAILURE

Early diagnosis and

management of some cases of chronic renal disease may prevent or retard the progression of the disease into ESRF

CHRONIC KIDNEY DISEASE

The term chronic renal

failure and end stage renal disease denote advanced renal damage for which renal replacement is the only option

CHRONIC KIDNEY DISEASE

Chronic Kidney diseases

are condition that has potential to cause progressive loss of kidney function and eventually lead to CRF.

CHRONIC KIDNEY DISEASE

-All patients with CRF have

CRD, but not all of those who have CRD are in CRF

CHRONIC KIDNEY DISEASE

CKD is used to describe

patient with kidney damage or decreased level of renal function for three months or more irrespective of the

CHRONIC KIDNEY DISEASE

underlying condition, and is defined as the presence of kidney damage or GRF below 2 60ml/min/1.73m

STAGE OF CHRONIC KIDNEY DISEASE

This is based on the level

of GFR, which is estimated from the level of serum Cr and height using the Schwartz formular:

STAGE OF CHRONIC KIDNEY DISEASE

GFR = Ht x 40 Plasma Cr (min/L/) OR 0.53 x Ht in con Plasma Cr in mg/min

STAGE OF CHRONIC KIDNEY DISEASE

The classification was

proposed by the National Kidney Foundation Disease Outcome Quality initiative

Classification of Stage
Stage GFR (ml/min/1.73m2) 90 60 89 Description

1
2.

Kidney damage with normal GFR Kidney damage with wild reduction of GFR

Classification of Stage 3. 4. 30 59 Moderate reduction of GFR 15 29 Severe reduction of GFR < 15 END STAGE (DIALYSIS)

5.

RISK FACTORS FOR CKD

VUR associated with recurrent

urinary infection and renal scaring Obstructive uropathy Prior history of acute Nephritis or Nephrotic syndrome Children with history of renal failure in pre natal period

RISK FACTORS FOR CKD

Family history of poly

cystic kidney or genetic renal condition Renal dysplasia or hypoplasia Low birth weight infant

RISK FACTORS FOR CKD

Prior history of Henoch

Schonlein purpura Presence of diabetes, hypertension Systemic lupus Erythematosis and vasculitis

CAUSES OF CRF Chronic Glomerulonephropathies constitutes the most cause of CRF in childhood, especially in the older child. Chronic pyelonephritis, associated with severe urinary tract malfunction like severe vesico-uretric reflux and obstruction uropathies such as posterior urethral valves in boys are significant cause of CRF.

CAUSES OF CRF
Renal dysplasia is often suggested

by concomitant presence of other congenital abnormalities. Other renal cause of CRF include haemolytic ureamic syndrome, congenital single kidney, bilateral renal hypoplasia , bilateral wilms tumor and cystinosis.

SYSTEMIC MANIFESTATION
The clinical feature of CRF include

-anorexia, -growth retardation - Anaemia,

-failure to thrive, -fatigability, -hypertension and osteodystrophy.

The late feature, with extreme reduction of GFR, are

- itching
-hyperkalaemia, - pulmonary oedema

-severe acidosis, - left venticular failure -peri cardial effusion

- altered sensorum

SYSTEMIC MANIFESTATION
The possibility of CRF should be

considered when one or more of these manifestation are present without an obvious cause. Other manifestation include, lack of energy, increase sleep, poor school performance, platelet dysfunction, and depressed cell mediated immunity, Gastric ulceration, severe itching.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

In CRF there is derangement of the function of the body resulting in acid-base disturbance, disturbance of salt and wate metabolism, various metabolism bone disorder, Anaemia, central nervous system, cardiovascular, endocrine, gastrointestinal and immunological disturbances as well as disturbances of nitrogen, carbohydrate and lipid metabolism.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

1) Anaemia: Normchromic,normocytic aneamia

occur in CRF and is due primarily to reduction in the synthesis of erythropoietin by the diseased kidney. Other causes of anaemia are hymolysis due to uremia and chronic blood loss from bleeding the gastrointestinal tract, and skin and mucosa membrane as result of bleeding disorder especially abnormal platelet homeostasis

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

2) Gastrointestinal: Acute

gastrointestinal ulceration, peptic ulcer disease, idiopathy ascitis and petechial haemorrhage from the gut, have been described with uraemic syndrome

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

3) Endocrine: Abnormal metabolism of the sex

hormones with absence of the pubertal growth spurt, delayed menarche and puberty with absent of secondary sexual characteristics has been frequently described in CRF. There also, is low level of serum thyroxine and abnormally elevation fasting growth hormone level, which explain the glucose intolerance in uraemia.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

4) Acid-Base Disturbance

A drop in GFR to about 20 30 ml/min/1.73 result in retention of fixed acid and a state of metabolism acidosis occur with increase in urinary excretion of calcium. There is depression of serum bicarbonate reabsorption in the proximal tubule, with a small percentage of the filtered load reabsorbed in the distal portion of the nephron. Failure to reabsorbed the filtered bicarbonate completely lead to urinary loss of this buffer and elevated urinary PH and limitation in the ability of the kidney to execute net acid and result in metabolism acido.sis

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

5)

Cardiovascular

-Mechanism of uraemic heart disease include fluid overload from salt and water retention, system arterial hypertension . other are anaemia, uraemia, electrolytes derangement K, Na, Ca , Mg. -Peri carditis with or without peri cardial effusion is frequently observed in patient with CRF and acute left ventricular failure and pulmonary oedema is a well known presenting feature in children with CRF -Majority of children with CRF has abnormal ECG finding and cardiovascular complication is cause of death on majority of cases

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

6) Neurological complication This is called Uraemic Encephalopathy

and consist of various neurological pretention. - non- specific general depression of cerebral function, fatigue, listlessness, drowsiness, poor concentration at school, to frank psychosis, hallucination, seizure and coma with decorticate posture.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

-Focal neurological sign may occur but are rare; more often being associated with hypertension encephalopathy or intracranial haemorrhage. -The exact pathophysiology of this cerebral dysfunction is unknown. - The degree of dysfunction is not commensurate with level of urea and Cr in the blood probably other biochemical metabolism in the blood are responsible

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

Peripheral neuropathy is a common

manifestation of CRF in adult with restless leg syndrome, characterized by peculiar creeping, prickling and tingling sensation in the lower limb.
Often worse in the night, other

symptom is burning feet syndrome.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

Full blown peripheral neuropathy may

subsequent develop with loss of vibration position, touch and pain sensation and loss of deep tender reflex. In children, frank peripheral neuropathy is rare but defect in nerve condition velocity are common.

PATHOHYSIOLOGY AND METABOLIC DISTURBANCE

7) Immunology

Suppression of normal immune mechanical form a part of the uraemic syndrome. Various degree of lymphopenia, delayed hypersensitivity reaction, abnormal polymorphonuclear, and monocyte function as well abnormal inflammably responses have been described. 8) Renal osteodystrophy

MANAGEMENT

1)

Serum e/u/cr: Ur level is serum generally above 6mg% while serum Cr is also 100ml/L. If serum Ur is abnormally high for an elevation serum Cr due to inability to eat, estimated urea level should be calculation from the creature urinary the ratio Urea Cr 1:17

2) Serum HCO3 is often low 3)Calculation of the eGFR 4) Serum calcium may be low, normal or high

MANAGEMENT

Other Investigation CXR cardiomegaly X-ray of Hand and wrist will show the

earliest radiological changes. If present, will subperiosteal erosion of the radial aspect of the middle phalange. Total skeletal surgery is unnecessary in detecting Ros. MCU IVP

MANAGEMENT
Treatment 1) Conservative Management

-When GFR is above 10ml/min/1.73 -Occasional when patient are receiving RRT -Oliguric or anuric pt should receive fluid equal to their insensible loss plus the urine out put in 24hrs to prevent fluid overload, i.e. fluid restoration. -If serum bicarbonate is 15mm/L or less, sodium bicarbonate may be given in a dose of 1ml/kg/day

MANAGEMENT
Avoid excessive salt intake with resultant fluid

overload 1.25 dihydoxy cholecalciferol or the synthezised ,1 hydoxy cholecalciferol In dose of 10 15mg/kg/day Anti HBP, particularly blocker (if there is no cardiac failure) Hydralazin control HBP ACEI useful in renal Hypertension Phosphate binder e.g. calcium carbonate.

MANAGEMENT
Low protein diet to prevent hyperfiltration and have been used to delay the onset of end stage renal esp in adult but in children, taking into consideration the growth most children will require 2g/kg/d of high molecular value. The use of Recombinat human erythropoietin therapy has markedly diminished the need to frequent blood transfusion in children with CRF in whom often iron therapy does not correct the anaemia.

Avoidance of drugs, there are nephrotoxic e.g. genticin

Renal Replacement Therapy

When ESRF set in, renal replacement therapy

must be given to prevent impeding death. This should be done when GFR is less than 10ml/min/1.75. Dialysis- PD - HAEMODIALYSIS RENAL TRANSPLANTATION

Dialysis
Chronic Ambulatory Peritoneal Dialysis (CAPD),

which is prefer by most central and can be done in very small children aged less than 2 years in whom renal transplantation is difficulty Ad: Better growth rates less restriction diet and fluid allowance, freedom to attend activities, less requirement for blood transfusion. Other peritoneal dialysis - Continuous Cycling Peritoneal Dialysis (CCPD) - Intermittent Peritoneal

Heamodialysis

Heamodialysis: especially

abdominal surgery - Required either a creation of an artero Venus shunt or a fistula

This is difficulty, if the child is

young with small vessel

Renal Transplantation

Renal Transplantation is the goal

to most children and cadaver or living donor can be used. Immunosuppressive therapy such as Azathioprine, Prednisolone or cyclosporin A . For life is mandatory to prevent host grafting rejection.