Chronic Renal Failure

Azotemia and Uremia

Azotemia = Renal insufficiency
Accumulation of nitrogenous waste products like urea, creatinine in blood, may recover with or
without dialysis. Azotemia is not severe enough to case any symptoms.
Uremia = Renal Failure
Accumulation of nitrogenous waste products like urea, creatinine in blood with symptoms. Definite
indication for dialysis.
Azotemia if not managed can lead to Uremia.

Causes of Renal Failure

Diabetes
HTN
Nephrotic-Nephritic Syndromes
Infections
Hereditary (Polycystic)
Toxins, Drugs
Vasculitis
Volume loss

This is not a complete list, It can also be grouped as Pre-renal, Renal and Post Renal.

Renal Replacement Therapy

1. Dialysis (Hemodialysis or Peritoneal)
2. Renal Transplantation
In future, we may have:
3. Wearable Dialysis Machines
4. Implantable Renal assist devices (IRAD)

Issues in Renal Failure

CNS

Problem

Mechanism

Comments/ Treatment

Intracranial Bleed (SDH)

Frequent Anticoagulant
administration during dialysis,
platelet dysfunction, HTN

Blood Products, Evacuate,

Leave alone if asymptomatic

Stroke

Accelerated Atherosclerosis due

to accumulation of unbreakable
glycation products

Prophylax with Routine Cardiac

medications cocktail, Treat like
any other stroke

Uremic Encephalopathy

Build up of toxins in plasma

Dialysis

Sensory Motor and

Autonomic Neuropathy

Build up of toxins in plasma

Dialysis

CVS
Coronary Artery Disease
(Can rely on cardiac
biomarkers if they are
on dialysis)

Accelerated Atherosclerosis due

Cardiac drugs cocktail, Do
to accumulation od unbreakable reperfusion for ACS and dialyse
glycation products
after PCI

Acute Pulmonary Edema

Secondary to heart failure, fluid

overload, ACS

O2, NIV, Nitrates, Diuretics and

Dialysis

Heart Failure aka Uremic

Cardiomyopathy

HTN, toxins in plasma,

Hyperparathyroidism

Heart Failures meds, May

Consider parathyroidectomy,
Dialysis

Uremic Pericarditis

Build up of toxins in plasma

May not have classic ECG

pericarditis changes, Dialysis,
Pericardiotomy

Cardiac Tamponade

? Build up of toxins in plasma

May not have Becks Triad,

Pericardiocentesis if unstable
(risk of bleeding),
Dialysis

Anemia

Lack of erythropoietin, poor

dietary intake, uremic bleeding,
decreased RBC survival

Erythropoietin Replacement

Immunocompromised

White Cells cant degranulate

and release toxins to kill the
bugs, Poor activation of immune
system due to lack of IL2

Dialysis (questionable
improvement)

Hemat

Hemat

Uremic Bleeding

Platelets dysfunction - cant

degranulate and cant form a clot

Buy time with Desmopressin,

Cryoprecipitate and plan
Dialysis

Anorexia, Nausea,
Vomiting, Gastritis

Build up of toxins in plasma

Antiemetics, Dialysis,
tranexemic Acid

Ascites

Fluid Overload

Drain Ascites, Dialysis

Constipation

Due to less fluid intake and KBind

High fibre diet, laxatives,

Dialysis

Calciphylaxis

Ca and P precipitation in tissues

Dialysis

Hyperparathyroidism with
risk of fractures

Vit D deficiency and high

phosphate leads to decreased
calcium levels > secondary
hyperparathyroidism

Phosphorus binding gels,

Dialysis, Ca and VitD
supplements

Metabolic Acidosis and

hyperK

Failling kidneys cant get rid of

acid and potassium

Prevent arrythmias, May try

bicarb but they need dialysis

GIT

Endocr
ine

Indications for Emergent Dialysis in renal failure

Refractory HyperK
Refractory Fluid Overload
Refractory/Severe metabolic acidosis
Urmeic Bleeding
Uremic Pericarditis
Uremic Encephalopathy
Symptoms are more important than the values
of urea and creatinine
Thank You!
Comments/Feedback
Lakshay Chanana (drlakshayem@gmail.com)
Twitter: @EMDidactic