Pathogenesis and Management of Renal Failure and Replacement Therapy for Stage V Chronic Renal Disease

dr. Heru Prasanto, Bambang Djarwoto

Sub bagian Ginjal Hipertensi, Bag Penyakit Dalam FK UGM / RSUP DR Sardjito, Yogyakarta

ACUTE RENAL FAILURE

ACUTE renal failure is characterized by a deterioration of renal function over a period of hours to days, resulting in the failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis.

The RIFLE classification of ARF is as follows:

Risk (R) - Increase in serum creatinine level X 1.5 or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours Injury (I) - Increase in serum creatinine level X 2.0 or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours Failure (F) - Increase in serum creatinine level X 3.0, decrease in GFR by 75%, or serum creatinine level > 4 mg/dL; UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours Loss (L) - Persistent ARF, complete loss of kidney function >4 wk End-stage kidney disease (E) - Loss of kidney function >3 months

Prerenal
Prerenal azotemia is rapidly reversible if the underlying cause is corrected. In the outpatient setting, vomiting, diarrhea, poor .uid intake, fever, use of diuretics, and heart failure are all common causes. Elderly patients are particularly susceptible to prerenal azotemia because of their predisposition to hypovolemia and high prevalence of renal-artery atherosclerotic disease. Among hospitalized patients, prerenal azotemia is often due to cardiac failure, liver dysfunction,or septic shock.

Etiology pre renal ARF,

hypovolemia, hypotension and hypoperfusion kidney: Severe blood loss: trauma, bleeding. Loss of plasma : combustio, peritonitis. Loss of water and electrolyte : acute gastroenteritis Hypoalbuminemia Heart failure: myocard infarct. Neonatus septic shock or severe asphyxia

Post renal Causes Acute renal failure occurs when both urinary outfow tracts are obstructed or when one tract is obstructed in a patient with a single functional kidney. Obstruction is most commonly due to prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders and often presents in the outpatient setting. A neurogenic bladder can result in functional obstruction. Other, less frequent, postrenal causes of acute failure can be intraluminal, such as bilateral renal calculi

ARF Post renal

Obstruction cause by: Congenital : valvula uretrovesical Urolithiasis Trombosis arteri/vena renalis Tumor (prostate, pelvis)

Intrinsic Causes Intrinsic renal diseases that result in acute renal failure are categorized according to the primary site of injury: tubules, interstitium, vessels, or glomerulus. Injury to the tubules is most often ischemic or toxic in origin. ischemic tubular necrosis represent when blood flow is suffciently the death of tubular cells. most cases are reversible if the underlying cause is corrected (Aminoglycoside antibiotics and radiocontrast agents, chemotherapeutic agents / cisplatin) irreversible cortical necrosis can occur if the ischemia is severe, especially if the disease process includes microvascular coagulation such as may occur with obstetrical complications, snake bites

intrinsic damage of tubule epithellial: acute tubular necrosis (ATN) Iskemic type: prolong ARF Nephrotoxic type: trombosis, hipertensi damage of glomerulus Acute Glomerulonefritis Hemolitic uremic syndrome Vascular disease: hypertension, thrombosis

Conditions That Lead to Ischemic Acute Renal Failure.

ARF Therapy

There is no consensus among nephrologists as to when to begin dialysis or how frequently to perform dialysis. Although studies that evaluated early and intensive dialysis suggested that such an approach improved survival and led to a more rapid recovery

Chronic kidney disease (CKD)

is a progressive loss of renal function over a period of months or years Five stages Each stage is a progression through an abnormally low and deteriorating glomerular filtration rate, which is usually determined indirectly by the creatinine level in blood serum

Signs and symptoms

can be detected as an increase in serum creatinine or protein in the urine.

As the kidney function decreases: Blood pressure is increased due to fluid overload and production of
vasoactive hormones leading to hypertension and congestive heart failure

Urea accumulates, azotemia / uremia

(symptoms ranging from lethargy to pericarditis and encephalopathy)

Potassium accumulates in the blood hyperkalemia Erythropoietin synthesis is decreased anemia Fluid volume overload pulmonary edema Metabolic acidosis, decreased bicarbonate by the kidney

Stage 1 CKD Slightly diminished function; Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2). Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies Stage 2 CKD Mild reduction in GFR (60-89 mL/min/1.73 m2) with kidney damage. Stage 3 CKD Moderate reduction in GFR (30-59 mL/min/1.73 m2) Stage 4 CKD Severe reduction in GFR (15-29 mL/min/1.73 m2) Stage 5 CKD Established kidney failure (GFR <15 mL/min/1.73 m2, or permanent renal replacement therapy (RRT)

Stages of Chronic Kidney Disease: A Clinical Action Plan

Stage

Description

GFR (mL/min/1.73m3)

Action

Kidney damage with normal or GFR

90

Diagnosis & Treatment, Treat comorbid condition, slowing progression, CVD risk reduction
Estimating Progression Evaluating & Treating complications Preparation for kidney replacement therapy Replacement (if uremia present)

2 3 4 5

Kidney damage with mild GFR Moderate GFR Severe GFR Kidney failure

60 89 30 59 15 29 < 15 or dialiysis

Treatment

The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to stage 5. Control of blood pressure and treatment of the original disease, whenever feasible, are the broad principles of management. Generally, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are used, as they have been found to slow the progression of CKD to stage 5.

Renal Replacement Therapy

When renal failure is severe, and about 90% of renal function is lost, a patient requires a form of renal replacement therapy to survive

a renal transplant or dialysis.

A renal transplant is the surgical placement of a kidney from a kidney donor into a patient with kidney failure.

High-risk factor in transplantation

Age Unfavorable psychological profile Unfavorable medical status
Pulmonary factors (smoking) Recurrent primary renal disease Diabetes Cardiovascular factors (unstable angina) Severe hypertension Neoplasia Chronic infection(s) Obesity

 Dialysis

hemodilysis peritoneal dialysis

is a process that cleans and filters the blood, removing harmful wastes and excess salt and fluids by passing blood across a semipermeable membrane. Wastes from the blood diffuse across the membrane into a cleansing solution (dialysate) and bicarbonate diffuses into the blood to neutralize excess acid. Dialysis can control blood pressure and help maintain a balance of electrolytes, including potassium, sodium, and chloride.

Gambar skematis dializer

Arah aliran darah

Inlet darah (merah)

Outlet darah (biru)

Arah aliran dialisat Outlet cairan dialisat Inlet cairan dialisat

Anatomy of a Hemofilter
blood in dialysate out Cross Section
hollow fiber membrane

dialysate in

Outside the Fiber (effluent) Inside the Fiber (blood)

blood out
23

Hemodialysis
can be performed at a dialysis center hemodialysis treatment is provided by trained nurses and technicians. Hemodialysis is usually performed 3 times weekly, with each treatment lasting 2 to 4 hours. Patients can read, write, sleep, talk, or watch television during treatment.

Peritoneal dialysis uses the peritoneal membrane, the lining of the abdomen, to remove excess water, wastes, and chemicals from the body. A dialysate passes through the abdomen via a surgically placed catheter. Fluid, wastes, and chemicals pass from capillaries in the peritoneal membrane into the dialysate. No machine is necessary. After 4 to 6 hours, the solution is drained back into the bag and replaced with fresh solution. The solution is usually changed 4 times a day.