Journal club.......

for dept of physiology JNMC @ aditya

Assessment of reversible risk factors causing

acute-on-chronic renal failureN Nand*, M Shrama**, H Kumar***

Prity Mehta****PGIMS, Rohtak - 124 001,

Haryana.

Journal, Indian Academy of Clinical Medicine l Vol. 13, No. 3 l July-September, 2012

By………. RAMESH NAYAK………

28/03/2014

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Contents:1.Introduction2.Objectives3.Material And Methods4.Results5.Discussion6.Conclusion7.Critical Appraisal

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Functions of kidney

1. Excretory function

2. Regulatory function

3.Endocrine function

4.Metabolic function

HOMEOSTASIS

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Renal failure

a)Acute b)Chronic

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a. Acute Renal Failure

- abrupt in onset and reversible

- AZOTEMIA most common . indicator

- Depending upon the cause . 3 types: Prerenal Postrenal Renal

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b. Chronic Renal Failure

- progressive and represents irreversible kidney structural damage.

- signs and symptoms occur gradually kidney has amazing compensatory ability.

- characterized by GFR reduction, reflects reduction in the number of functional nephrons.

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Stages of progression of CRF:

1. Diminished Renal

Reserve

2. Renal Insufficiency

3. Renal Failure and

4. End-Stage Renal

Disease(ESRD)

CKDSTAGE 1

CKDSTAGE 2

CKDSTAGE 3

CKDSTAGE 4

eGFRmL/min ≤50% ≤(50-20)% ≤20% ≤5%

serum BUN & creatinine levels still normal.

No symptoms seen.

earliest symptom isosthenuria

azotemia, anemia & hypertensionbegin to appear.

kidneys cannot regulate volume & solute composition

edema, metabolic acidosis &hyperkalemia develop.

uremia may ensue with neurologic,GI and CV manifestation

Histologically reduction in renal capillaries.

Atrophy and fibrosis in tubules.

kidney mass usually reduced.

TO,1. Diminished Renal

Reserve

2. Renal Insufficiency

3. Renal Failure and

4. End-Stage Renal

Disease(ESRD)

CKDSTAGE 1

≤50%

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Manifestations of CRF:

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ACUTE-ON-CHRONIC RENAL FAILURE

Any sudden decline in renal functions in patients with known chronic kidney disease

Each episode of acute attack - can be attributed to - one or more reversible risk factors.

Various reversible risk factor contributing to acute-on-chronic renal failure are: Volume depletion Urinary tract obstruction Infection Hypotension Electrolyte imbalance Accelerated hypertension Nephrotoxic drugs

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Renal function tests:

1. Urine analysis (physical, chemical and microscopic examination)

2. Blood analysis (blood urea, plasma creatinine, serum protein, cholesterol and . electrolyte)

3. Renal clearance tests (to measure GFR and RBF)

4. Radiology and renal imaging

5. Renal biopsy

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Management of renal failure:

1) Conservative management - preventing deterioration of remaining renal function and

- helps the body in compensating for the existing impairment.

2) Renal replacement therapy - Dialysis and

- Renal transplantation

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Dialysis.

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Assessment of reversible risk factors causingacute-on-chronic renal failure

1.PREVALENCE:

ESRD reached epidemic proportions – treatment becoming an unbearable health care burden.

conservative estimate of ESRD burden - population of 1.1 billion - around 1,650,000 people develop ESRD in india annually.

Taking conservative approach, if all patients were to be treated - cost burden over $6.5 billion annually - health care budget for all of India $3.5 billion.

QUEST india | DaVita’s Clinical Journal for Nephrologists July 2007 Issue 9 By H. Sudarshan Ballal, M.D.

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2.Introduction Any sudden decline in renal functions in patients with known chronic kidney disease (CKD)

Each episode of acute attack can be attributed to one or more reversible risk factors.

Timely management - renal function brought back to basal level- preventing from ESRD - reducing the cost of renal replacement therapy.

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3.OBJECTIVE:

- Evaluate risk factors - their degree of reversibility - in cases of acute-on-chronic renal failure

admitted to a tertiary care hospital, over a period of one year, i.e., from November, 2006 to October, 2007.

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4.MATERIAL AND METHODS:

MATERIAL:

The study included 100 cases of acute-on-chronic renal failure mean age of (48.69 ± 16.02) years. 62 men and 38 women.

The diagnosis of acute-on-chronic renal failure was based on , patients with CRD - presenting with sign and symptoms of acute renal failure or - who presented with

0.5 mg/dl, if baseline serum creatinine was < 3 mg/dl

rise in serum creatinine of

1 mg/dl, if baseline was > 3 mg/dl with in one week period.

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METHODS:

admitted in the ward - average period of 14.62 days (range: 9 to 24 days) . - managed conservatively following thorough clinical evaluation and investigations.

Specific management of reversible factor(s) and haemodialysis, whereever needed was also done.

Observations of various parameters were recorded at baseline and subsequently at 1 week and 2 week periods which included 24-hour urine volume, blood urea, serum creatinine, and creatinine clearance.

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To compare the degree of reversibility, the patients were divided into 4 groups depending upon their GFR;

GFR (30 - 59 )ml/min group 3 GFR (15 - 29 )ml/min group 4 GFR (5 – 15) ml/min group 5a and GFR < 5 ml/min group 5b.

Reversibility of these parameters was then statistically analysed.

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5.RESULTS : Majority of patients were found to have more than one reversible risk factor Average being 2.62 (ranging . from 1to 4)

however, only one factor was taken as the major factor depending upon the clinical situation.

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Table II depicts degree of reversibility in patients having specific aggravating factors

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Maximum reversibility was found in patients in stage 4 and least in stage 5b .

GFR (30 - 59 )ml/min group 3 GFR (15 - 29 )ml/min group 4 GFR (5 – 15) ml/min group 5a GFR < 5 ml/min group 5b.

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6.DISCUSSION:

Patients presenting in severe uraemic state - not suffering from end-stage renal . disease; rather – had significant degree of reversibility of renal function . study showed, majority of patients were having more than one reversible risk factor (average 2.62).

Conservative management + haemodialysis and correction of reversible risk factor(s) , resulted in significant improvement in mean creatinine clearance after 2 weeks of follow-up. proved better chances of reversibility even in patient with stage 3 and . stage 4 of CRF.

However, in the earlier studies, the net degree of reversibility was found to be low – probably because the patients included were of advanced renal failure (creatinine clearance < 15 ml/min)

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a)Sepsis

Most common and major factor infecting urinary tract, identified in the present study.

Established that patients with CKD - increased risk of sepsis - causes acute deterioration of renal function. (which is due to renal vasoconstriction caused by endothelin )

However the most common site of infection in previous studies was found to be different by different investigators.

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b)Accelerated Hypertension

Found to be major factor in 19 patients and had lower degree of reversibility, although it was statistically significant.

Causes mucoid intimal proliferation and fibrinoid necrosis in renal vasculature which is irreversible.

It was observed by many investigators that patients presenting with acute-on-chronic renal failure had a poor outcome due to accelerated hypertension.

While others observed that with long term control of blood pressure, renal function recovers sufficiently to allow for withdrawal of dialysis.

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c)Volume depletion

was found to be a major factor in 10 patients with maximum degree of reversibility,

whereas patients who had hypotension along with volume depletion had a lower degree of reversibility.

Results of heart failure and bleeding were not statistically significant because number of observation was less than 5.

Mc Innes observed that patients with pre-renal failure had 60% recovery, whereas patients with intrinsic renal failure had 48% mortality.

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d)Electrolyte disturbance

• Salt depletion - aggravating factor & found hyponatraemia - most common electrolyte disturbance

• Burkhard - hyponatraemia was the most common electrolyte imbalance

It was not a strong predictor of renal function decline Hypernatraemia was found to be a stronger predictor.

• Hyponatraemia - most common electrolyte disturbance in the present study - found minimum degree of reversibility in patients with electrolyte disturbance

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e)Obstructive uropathy

Many investigators have observed good reversibility of renal function on release of obstruction.

However, Mc Innes found poor outcome in these patients which was probably due to malignant disease in the pelvis.

In this study, 14 patients had obstructive uropathy as a major cause, . and it was second most reversible factor.

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7.CONCLUSION

On the basis of results of the present study it can be concluded that: - Patients presenting in a severe uraemic state may not be suffering from ESRD and each patient should be investigated for the presence of reversible risk factor(s). so that * renal function can be restored and * the need of renal replacement therapy can be . delayed.

- Volume depletion and urinary tract infection were found to be the most reversible aggravating factors observed by the study.

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8.CRITICAL APPRAISAL

• Type of study not mentioned.

• Place where study done, not mentioned clearly.

• Basis of inclusion criteria not explained.

• Method of statistical analysis not mentioned.

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Refrences:

Medical Physiology by Indu Khurana

Pathophysiology (Concepts of altered health status) by Carol Mattson

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Thank You…………….