chronic renal failure lec 3

DISORDERS OF THE

URINARY SYSTEM

CHRONIC R

ENAL

FAIL

URE

DR. ASMATULLAH SAPAND

A H M A D S H A H A B D A L I I N S T U T U T E O F H I G H E R E D U C AT I O N D E P A R T M E N T O F I N T E R N A L M E D I C I N E K H O S T - A F G H A N I S T A N

10 . 05 . 2 016

MANAGEMENT OF COMPLICATIONS

RENAL OSTEODYSTROPHY:• This is the term used for various forms of bone

disease that develop in chronic renal failure i.e. Osteomalacia, Osteoporosis, Secondary Hyperparathyroid Bone Disease And Osteosclerosis.

MANAGEMENT OF COMPLICATIONS

1. OSTEOMALACIA:• Deficiency of 1,25 dihydroxy

cholecalciferol(active-vit.D).• Low vitamin D results in decreased calcium

intestinal absorption(hypocalcemia).• Hypocalcemia results in reduction of osteoid

calcification and finally Osteomalacia.

MANAGEMENT OF COMPLICATIONS

2. HYPERPARATHYROID BONE DISIEASE:• Low serum calcium causes PTH secretion from

the parathyroid gland(secondary hyperparathyroidism)

• Resorption of calcium from bone.• Formation of cysts within the bone(osteitis

fibrosa cystica).

MANAGEMENT OF COMPLICATIONS

3. OSTEOPOROSIS: causes from malnutrition in chronic renal failure.

4. OSTEOSCLEROSIS: cause is unknown and occurs in sacrum, base of the scull and vertebrae.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

• GFR below 25% of normal results in low phosphate excretion(hyperphosphatemia)

• Hyperphosphatemia results in hypocalcemia due to deposition of calcium phosphate in bone.

• Hypocalcemia results in secondary hyperparathyroidism and its consequences.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

Clinical features:• Bone pain, proximal muscle weakness, fractures,

pruritus and extra-skeletal calcification. Treatment:• Treatment should be started early in the course of

progressive renal failure.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

Goal of Treatment:1. To maintain serum calcium and phosphate.2. To prevent hyperparathyroidism.3. To prevent extra-skeletal calcification.4. To maintain normal bone histology.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

Correction of Hyperphosphatemia and secondary hyperparathyriodism:

1. Dietary restriction of Phosphate2. Use of Phosphate binding agents

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

6. Dietary restriction of Phosphate:• Dietary restriction of phosphate is advised when

GFR falls below 50ml/min.• Goal is to maintain phosphorous level between

4-5mg/dl.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

6. Use of Phosphate binding agents:• Calcium carbonate 500mg-2g orally with meal.• If phosphorous level cannot be maintained between

4-5mg/dl or the initial phosphorous level is >7mg/dl then Aluminium hydroxide 15-30ml is used with meals.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

Treatment of hypocalcemia:• If hypocalcemia persists after phosphate has been

controlled, Vit.D3 may be added.• Alfacalcidol 0.25mcg/day.• Note: vitamin D increases gut phosphorous absorption

and may therefore exacerbate hyperphosphatemia.

MANAGEMENT OF COMPLICATIONS

5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:

Indications of parathyroidectomy:• Calciphylaxis.• Severe hypercalcemia.• High PTH level.

THANK YOU