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 A T I O N

D E PA 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 TA N

Clinical Investigation of CRF patient:

• Blood urea is raised.

• Serum creatinine (50%).

• Electrolytes: Hyponatremia, Hyperkalemia (endstage), hypocalcemia, hyperphosphatemia.

• Creatinine clearance is low. Normal(80-140ml/min).

• U/S: renal size<10cm.

• Renal biopsy

• Urine analysis: protienuria, hematuria, renal casts.

Management of CRF patient:

• Dietary modifications.

• Treatment of complications.

• Dialysis.

• Renal transplantation.

DIET

• Protein restriction: 0.6-1g/kg. (dialysis).

• Potassium restriction: <60mEq/d when GFR <10-

20ml/min. foods.

• Phosphorus restriction: below 4.5mg/dl. Avoid meat,

milk and egss. More carbohydrate and fat.

• Salt and water: 2-3L/d

• Sodium: avoid in patients of HTN, HF and edema.

MANAGEMENT OF COMPLICATIONS

• Anemia: GFR below 20-25ml/min due to:

• Reduced erythropoietin.

• Reduced RBC survival.

• BM depression.

• Reduced iron intake due to anorexia.

MANAGEMENT OF COMPLICATIONS

• Management of Anemia:

• Start treatment when Hct <30%.

• Rule out other causes of anemia.

• Inj. Erythropoietin 20-50units/kg s/c 3times/week.

• HTN is the side effect of Erythropoietin.

MANAGEMENT OF COMPLICATIONS

Hypertension (HTN): due to:

• Salt and water retention.

• Hyper-reninemia.

• Sympathetic over activity.

• Glomerular disease is more associated with HTN.

MANAGEMENT OF COMPLICATIONS

• Management of Hypertension (HTN):

• Salt restriction.

• Loop diuretics 40-400mg/d

• ACE inhibitors: but avoid in hyperkalemia and SCr>3mg/dl.

• CCBs are usually used.

• Beta-blockers may be used.

• Dialysis.

MANAGEMENT OF COMPLICATIONS

Hyperkalemia (K+ >4.9mEq/l) when GFR <l0ml/min.

• Absent until endstage due to adaptive mechanisms.

Predisposing factors: Exogenous: K-sparing diuretics,

ACE-Is, NSAIDs, and betablockers.

Endogenous: hemolysis, trauma and infection.

MANAGEMENT OF COMPLICATIONS

Manifestations of Hyperkalemia:

• Muscle weakness.

• Muscle paralysis.

• Irritability.

• Cardiac arrhythmias (>6meq/l): Prolonged PR-interval,

Peaked P-waves, short QT-interval.

MANAGEMENT OF COMPLICATIONS

Management of Hyperkalemia:

• Dietary restriction of K+.

• Avoid drugs that cause hyperkalemia.

MANAGEMENT OF COMPLICATIONS

Prevention of cardiac arrhythmias:

• Inj. Calcium gluconate 10ml iv over 2-3 mins.

• Onset: 2-3 mins, duration: 30-60mins.

• The second dose is is given if there is no any change

in the ECG.

• If bradycardia occurs then the injection should be

stopped.

MANAGEMENT OF COMPLICATIONS

Shift K+ intracellularly:

• Regular insulin 10 units iv + 50ml 50% glucose iv over five minutes.

• Onset 30mins, duration: 4-6 hours.

• Sodium bicarbonate.

• Beta-2 agonist.