1. Chronic Renal Failure GONAH + skin + neuro + GIT
Concise Long Case Approach Growth (paeds) Height/ weight
Osteodystrophy Bone pain
History Fractures
Arthritis
Presenting complaint Proximal myopathy
“I have renal failure” Nutrition Protein intake
complications Water restriction (glomerular) or excess (interstitial)
unrelated problem Electrolytes
Anemia Pallor, lethargy, fatigue
Past history SOB
first diagnosis when Hypertension treatment
presenting complaint Skin Sallow
o enquire about urinary symptoms Pruritis
frothy urine GIT NVD
0
hematuria Neuro Seizures – 2 electrolyte disturbances
oliguria/anuria/polyuria/nocturia Encephalopathy
Peripheral neuropathy
etiology:
Complications of treatment
Commonest Other Dialysis – bleeding/ infections/ occlusion
DM Renal Immunosuppressive drugs – cyclosporine/ azothioprine/ prednisolone
ask for past history Renovascular
ask for polyuria/polydipsia/polyphagia Interstitial nephritis e.g. drugs Functional – days off work/school, change of job, financial
HTN Cystic kidney diseases – family history The standard remaining history
ask NSAIDs—analgesic nephropathy
GN Pyelonephritis e.g. told of kidney
VITAMIN infection? Fever? Physical examination
Vascular – HSP – rashes/joint/abdpain Stones – loin to groin pain, previous
Infectious – strep sore throat/ HBV stones
General Ht/Wt
Toxin – gold/ penicillamine Anatomical – e.g. VUR, BPH
Cachexia
Autoimmune – SLE symptoms o
Myoclonus 2 uremia
Metabolic – DM Extrarenal o
0 Cusingoid appearance 2 steroids
1 causes SLE
Skin Sallow
systemic sclerosis
Scratch marks
myeloma
Hands/ Arms Asterixis
Leuconychia
Investigations done
Lindsay’s ½ and ½ nails (proximal white distal brown)
U/S – anatomical malformations
Palmar crease pallor
Biopsy - GN
AV fistula – thrill present is important sign of patency
Myopathy
Management
medications Face/ chest Fundoscopy – HTN/DM changes
dialysis Anemia
AV grafts Central line
Transplant/ waiting list? Tanner Staging
Rickety rosary ribs
Disease progression and Complications of disease Heart Pericardial rub
CCF
DO YOU STILL PASS URINE NOW? (GIVES AN ESTIMATION OF SEVERITY OF Bruit suggest vascular cause of CRF
RENAL FAILURE) Lungs Creps

2. Abdomen Nephrectomy scar – usu. postero-lateral Management
Transplant scar (usu iliac fossa) and transplant kidney
Kidneys ballotable, bruit Growth failure Treat all contributors to growth failure
Bladder Malnutrition – inadequate protein
Enlarged prostate Anemia
Legs Edema Osteodystrophy
Neuropathy GH resistance
PVD
Genu varum If ht<3%, velocity<50%, give rHGH tx
Other Bone and joint tenderness Osteodystrophy Low phosphate diet (eg avoid diary products)
BP Phosphate binders (CaCO3, Ca acetate)
Calcium supplements (CaCO3, Ca acetate)
Manifestations of DM, HTN, SLE Vitamin D supplementation
Nutritional If HD/PD, give recommended daily allowance + additional
protein to compensate for losses from dialysis
Investigations Fluid – fluid restriction in ESRF and fluid overload type CRF
to confirm diagnosis of CRF (eg 500ml/day, keep wt gain to <1kg/day), if salt-losing type
to determine etiology of CRF CRF, encourage H20 intake
to look for complications of CRF Na 2g/d
K usu well maintained, treat as emergency if hyperK
Diagnosis & U/E/Cr Creatinine to estimate GFR Ca gluconate
staging By MDRD study equation Insulin + dextrose
By Cockcroft-Gault formula Salbutamol
Etiology Bloods Plasma glucose Resin (Ca Resonium)
ASOT/ HBV/ ANA/ C3 Dialysis
Urine Urinalysis Low phosphate diet 800mg/day
Radiology Renal U/S – cysts Anemia Causes of Anemia
IVU – Stones Decreased EPO synthesis
MCU – if suspect anatomical abnormalities in Shortened RBC survival due to uremia
paeds Management
DMSA/ DTPA Adequate dialysis
Biopsy GN Keep >10g%
Complications Bloods FBC – Anemia Do Fe studies (Fe, ferretin, transferring, TIBC)
Serum – Ca/ PO4/ ALP/ PTH rEPO if not Fe-deficient
U/E/Cr – electrolyte imbalance Hypertension ACE-inhibitor
Radiology CXR – heart/lungs Ca++ blocker
Bone Xrays Neurological Electrolyte control
Stages of CKD (based on KDOQI guidelines from the National Kidney Foundation)
2
Stage GRF (ml/min/1.73m )
1 ≥90
2 60-89
3 30-59
4 15-29
5 = ESRD <15

3. Issues: CKD Vit D products (eg calcitriol)
A) Ca/PO4 metabolism in CKD - give if iPTH >21 or 3x normal upper limit
- contraindications: Ca- PO4 >55, PO4 >2.0 or iPTH <15 (as further suppression of iPTH
by Vit D will cause impaired bone remodeling and higher risk of fractures
Decreased renal Decreased Acidosis secondary to - monitoring of iPTH – ideally, yearly in stage 3, half yrly in stage 4, 4-6 mthly in stage 5
excretion of PO4 renal mass
+
decreased H excretion 4) Secondary hyperparathyroidism due to hyperplasia of parathyroid gland
iPTH usually >100
perform U/S or Sestamibi scan to locate PTH glds, as there may be >4. Sestamibi scan
preferred
Decreased Rx: surgical removal +/- partial reimplantation of portion of PTH gland
hydroxylation of Vit D 5) Treating hypocalcaemia
Decreased GI IV Ca Gluconate contains 2.4mmol/10ml, IV CaCl2 contains 7 mmol/10ml of calcium
Ca absorption ions
Higher risk of phlebitis with CaCl2, and also, more severe in event of extravasation.
Always give CaCl2 intra-hemodialysis, via central line, or at least via large bore cannula
Decreased if possible, unless in event of emergency.
serum Ca
Increased bone B) Anaemia in CKD
Increased iPTH osteoclastic activity Causes LVH and increase risk of cardiovascular disease
secretion Ideal target 11-11.5 g/dL, however locally, usually aim for 8g/dL in view of Rx costs.
(Note: Hb > 12.5 also a/w increased mortality)
iPTH/PO4 Work up:
iPTH and PO4 levels start rising o Fe panel – Ferritin <200 + Tsat <20% = Fe deficiency in hemodialysis
exponentially from CKD stage 3 (in peritoneal dialysis, limit for ferritin is <100)
increased PO4 levels correlates to greater Tsat = transferrin saturation = Fe ÷ transferring x100%
cardiovascular risk o Vit B12/folate
o PBF
o OGD
o +/- stool OB
Mx 1 2 3 4 5 Mx
1) Diet – first line Fe Fumarate – 400-800mg/day, give on empty stomach (eg ON)
- limit PO4 intake to 800mg/day (dietician r/v) IV venofer 100mg x 8-10 doses. CI: Ferritin >500 or Tsat >50%
2) Phosphate binders Erythropoeitin
i) CaCO3 - higher elemental Ca load, & better tasting. Therefore better for o Start if Hb <10-11. Starting dose 100unit/kg/wk (eg 6000U/wk).
calcium supplementation Monitor for 3-4 wks before increasing dose as necessary.
ii) Ca Acetate – higher phosphate binding capacity, but large and bad tasting. o Max 30,000 U/wk
Better for managing high phosphate levels o If poor response, consider possible causes
iii) MgSO4 – bad tasting, risk of Mg toxicity. Common SE of diarrhea Inflammation/infection (raised ferritin)
iv) Al(OH)3 – risk of aluminium toxicity (eg poor BP ctrl, encephalopathy), not for Malnutrition (low albumin)
use for >6wks. Secondary hyperparathyroidism
v) Seralamer – amino acid polymer. Gd for ctrl of acidosis as well, but expensive Malignancy
vi) Dialysis Aluminium toxicity
Give CaCO3/ Ca acetate between meals if trying to supplement Ca. Give with meals if ACE/ARB
trying to bind phosphate. Insufficient dialysis
Calcium-phosphate binding product = [Ca] x [PO4] Pure red cell aplasia (rare)
- if >55 (calculations in mmol), OR if [Ca] 2.50 mmol/L, avoid Ca based phosphate
binders in view of risk of metastatic calcium product deposition
Targets: CKD Stage 3-4 keep [PO4] <1.5; Stage 5 keep [PO4] <1.8
Low phosphate levels also indicate likely malnutrition, as PO4 is found in high protein
Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY,
food o=UCSI University, School of Medicine, KT-
Campus, Terengganu, ou=Internal Medicine
3) Calcium supplementation Group, email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4
CaCO3/ Ca acetate between meals students.
Date: 2009.02.22 15:45:33 +08'00'

4. CHRONIC RENAL FAILURE WITH FLUID OVERLOAD – PATHWAY Treatment Orders:
1. Diuresis with IV frusemide:
Investigations: 120-240 mg/8hrly (if serum Cr > 400 μmol/L)
• FBC--anaemia 80-120 mg/8hrly (if serum Cr < 400μmol/L)
• PT/PTT, GXM—for dialysis, transfusion If no response, step up to maximum OR infusion at 30 mg/hr
• U/E/Cr/HCO3/Glucose—renal fxn, DM Urinary catheter if no urine output > 6hrs
• HbA1c if diabetic--DM
• Ca/Phosphate/Magnesium—renal osteodystrophy 2. Exclude cardiac event
• Fasting iPTH—endocrine compx Check baseline ECG
• LFT If pt has IHD, do CK/CKMB/Trop T
Repeat ECG x3
• Fasting lipids--hyperlipidaemia
• ECG/CXR )
3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or
• ABG on room air—metab acidosis ) exclude AMI hyperkalaemia)
• CK/CKMB ) PT/PTT, GXM
• UFEME, Urine c/s If for dialysis, trace Hep/HIV status.
If results > 6mths, order HBsAg, Anti-HCV, HIV
Day 2: 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy – refer
• If Hb<11 g/dL: pharmacist and inform on cost
Fe/TIBC
Ferritin 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral
B12 / folate frusemide, consider discharge
Stool OB x3
• If Hb<6 g/dL 6. Discharge plan:
Consider OGD, transfusion, thal workup etc Fluid restriction
Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM))
Nutrition: When to seek medical help: skin turgor, pitting oedema, weakness, fatigue,
• Low salt muscle cramps, N/V
• Low protein 0.8g/kg/day Skin care
• Low phosphate Identify primary physician, appointments, home care etc.
• Low potassium
• DM 1500/1800/2000 kcal Referral Plan (Day 2 onwards):
• If Cr > 400 μmol/L
Fluids: Assess ADL (toilet needs, dressing, feeding)
• 500ml/day (if serum Cr > 400 μmol/L) If can’t do any one ADL, refer MSW
• 800ml/day (if serum Cr < 400μmol/L) If can do all, refer renal coordinator, vascular surgeon
• If Cr < 400 μmol/L, refer renal coordinator, MSW, vascular surgeon as required
• Others: pharmacist, physiotherapist, psychologist etc.
Assessment:
• Vital signs
• Height/weight
• Urine dipstick
• Pruritus
• Oedema – sites and severity Digitally signed by DR WANA HLA
• Compliance with fluid restriction SHWE
• I/O charting DN: cn=DR WANA HLA SHWE, c=MY,
o=UCSI University, School of Medicine,
• IV plug KT-Campus, Terengganu, ou=Internal
• O2 therapy Medicine Group, email=wunna.
hlashwe@gmail.com
• Urinary catheter if required Reason: This document is for UCSI year
4 students.
Date: 2009.02.22 15:43:25 +08'00'