Stages of Dehydration

Acute Renal Failure (ARF)

• In the oliguric stage, if the patient does not receive sufficient fluid, dehydration, hypotension, and electrolyte disturbance become manifested.
• Clinical manifestations of ARF include: • Generalized muscle weakness • Hypotonia • Weak or loss of deep reflex • Arrhythmia • Acute renal failure
• Prognosis of ARF is good with complete recovery if detected early and received proper medical treatment, but can progress to Chronic Renal Failure (CRF) or even death from complications.

Recovery Stage of ARF

• In this stage, urine volume returns to normal gradually with normal specific gravity.
• Kidney functions and serum electrolyte return to normal values.
• Complete recovery from previous clinical manifestations and restoration of wellbeing occur.

Investigations of ARF

• Urine analysis may be helpful to differentiate between pre-renal and renal causes of ARF.
• Parameters include urine specific gravity, proteinuria, and casts (broad cell casts are characteristic to CRF).

Treatment of ARF

• Treatment of hyperkalemia: • Cardiac monitoring • Insulin and glucose infusion • Sodium polystyrene sulfonate • Calcium gluconate
• Treatment of acidosis: • Sodium bicarbonate I.V.
• Treatment of hyperphosphatemia: • Phosphate binders
• Dialysis is indicated in: • Uraemic coma not responding to medical treatment • Serum K > 7mEq/L • Serum bicarbonate < 12mEq/L • Arterial pH < 7.15 • Prolonged oliguric stage with daily rapid rise of blood urea and serum creatinine

Chronic Renal Failure (CRF)

Clinical Picture of CRF

• Clinical manifestations of CRF include: • Respiratory manifestations:
  • Rapid deep breathing (Kussmaul's breathing)
  • Pulmonary edema
  • Pleurisy and pleural effusion • GIT manifestations:
  • Dry mouth
  • Unpleasant taste
  • Uremic (ammoniacal) odor
  • Anorexia
  • Nausea
  • Vomiting • Cardiovascular manifestations:
  • Hypertension
  • Cardiac arrhythmia
  • Uremic cardiomyopathy
  • Coronary heart disease • Urinary manifestations:
  • Water disorders • Genital manifestations:
    • Male: Impotence, infertility
    • Female: Amenorrhea, infertility • Skin manifestations:
  • Uremic frost • Ocular manifestations:
  • Uremic retinopathy • Metabolic manifestations:
  • Hypoglycemia due to decrease renal clearance of insulin
  • Impaired glucose tolerance due to insulin resistance • Dialysis complications • Skeletal manifestations:
    • Osteodystrophy

Investigations of CRF

• GFR assessed by creatinine clearance
• Biochemical changes: • Increase serum creatinine and blood urea • Increase alkaline phosphate
• Blood picture: Anemia may occur
• Skeletal survey for 2ry hypertension
• Plain x-ray and abdominal U/S to detect complications

Treatment of CRF

• TTT of the cause
• Rest and adequate sleep
• Diet control: • Protein restriction to 0.5 gm/Kg/day • Carbohydrates to supply enough caloric requirements • Fat restriction to correct hyperlipidemia • Caloric intake: 35 Kcal/Kg/day • Salt restriction • Sufficient fluid intake: 2-3 L/day • K-rich diet
• Correct electrolyte imbalance: • Na deficient: 1-2 gm/day • K restriction in hyperkalemia • Ca supplementation • Decrease P04 supplement
• Symptomatic treatment: • Hypertension • Anemia • Heart failure • Osteodystrophy

Anemia in Chronic Renal Failure

Etiology of Anemia in CRF

• All types of anemia can occur
• Erythropoietin decrease
• Bone marrow depression by toxins
• Hemolytic anemia due to toxins
• Fe decrease due to anorexia
• Blood loss
• Bone marrow fibrosis due to aluminum toxicity in patients on dialysis
• Dilutional anemia

Clinical Picture of Anemia in CRF

• Pallor
• Fatigue
• Intolerance to cold
• Anorexia
• Dyspnea on exertion
• Palpitation
• Angina pectoris
• Depression
• Cognitive deterioration
• Drowsiness
• Sleep disturbance
• Sexual dysfunction
• Blurred vision

Management of Anemia in CRF

• Efficient dialysis
• Iron and folate supplementation
• Blood transfusion (rarely)
• EPREX (Recombinant Human Erythropoietin): • Indications: Absolute or relative deficiency of erythropoietin • Regimen: Initial dose varies from 50-150 U/Kg/week • Maintenance dose: Target hemoglobin level is 10-12 gm/dl • Iron supplementation is essential with EPREX • Advantages: No need for blood transfusion, improvement of quality of life, cardiovascular performance, and sexual potency • Side effects: Flu-like syndrome, high cost, elevation of blood pressure, and rare thrombosis