NEPHROLOGY

 

ACUTE  RENAL FAILURE

    

     Even when 90% of the nephrons are destroyed , the kidney function is yet normal.

 

 In hypovolumia or shock if prolonged , acute Tubular Necrosis develops and less than 500 ml of urine is passed daily.

 

Vomiting rids the body of  Potassium ( decreases Hyperkalaemia ) and sodium,

 

BP rises in an attempt to increase renal perfusion ,

 

Anorexia ensures low protein input and thereby decreasing production of  Blood urea nitrogen.

 

Eventually gradual  increase in urine output occurs and diuretic phase may develop which reduces the retained sodium, potassium and urea.

 

Outcome is not decided by the Renal failure but by the underlying cause.

 

No treatment as yet is known to reduce the duration of Acute Tubular Necrosis.

 

 

CHRONIC RENAL FAILURE

 

i)                     It is an irreversible deterioration of renal function . It is apparent only after GFR ( Glomerular Filtration Rate ) falls from 120 ml / min to 20ml / min . The skin takes over and excretes the increased Urea, etc in the sweat.

 

ii)                   Metabolic Acidosis resulting from diminished excretion of acids is compensated by the loss of chloride ions in vomiting or sweating.

 

iii)                  Increased nitrogenous excretion occurs via diarrhoea.

 

iv)                  There is hyper secretion of Renin Angiotenin, Aldosterone system which could be considered beneficial to renal perfusion.

 

v)                    Mobility and Exercise in the patient helps to preserve muscle mass, decreased Nitrogen production and encourage carbohydrate metabolism.

 

vi)                  Osteomalacia - The decreased production of active Vitamin D causes a decrease in Serum Calcium as bone is eroded. The phosphorous retention by the Kidney and the decreased Calcium indirectly stimulates the Parathyroid gland and PTH secretion and raises Serum Calcium to counter the fall in calcium. Ultimately hyperplasia of Parathyroid gland occur and increase calcium annd increase Bone density and counteracts the Osteomalacia. Initially PTH increase erodes bone later PTH hyperplasia densifies the bone.

 

vii)                 Polyuria serves to increase BUN and toxic excretion.

Raised Urea and Creatinine (uptoCrn 14, BUN 200) can be tolerated by the body and are not necessarily toxic to the body.

 

URINARY TRACT OBSTRUCTION

 

Usually renal calculi settle comfortably in renal pelvis and most often causing incomplete obstruction and not interfering with the flow.

 

If they get impacted in the ureter, they are almost always passed via strong ureteric contraction called renal colic which usually subside within 2 hours.

 

A calculus takes about 3 years to form and may remain asymptomatic for years together.

 

Stones less than 0.5 cm pass spontaneously and larger stones stay comfortably in the Renal pelvis.

 

RENAL TRANSPLANTATION

 

Is usually performed in Chronic Renal Failure where GFR has fallen radically as shown below :

 

                     GFR                      CRN                               

NORMAL   ( 150ml/min)         1mg%                                  

                        50                      2mg%                                   

        10                      6                                     

         2                       16                                  

 

Complications in CRF  develop when creatinine reaches 8- 10 mg %.

 

Transplantation is via  a compatible Kidney graft and has a 90 % patient survival for 3 years

 

Long term Immunosuppressants are required and these are themselves nephrotoxic . Immunosuppressants cause opportunistic infection and 50 % patients develop skin cancer.

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