Chronic renal failure (CRF) is a progressive deterioration of renal function that ends in uremia and its complications, which can lead to death unless dialysis is begun or a transplant is performed. Chronic renal failure develops in three major stages that progress from the decreased renal reserve, to renal insufficiency, and finally to irreversible renal failure. The following are the common causes of renal failure.
Causes of renal failure
Collagen-related disorders
- Hypertrophy/hypoplasia
- Systemic lupus erythematosus
- Polyarteritis nodosa
- Progressive systemic sclerosis
- Metabolic disorders
- Diabetes mellitus
- Urate nephropathy
- Chronic urinary tract infections
- Oxalate nephropathy
- Amyloidosis
Congenital defects
- Polycystic kidney disease
- Renal tubular acidosis
- Alport’s syndrome
- Medullary cystic disease
- Obstructive nephropathy
- Ureteral or urethral strictures
- Calculi
- Neoplasms
- Retroperitoneal fibrosis or tumours
- Prostatic disease
- Congenital anomalies
- Glomerular diseases
- Glomerulonephritis
- Acute nephrotic syndrome
- Tubular damage
- Hereditary cellular membrane defects
- Chronic electrolyte imbalances (proximal and distal tubular acidosis, hypokalemia nephropathy, calcium nephropathy) disorders
- Infectious disorders
- Reflux chronic nephritis
- Analgesic nephropathy
- Idiopathic disorders
Vascular problems
- Sclerosis and narrowing of the afferent and efferent arterioles and glomerular capillaries
- Nephrosclerosis
- Renal artery sclerosis
- Hypertension
Symptoms of impending kidney disease are often deceptively mild in comparison to the potential severity of the disorder. In CRF, the parenchymal cellular function is slowly lost. All function of one kidney and two-thirds of the other may be gone before signs and symptoms appear.
Renal function is evaluated by the GFR, which indicates the amount of a substance cleared from the blood in one minute. When the GFR begins to fall and the BUN and creatinine levels rise, there is a tendency toward rapid progression to end-stage renal failure.
The clinical manifestations of CRF can be described as uraemia. The term uraemia describes a number of complex symptoms resulting from the accumulation of toxins in the blood because of a decline in renal function. In advanced uraemia, some functions of virtually every organ system in the body may become abnormal.
Clinical manifestation of uraemia
Cardiopulmonary system
- Hypertension
- Pericarditis
- Congestive heart failure
- Pulmonary edema
- Dysrhythmias
Neurologic system
- Fatigue
- Lethargy
- Muscular irritability
- Peripheral neuropathology
- Seizures
- Mental confusion
- Coma
Dermatologic system
- Pallor
- Hyperpigmentation
- Pruritis
- Ecchymosis
- Dry skin
- Uraemic frost
Metabolic system
- Protein intolerance
- Carbohydrate hyperglycemia
- Hyperlipidemia
- Gastrointestinal system
- Anorexia
- Nausea
- Vomiting
- Urinous breath
- Gastritis
- Gastrointestinal bleeding
- Diarrhea
- Peptic ulcers
Reproductive system
- Sexual dysfunction
- Menorrhagia
- Amenorrhea
- Infertility
- Decreased libido
- Decreased testosterone
Hematologic system
- Anaemia
- Hemolysis
- Bleeding tendencies
- Decreased resistance to infection
Skeletal system
- Pathologic fractures
- Bone inflammation
- Osteitis fibrosa
- Osteomalacia
Evaluation of CRF is based on the history and presenting signs and symptoms. Ultrasound, IVP, renal angiography, or scan and imaging tests are used to evaluate renal abnormalities. Renal biopsy can confirm a diagnosis. Blood tests may include a complete blood count, evaluation of blood gases, serum protein, BUN, creatinine, and uric acid levels.
The treatment for CRF has two stages. The first stage consists of conservative measures that include reducing symptoms, preventing complications, and controlling problems. Conservative measures include
- Determining and treating the cause of the renal failure; maintaining salt and water balance;
- Correcting any urinary tract obstruction;
- Detecting and treating infections early;
- Controlling hypertension;
- Consuming a low protein, high calorie diet;
- Preventing and treating renal bone disease;
- Modifying drug therapy with alterations in renal function; and
- Detecting and treating complications (eg, hyperkalemia, anemia, metabolic acidosis, hyperthyroidism.
These conservative measures help to delay the progressive deterioration of renal function. For example, hypertension must be treated, salt and water intake controlled, urine output maintained at as high a level as possible, and protein intake reduced to keep down the level of urea in the blood. The second stage of CRF begins when conservative measures are no longer effective. Then, the only treatments are either dialysis or transplantation.
Management
The clinical management of the patient with progressive renal failure may be divided into several components:
- Early recognition of renal failure;
- Monitoring the progression of renal failure;
- Detection and correction of reversible causes of renal failure;
- Institution of interventions to delay progression of renal failure;
- Avoidance of additional renal injury;
- Treatment of complications (ie, acid-base, mineral, and fluid-electrolyte abnormalities) of renal failure; and
- Planning ahead for renal replacement therapy (dialysis or transplantation).