Chronic Renal Failure

Pathophysiology of Chronic Renal Failure: [4,6] The exact pathogenesis of the clinical syndrome of uraemia is unknown. The pathophysiology of uraemic syndrome is attributable to accumulation of products of protein metabolism and loss of other renal functions such as fluid and electrolyte homeostasis and synthesis of certain hormones (1,25 – dihydroxy cholecalciferol). [5] The various uremic toxins [7] are byproducts of protein and aminoacid metabolism such as urea, guanido compounds, methyl guanidines, urates, hippurates, end-products of aromatic amino acid metabolism and other nitrogenous substances, inhibitors of ligand protein binding, glucurono conjugates and inhibitors of somatomedin and insulin action. The pathophysiology has been explained based on two hypothesis. They are as follows:

DECLARATION I Dr. C. VASUDEVAN declare that, I carried out this work on, “ THYROID DYSFUNCTION IN CHRONIC RENAL FAILURE ” at the Department of Medicine, Govt. Rajaji Hospital during the period of August 2008 to October 2009. I also declare that this bonafide work or a part of this work was not submitted by me or any others for any award, degree, diploma to any other University, Board either in India or abroad.

Apart from his study, various studies conducted in this line have showed different results. In our study, patients only on conservative management were studied. This is because thyroid profile undergoes changes due to dialysis independent of that due to chronic renal failure. Dialysis also changes the previous serum status of thyroid hormone in the patients with renal failure. Many studies have conducted by comparing CRF patients conservative Management and Hemodialysis by Ramirez 42 and kayima et al 29 .

Urea Metabolism in Chronic Renal Failure Mackenzie Walser J Clin Invest. 1974;53(5):1385-1392. https://doi.org/10.1172/JCI107687. Urea degradation was measured during 16 experiments in 13 chronic uremic patients being treated with essential amino acids or their analogues. [ 14 C]Urea was injected i.v. and the clearance of labeled urea from its volume of distribution was compared with the

49 RESULTS OF STUDY A cross sectional observational study was carried out in government Rajaji hospital from February 2017 to August 2017. 60 patients were included in the study after an informed consent was obtained. Patients included in study were divided into two groups. Study group were people with chronic renal failure age between 18 to 50 years male and 18 to 45 years female . Control group were people were apparently healthy individuals without chronic renal failure age between 18 to 50 years male and 18 to 45 years female. History and clinical examination was taken for each patients. Then X ray right hand AP view taken and axial skeletal survey done . Relevant laboratory investigations were done. Metacarpocortical index was calculated from X ray right hand and it was statistically analysed with other laboratory parameters and results were obtained. The statistical results of the study of the 60 patients were summarised as follows :

METHODS This was an observational study which was carried out in patients attending the nephrology department of our hospital Dr D.Y. Patil Medical College and Hospital, Pimpri, Pune diagnosed with chronic renal failure during July 2017 to July 2019. The study was conducted after getting required clearance from Institutional ethical committee. 50 patients diagnosed with chronic kidney disease, attending nephrology clinic were examined based on the inclusion and exclusion criteria mentioned below.

In uraemia the action of thyroid hormones at nuclear level are not compromised. Recent study showed increased receptor expression to preserve tissue Euthryroidism 52 . DIAGNOSIS OF PRIMARY THYROID DISEASES IN CRF Recent studies have shown the prevalence of hypothyroidism is increased in chronic renal failure, and also several clinical features of both hypothyroidism and chronic renal failure are similar, so differentiating both the conditions on clinical background is less likely. Hence, all the CRF patients with symptoms of

Anemia can develop in the early stages of kidney disease and get worse as renal disease progresses. Nearly all patients in end stage renal disease (the point where dialysis becomes necessary) have anemia (Zarychanski & Houston2008 ) . In addition to the well known symptoms of fatigue, dizziness, and shortness of breath, anemia has been associated with more severe adverse outcomes, such as cardiovascular complications including left ventricular hypertrophy and congestive heart failure. Hypoxia caused by anemia stimulates the renin-angiotensin- aldosterone system and contributes to renal vasoconstriction. These factors further exacerbate proteinuria by increasing protein in the renal tubules in patients with renal failure(Al-Khoury et al. 2007) Other general complications associated with anemia include reduced cognitive function and mental acuity, impaired quality of life, and the need for blood transfusions(Scortegag M et al. 2005) .Meaning that anemia in chronic renal failure reacquired for a good management , the main stimulus for anamia is by secretion of erythropotien the primary stimulus for production of EPO is hypoxia ,a deficiency in tissue oxygen levels increases the activity of hypoxia- inducible factor 2a, which binds to hypoxia-responsive elements locate in the enhancer region of the EPO gene in order to activate transcription( Karine et al. 2011) .The analysis of data in this study revealed that the level of erythropoiten in patients with chronic renal failure are higher than in control but this elevation are insufficient to correct anaemia either due to insufficient secretion of erythropoietin level secretion from damaged kidney tissue or due to erythropoietin resistance this conclusion conferred by another study which indicated that the high EPO levels in patients with are inappropriately low for the degree of anemia (KDIGO 2012) .These data indicate that in CKD, there is a relative EPO deficiency as well as resistance of bone marrow to endogenous EPO.

In patients with chronic renal failure, NaHCO3 therapy may correct or prevent acidemia. It has been proposed that the NaHCO3 required will not result in clinically significant Na retention comparable to that from similar increases in NaC1 intake. In each of ten patients with chronic renal failure, creatinine clearance (Ccr) range 2.5-16.8 ml/min, on an estimated 10-meq Na and C1 diet, electrolyte excretion was compared on NaHCO3 vs NaC1

Few data describe the natural history of renal func- tion in unselected populations. A population-based cohort study found two thirds of normal elderly peo- ple to have a decline in GFR averaging 0.75 mL/min yearly. 24 One third of hypertensive men lose renal function over 7 years. 25 Combined data from popu- lation surveys, clinical trials, and the United States renal failure register suggest that 5% of hypertensive patients with elevated creatinine levels will require dialysis. 26 Of a large group with chronic renal failure of various causes in a clinical trial, 85% suffered pro- gressive loss of GFR at an average of 4 mL/min yearly. 27 Finally, overt diabetic nephropathy can prog- ress at 10 to 12 mL/min yearly when hypertension is untreated. 28

ABSTRACT Aim: To make comparative evaluation of objective oral clinical findings and subjective oral symptoms in patients with chronic renal failure (CRF) undergoing various therapeutic treatments, and to find possible link between subjective symptoms and objective clinical findings. Material and methods: We examined 90 patients with chronic renal failure divided into three groups: patients with CRF undergoing hemodialysis, patients with CRF without hemodialysis and serum creatinine <120μmol / L and patients with renal transplantation. Swab for Candida Albicans was taken from the oral mucosa. Oral changes were followed on the entire mucosal surface of the oral cavity and were classified into subjective and objective findings. Results: Certain oral changes showed a predisposition to a particular group of patients, such as petechiae and ecchymoses in the dialysis group and gingival enlargement in transplant group. Coated tongue, thirst, pale oral mucosa and dry fissured lips were the most frequent oral symptoms and changes among all CRF patients independently in which group they have belonged. Significant association was found between xerostomia and coated tongue and between unpleasant taste and coated tongue in all studied patients. Conclusion: The stadium and consequently severity of chronic renal disease as well as the type of treatment have influence on the severity of the oral clinical finding.

PATHOGENESIS OF ANAEMIA IN CHRONIC RENAL FAILURE CHARACTERISTICS OF ANAEMIA IN CHRONIC RENAL FAILURE The peripheral blood film from a uraemic patient usually shows a normochromic normocytic anaemia, occasionally with fragmented red cells or burr cells. The reticulocyte count is usually low for degree of anaemia although white cell count is usually normal 31 . There may be reduced, normal, or increased cellularity of the bone marrow and the erythroid : myeloid ratio may be decreased. But hyperplasia of the erythroid marrow is insufficient to compensate for anaemia present. There is reduced red cell mass but normal total blood volume except in patients who are fluid overloaded. Also a reduction in red cell life span contributes. Factors suggested as contributors to the shortened red cell survival include blood loss, toxic haemolysis and hypersplenism. The depression in erythropoiesis is explained by relative erythropoietin deficiency, the effect of uraemic inhibitors, iron or folate deficiency, aluminum toxicity, and marrow fibrosis resulting from hyperparathyroidism.

Significant pruritus affects 15 – 49% of patients with chronic renal failure. Pruritus more commonly begins approximately 6 months after initiation of dialysis and typically increases with the length of time on dialysis. It has no consistent association with age, sex, race or precipitating disease. Pruritus may be episodic or constant, localized or generalized and mild or severe. The axillae, scalp, nose and ears are the most frequent areas of pruritus. When localized, the forearms and upper back predominantly are affected 2 . Pruritus often worsens at bedtime. Pruritus is not a feature of acute renal failure. For about 25% of the patients with pruritus, it occurs only during or soon after dialysis and it is more severe at these times for an additional 42% of the patients. 8

It has been suggested that a sustained rise in resting levels of cytosolic calcium [Ca2+]i of pancreatic islets is responsible for impaired insulin secretion in chronic renal failure (CR[r]

a practical approach Received: 22 September 2003 / Revised: 22 June 2004 / Accepted: 24 June 2004 / Published online: 21 October 2004 IPNA 2004 Abstract The prevention of systemic viral and bacterial infections by effective vaccination represents an essential task of pediatric nephrologists caring for children with chronic renal failure (CRF) undergoing renal transplan- tation (RTPL) with life-long immunosuppression. This review addresses three issues: risk of vaccine-preventable diseases, safety, immunogenicity, and clinical efficacy of available vaccines, and implementation of immunization guidelines. Infections (including vaccine-preventable in- fections) represent the leading cause of morbidity and mortality in children on dialysis and after RTPL. Vacci- nation in children with CRF and after RTPL is safe and does not cause reactivation of an immune-related renal disease or rejection after RTPL. Children with CRF gen- erally produce protective serum antibodies to primary vaccinations with killed or component vaccines and live virus vaccines; some children on dialysis and after RTPL may not respond optimally, requiring repeated vaccina- tion. Proof of vaccine efficacy is absence of disease, which can only be confirmed in large cohort studies. A few observational studies provide evidence that vaccina- tion has contributed significantly, at least in the western hemisphere, to the low prevalence of vaccine-preventable diseases among children with CRF. Close cooperation between the local pediatrician/practitioner and the pedi- atric nephrologist is essential for successful implementa- tion of the vaccination schedule.

The goal of the summer camp hemodialysis program was to provide a full recreational experience for the child with chronic renal failure, while ensuring his special medical.. (Received Se[r]

J Clin Invest. 1978;61(4):884-894. https://doi.org/10.1172/JCI109014. Micropuncture studies were carried out in rats to determine changes in tubular transport of phosphate which occur in chronic renal failure and secondary hyperparathyroidism. Rats underwent subtotal nephrectomy (NX) and were fed a low calcium, high phosphorus diet for 3--4 wk. Other groups consisted of normal control animals, normal rats infused with sodium phosphate to raise filtered load of phosphate, subtotal NX rats parathyroidectomized (PTX) on the day of experiment, and normal PTX rats infused with sodium phosphate. It was found that filtered phosphate/nephron is markedly increased in subtotal NX rats due to high single nephron filtration rates, proximal tubular fluid plasma phosphate ratios are less than 1.0, and fractional reabsorption of phosphate is decreased in the proximal tubule. More phosphate was present in the final urine than in surface distal convoluted tubules. Acute PTX in subtotal NX rats resulted in a striking increase in proximal phosphate reabsorption, and urinary phosphate became approximately equal to that remaining in surface distal tubules.

Echocardiography provides an excellent non invasive method to delineate details of anatomy of cardiac cavity, wall dimensions, and wall movements. The study population consists of chronic renal failure patients admitted in this hospital for the period from March 2005 to February 2006. They are basically divided into three groups according to Glomerular Filtration rate calculated by using one of the standard equations, Cockroft – Gault equation and each group consisted of thirty patients. In my study, of the thirty patients in each group, twenty patients were with hypertension and ten patients were without hypertension and not receiving any antihypertensive drugs.

The absorption and metabolism of vitamin D 3 - 3 H was studied in eight patients with chronic renal failure. Although the intestinal absorption of vitamin D 3 - 3 H was normal, the metabolic fate of the vitamin was abnormal as characterized by a twofold increase in fractional turnover rate, an abnormal accumulation of biologically inactive lipid-soluble metabolites, and the urinary excretion of both vitamin D 3 - 3 H and biologically inactive metabolites.

R E S U M O A homocisteína é um aminoácido sulfurado proveniente do metabolismo da metionina, cujo acúmulo anormal no plasma é um fator de risco para doenças vasculares, tanto na população em geral como nos pacientes com insuficiência renal crônica. Nestes, a prevalência de indivíduos com hiperhomocisteinemia é bastante elevada, mesmo na fase não dialítica da doença, em que a função renal está diminuída, mas ainda não é necessário tratamento dialítico. O principal fator que parece estar implicado na elevação dos níveis de homocisteína nestes pacientes com insuficiência renal crônica é a perda da massa renal, já que esta exerce uma importante função no metabolismo desse aminoácido. O tratamento da hiperhomocisteinemia na população em geral consiste na suplementação com as vitaminas envolvidas no seu metabolismo (folato, B 6 e B 12 ). Porém, em pacientes com insuficiência renal crônica, este tratamento não é completamente eficaz, pois apesar de promover a redução dos níveis de homocisteína, não alcança a normalização dos mesmos na maioria dos pacientes. Este estudo compreende uma revisão da etiologia da hiperhomocisteinemia na insuficiência renal crônica, sua relação com as doenças vasculares, seus principais determinantes e as formas de tratamento.