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[C676]Chronic Renal Failure Pathophysiology

by Krishan B Kumar, Kri

The patient complains of marked loss of appetite, nausea and recurrent vomiting (especially in the morning). These are the early symptoms, and the patient may report only with these vague complaints, and at such a stage, it is only the clinician who can clinch the diagnosis, provided the patient reports to him well in time.

The taste of the mouth gets altered. A marked ulceration may follow in the mouth as well as in the stomach and/ orintestine, leading to haemorrhage in both the stomach and the intestine, causing--vomiting of blood (haematemesis) or the passing of blood in stools (melaena). There is a marked pain in the abdomen and the patient usually reports as a case of bleeding peptic ulcer. Loss of fluids, as a result of vomiting/ haemorrhage, further deteriorates kidney functions as a result of dehydration. Hiccoughs are another symptom as the disease progresses.

In addition, blood pressure rises as a result of the damage to the kidneys, called 'renal hypertension'. Sometimes, the patient may be already suffering from high blood pressure, which may have contributed to the injury to the kidneys. Further, heart failure may occur due to the persistent elevation of blood pressure. In advanced cases, the pericardium, i.e. the membrane covering the heart may also be involved (pericarditis) .

Fall in haemoglobin (chronic anaemia) becomes a constant feature of CRE As the blood urea/serum creatinine rises, haemoglobin falls accordingly, and both are so corelated that even an estimation of haemoglobin, which is a simple test, can indicate the progress of the disease. The fall in haemoglobin occurs due to the toxic effect on the bone marrow, which gets depressed, as well as due to haemorrhages in the stomach/ intestine, etc. Anaemia is difficult to treat as the patient cannot tolerate oral iron due to constant nausea, vomiting and ulceration in the gastrointestinal tract.

Soon the lungs may be affected, and the patient may experience difficulty in breathing (uraemic lungs).

In the same way, the bones may be affected (renalosteodystrophy), and, likewise, the peripheral nerves may be involved (neuropathy), and there may develop a marked weakness in the muscles (myopathy), and a number of other conditions like muscle twitches / tremors etc. may show up.

The brain or the central nervous system may be involved, leading to drowsiness and even coma. CRF or uraemia is one of the important causes of coma:

Sometimes epilepsy/epileptic fits may also manifest itself. Epilepsy may be the only presenting signal of CRF, i.e. the patient can present himself as a case of epilepsy, and if blood ureal serum creatinine estimation is done, his blood urea may be as high as 400 mg/ dl, and likewise there will be a higher level of serum creatinine. Although such cases are not common, the estimation of blood urea/serum creatinine in all cases of epilepsy may prove rewarding, in excluding advanced cases of CRF.

There may also occur high levels of blood uric acid (hyperuricaemia), as a result of blood uric acid not being excreted by the kidneys fully. This results in the various complications of high blood uric acid. Marked itching (pruritus) of the whole body adds to the misery of the patient, and it hardly responds to any treatment.

Hence, as a result of CRF, almost every part of the body gets significantly involved, threatening the life of the patient.

There should be a regular/periodic check-up of the urine, for any infection/pus cells or growth of any bacteria. A CRF kidney is more prone to infection, and if infection is not prevented/ controlled, there is a danger of further kidney damage/failure. The infection should be treated on the lines explained in the topic on urinary tract infection (UTI). However, a word of caution - if on culture and sensitivity of the urine, various antibiotics are available for treating the infection, only those should be administered which are least toxic for the kidneys.

(ii) Prevent obstruction in the urinary tract

In case there is an obstruction in the urinary tract, as a result of the benign enlargement of the prostate (BEP), or urinary stones, or some other cause, the obstruction should be removed. Since obstruction in the urinary tract increases the infection in it can further damage the kidneys.

(iii) Avoid unnecessary usage of drugs

A case of CRF should not to be any drugs on his own unnecessarily. He should take only limited drugs, as prescribed by a specialist. Any indiscriminate use of drugs may immediately shift the patient to an unstable condition. If that happens, stop the drug immediately, so that his condition may revert to the stable state.

(iv) Avoid radiographic dyes

Radiographic dyes should also be avoided as far as possible, since these dyes are likely to damage the kidneys. Thus, intravenous pyelography, etc. is least recommended in such cases. Now other tests are available. Moreover radiation has its own side-effects.

(v) Strict control of diabetes and hypertension

Both these conditions, if not strictly controlled, will damage the kidneys further. Hence the prevention of further damage to the kidneys requires a rigid control of both these conditions.

Hypertension is usually associated with CRF, and sometimes blood pressure may be markedly elevated, making the condition unstable, which must be brought to normal quickly, so that the condition returns to the stable level.

(vi) Strict control of diet

If this step is not strictly followed, the patient may enter into an unstable stage. And, if taken seriously, an improvement in the condition of the patient may be noticed. The diet of a patient of CRF is prescribed by the specialist. However, broadly speaking, an intake of more protein in the food will elevate the blood urea, which is dependent on protein, and this elevated urea in the blood will further worsen the condition of the patient, which should be avoided. Protein alone makes the condition stable/unstable. A high-protein diet may make the condition of the patient so unstable so that a dialysis may become necessary. On the other hand, a low-protein diet may make the condition absolutely stable.

(vii) Rigid follow-up

A case of CRF has to be monitored strictly and regularly, even constantly. Depending on the condition of the patient, it may be assessed weekly/fortnightly/monthly. At each visit, serum creatinine should be repeated, besides a detailed check-up of the patient. It is understood that the patient will get his blood pressure and blood sugar, if diabetic, checked up daily. However, any sudden rise in serum creatinine should be noted carefully, and critically examined. It can be a true sign of uncontrolled diabetes/hypertension, infection, dehydration, necessitating immediate attention, and treatment. Otherwise the condition is likely to become unstable, either temporarily or even permanently. In such a situation, the condition of the patient is somewhat alarming and he may need dialysis at any moment. However, constant vigilance and quick response to any complication may keep the patient stable for years together. Maintenance dialysis is expensive, and may not be within the reach of everyone. Therefore, prevention of the disease is the only way to meet the situation.

It would be ideal if there is some national policy / programme for the over-all prevention of this disease. At the same time, all hidden cases must be discovered/ treated. Summing up, early detection, prevention, including mass realization about the various especially serious aspects of the disease, should be the key to such a national programme.

Article Source : hiv conditions

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