Chronic renal failure Dr.H.N.Sarker FCPS(Medicine),MACP(USA), MRCP(UK),FRCP(GLASGO) Associate Professor. Medicine

Chronic renal failureChronic renal failure

Dr.H.N.SarkerDr.H.N.Sarker

FCPS(Medicine),MACP(USA),FCPS(Medicine),MACP(USA),MRCP(UK),FRCP(GLASGO)MRCP(UK),FRCP(GLASGO)

Associate Professor.Associate Professor.

MedicineMedicine

Introduction Introduction

Chronic renal failure (CRF) refers Chronic renal failure (CRF) refers to an irreversible deterioration in to an irreversible deterioration in renal function which classically renal function which classically develops over a period of years . develops over a period of years .

IntroducttionIntroducttion

Initially, it is manifested only as a Initially, it is manifested only as a biochemical abnormality. Eventually, loss biochemical abnormality. Eventually, loss of the excretory, metabolic and endocrine of the excretory, metabolic and endocrine functions of the kidney leads to the functions of the kidney leads to the development of the clinical symptoms and development of the clinical symptoms and signs of renal failure, which are referred to signs of renal failure, which are referred to as uraemia. as uraemia.


When death is likely without renal When death is likely without renal replacement therapy, it is called end-stage replacement therapy, it is called end-stage renal failure (ESRF). renal failure (ESRF).


The Kidney Disease Outcomes Quality The Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Initiative (K/DOQI) of the National Kidney Foundation (NKF) defines chronic kidney Foundation (NKF) defines chronic kidney disease as either kidney damage or a disease as either kidney damage or a decreased kidney glomerular filtration rate decreased kidney glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for (GFR) of less than 60 mL/min/1.73 m2 for 3 or more months. 3 or more months.


Whatever the underlying etiology, the Whatever the underlying etiology, the destruction of renal mass with irreversible destruction of renal mass with irreversible sclerosis and loss of nephrons leads to a sclerosis and loss of nephrons leads to a progressive decline in GFR. The different progressive decline in GFR. The different stages of chronic kidney disease form a stages of chronic kidney disease form a continuum in time; prior to February 2002, continuum in time; prior to February 2002, no uniform classification of the stages of no uniform classification of the stages of chronic kidney disease existed. chronic kidney disease existed.


At that time, K/DOQI published a At that time, K/DOQI published a classification of the stages of chronic classification of the stages of chronic kidney disease, as follows:kidney disease, as follows:Stage 1: Kidney damage with normal or Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)increased GFR (>90 mL/min/1.73 m2)Stage 2: Mild reduction in GFR (60-89 Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2)mL/min/1.73 m2)


Stage 3: Moderate reduction in GFR (30-Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m2)59 mL/min/1.73 m2)

Stage 4: Severe reduction in GFR (15-29 Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2)mL/min/1.73 m2)

Stage 5: Kidney failure (GFR <15 Stage 5: Kidney failure (GFR <15 mL/min/1.73 m2 or dialysis)mL/min/1.73 m2 or dialysis)


In stage 1 and stage 2 chronic kidney In stage 1 and stage 2 chronic kidney disease, GFR alone does not clinch the disease, GFR alone does not clinch the diagnosis. Other markers of kidney diagnosis. Other markers of kidney damage, including abnormalities in the damage, including abnormalities in the composition of blood or urine or composition of blood or urine or abnormalities in imaging tests, should also abnormalities in imaging tests, should also be present in establishing a diagnosis of be present in establishing a diagnosis of stage 1 and stage 2 chronic kidney stage 1 and stage 2 chronic kidney disease. disease.

PathophysiologyPathophysiology

Approximately 1 million nephrons are Approximately 1 million nephrons are present in each kidney, each contributing present in each kidney, each contributing to the total GFR. Regardless of the to the total GFR. Regardless of the etiology of renal injury, with progressive etiology of renal injury, with progressive destruction of nephrons, the kidney has an destruction of nephrons, the kidney has an innate ability to maintain GFR by innate ability to maintain GFR by hyperfiltration and compensatory hyperfiltration and compensatory hypertrophy of the remaining healthy hypertrophy of the remaining healthy nephrons. nephrons.


This nephron adaptability allows for This nephron adaptability allows for continued normal clearance of plasma continued normal clearance of plasma solutes so that substances such as urea solutes so that substances such as urea and creatinine start to show significant and creatinine start to show significant increases in plasma levels only after total increases in plasma levels only after total GFR has decreased to 50%, when the GFR has decreased to 50%, when the renal reserve has been exhausted. The renal reserve has been exhausted. The plasma creatinine value will approximately plasma creatinine value will approximately double with a 50% reduction in GFR. double with a 50% reduction in GFR.


A rise in plasma creatinine from a baseline A rise in plasma creatinine from a baseline value of 0.6 mg/dL to 1.2 mg/dL in a value of 0.6 mg/dL to 1.2 mg/dL in a patient, although still within the reference patient, although still within the reference range, actually represents a loss of 50% of range, actually represents a loss of 50% of functioning nephron mass. functioning nephron mass.

Types and causes Types and causes

Chronic renal failure (CRF) can be Chronic renal failure (CRF) can be classified by the site (location) of primary classified by the site (location) of primary damage: damage:

Pre-renal CRF Pre-renal CRF

Renal CRF Renal CRF

Post-renal CRF (obstructive Post-renal CRF (obstructive uropathy) uropathy)

Pre-Renal CRFPre-Renal CRF

Some medical conditions cause continuous Some medical conditions cause continuous hypoperfusion (low blood flow) of the hypoperfusion (low blood flow) of the kidneys, leading to kidney atrophy kidneys, leading to kidney atrophy (shrinking), loss of nephron function, and (shrinking), loss of nephron function, and chronic renal failure (CRF). chronic renal failure (CRF).

Pre-Renal CRFPre-Renal CRF

These conditions includeThese conditions include poor cardiac functionpoor cardiac function,, chronic liver failure, chronic liver failure,

and and atherosclerosis ("hardening") atherosclerosis ("hardening") of the of the renal arteries. renal arteries.

Each of these conditions can induce Each of these conditions can induce ischemic nephropathy ischemic nephropathy

Renal CRFRenal CRF

Chronic renal failure caused by changes Chronic renal failure caused by changes

within the kidneys, is called renal CRF, within the kidneys, is called renal CRF, and is broadly categorized as follows: and is broadly categorized as follows:

Diabetic nephropathyDiabetic nephropathy- kidney disease - kidney disease associated with associated with diabetesdiabetes; the most ; the most common cause of CRFcommon cause of CRF

Renal CRFRenal CRF

Hypertensive nephrosclerosis-Hypertensive nephrosclerosis- the the second leading cause of CRFsecond leading cause of CRF

Chronic glomerulonephritisChronic glomerulonephritis, a condition , a condition caused by diseases that affect the caused by diseases that affect the glomeruli and bring about progressive glomeruli and bring about progressive dysfunction –dysfunction –

Membranous nephropathy,Membranous nephropathy,

immunoglobulin A (IgA) nephropathy, immunoglobulin A (IgA) nephropathy,

Renal CRFRenal CRF

focal and segmental glomerulosclerosis focal and segmental glomerulosclerosis (FSGS),(FSGS),

membranoproliferative glomerulonephritis, membranoproliferative glomerulonephritis,

rapidly progressive (crescentic) rapidly progressive (crescentic) glomerulonephritisglomerulonephritis

Renal CRF Renal CRF

Chronic interstitial nephritisChronic interstitial nephritis- a condition - a condition caused by disorders that ultimately lead to caused by disorders that ultimately lead to progressive scarring of the interstitiumprogressive scarring of the interstitium

Renal vascular CRFRenal vascular CRF- large vessel - large vessel abnormalities such as abnormalities such as renal artery renal artery stenosisstenosis (narrowing of the large arteries (narrowing of the large arteries that supply the kidneys)that supply the kidneys)

Renal CRF Renal CRF

VasculitisVasculitis, inflammation of the small , inflammation of the small blood vessels-blood vessels-– systemic lupus erythematosussystemic lupus erythematosus– sclerodermascleroderma– Goodpasture syndromeGoodpasture syndrome– Wegener granulomatosisWegener granulomatosis– mixed cryoglobulinemiamixed cryoglobulinemia– Henoch-Schönlein purpura, Henoch-Schönlein purpura,

Renal CRFRenal CRF

Cystic kidney diseaseCystic kidney disease, kidney disease , kidney disease distinguished by multiple cysts distinguished by multiple cysts ((Polycystic kidney disease )Polycystic kidney disease )

Hereditary diseases of the kidney, such as Hereditary diseases of the kidney, such as Alport's syndromeAlport's syndrome

Post-Renal CRFPost-Renal CRF

Interference with the normal flow of urine Interference with the normal flow of urine can produce backpressure within the can produce backpressure within the kidneys, can damage nephrons, and lead kidneys, can damage nephrons, and lead to obstructive uropathy, a disease of the to obstructive uropathy, a disease of the urinary tract.urinary tract.

Abnormalities that may hamper urine flow Abnormalities that may hamper urine flow and cause post-renal CRF include the and cause post-renal CRF include the following: following:


Bladder outlet obstructionBladder outlet obstruction due to an due to an enlarged prostate gland or bladder stoneenlarged prostate gland or bladder stone

Neurogenic bladderNeurogenic bladder, an overdistended , an overdistended bladder caused by impaired communicator bladder caused by impaired communicator nerve fibers from the bladder to the spinal nerve fibers from the bladder to the spinal cordcord


Kidney stonesKidney stones in both ureters . in both ureters .

Retroperitoneal fibrosisRetroperitoneal fibrosis..

Vesicoureteral refluxVesicoureteral reflux (VUR), the (VUR), the backward flow of urine from the bladder backward flow of urine from the bladder into a ureterinto a ureter

PathogenesisPathogenesis

Disturbances in water, electrolyte and acid-Disturbances in water, electrolyte and acid-base balance contribute to the clinical base balance contribute to the clinical picture in patients with CRF, but the exact picture in patients with CRF, but the exact pathogenesis of the clinical syndrome of pathogenesis of the clinical syndrome of uraemia is unknown. uraemia is unknown.

Pathogenesis Pathogenesis

Many substances present in abnormal Many substances present in abnormal concentration in the plasma have been concentration in the plasma have been suspected as being 'uraemic toxins', and suspected as being 'uraemic toxins', and uraemia is probably caused by the uraemia is probably caused by the accumulation of various intermediary accumulation of various intermediary products of metabolism.products of metabolism.

Clinical FeatureClinical Feature

Patients with chronic kidney disease Patients with chronic kidney disease stages 1-3 (GFR >30 mL/min) are stages 1-3 (GFR >30 mL/min) are generally asymptomatic and do not generally asymptomatic and do not experience clinically evident disturbances experience clinically evident disturbances in water or electrolyte balance or in water or electrolyte balance or endocrine/metabolic derangements. endocrine/metabolic derangements.


Generally, these disturbances clinically Generally, these disturbances clinically manifest with chronic kidney disease manifest with chronic kidney disease stages 4-5 (GFR <30 mL/min). Uremic stages 4-5 (GFR <30 mL/min). Uremic manifestations in patients with chronic manifestations in patients with chronic kidney disease stage 5 are believed to be kidney disease stage 5 are believed to be primarily secondary to an accumulation of primarily secondary to an accumulation of uraemic toxins . uraemic toxins .

Clinical Feature Clinical Feature

Patient usually presents with features of Patient usually presents with features of hyperkalemia , metabolic acidosis and hyperkalemia , metabolic acidosis and uremia.uremia.


Uraemic symptoms can affect every organ Uraemic symptoms can affect every organ system, most noticeably the following: system, most noticeably the following:

Gastrointestinal systemGastrointestinal system––anorexia,nausea, vomiting, food distaste anorexia,nausea, vomiting, food distaste (often described as bland, metallic, "like (often described as bland, metallic, "like cardboard"), hiccup .cardboard"), hiccup .


Neurological systemNeurological system–cognitive –cognitive impairment, personality change, asterixis impairment, personality change, asterixis (motor disturbance that affects groups of (motor disturbance that affects groups of muscles), muscular twitching, fits, muscles), muscular twitching, fits, drowsiness and coma. drowsiness and coma.


Blood-forming systemBlood-forming system–anemia due to–anemia due to relative deficiency of erythropoietin relative deficiency of erythropoietin

diminished erythropoiesis due to toxic effects of diminished erythropoiesis due to toxic effects of uraemia on marrow precursor cells uraemia on marrow precursor cells

reduced red cell survival reduced red cell survival

increased blood loss due to capillary fragility and increased blood loss due to capillary fragility and poor platelet function poor platelet function

reduced dietary intake and absorption of iron and reduced dietary intake and absorption of iron and other haematinicsother haematinics

– easy bruising and bleeding due to abnormal plateletseasy bruising and bleeding due to abnormal platelets


Pulmonary systemPulmonary system–fluid in the lungs, –fluid in the lungs, with breathing difficultieswith breathing difficulties

Cardiovascular system Cardiovascular system –chest pain due –chest pain due to inflammation of the sac surrounding the to inflammation of the sac surrounding the heart (pericarditis) and pericardial effusion heart (pericarditis) and pericardial effusion (fluid accumulation around the heart)(fluid accumulation around the heart)

Skin Skin –generalized itching, pruritus.–generalized itching, pruritus.

MyopathyMyopathy. .


Renal osteodystrophyRenal osteodystrophy -This metabolic -This metabolic bone disease which accompanies CRF bone disease which accompanies CRF consists of a mixture of osteomalacia, consists of a mixture of osteomalacia, hyperparathyroid bone disease (osteitis hyperparathyroid bone disease (osteitis fibrosa), osteoporosis and osteosclerosis .fibrosa), osteoporosis and osteosclerosis .


Osteomalacia results from diminished Osteomalacia results from diminished activity of the renal 1α-hydroxylase activity of the renal 1α-hydroxylase enzyme, with failure to convert enzyme, with failure to convert cholecalciferol to its active metabolite, cholecalciferol to its active metabolite, 1,25-dihydroxycholecalciferol. A deficiency 1,25-dihydroxycholecalciferol. A deficiency of the latter leads to diminished intestinal of the latter leads to diminished intestinal absorption of calcium, hypocalcaemia and absorption of calcium, hypocalcaemia and reduction in the calcification of osteoid in reduction in the calcification of osteoid in bone. bone.


The physical examination often is not very The physical examination often is not very helpful but may reveal findings helpful but may reveal findings characteristic of the condition underlying characteristic of the condition underlying chronic kidney disease (eg, chronic kidney disease (eg, hypertension,diabetis, severe hypertension,diabetis, severe arteriosclerosis , lupus)or complications of arteriosclerosis , lupus)or complications of chronic kidney disease (eg, anemia, chronic kidney disease (eg, anemia, bleeding diathesis, pericarditis). bleeding diathesis, pericarditis).

Investigations Investigations

Haematology Haematology

Full blood count Full blood count

Urinanalysis-Urinanalysis-

Dipstick proteinuria may suggest a Dipstick proteinuria may suggest a glomerular or tubulointerstitial problem. glomerular or tubulointerstitial problem.

The urine sediment finding of RBCs, RBC The urine sediment finding of RBCs, RBC casts, suggests proliferative glomerulonephritis. casts, suggests proliferative glomerulonephritis.

InvestigationsInvestigations

Urinanalysis- Urinanalysis- Pyuria and/or WBC casts Pyuria and/or WBC casts are suggestive of interstitial nephritis are suggestive of interstitial nephritis (particularly if eosinophiluria is present) or (particularly if eosinophiluria is present) or urinary tract infection.urinary tract infection.

Twenty-four–hour urine collection for total Twenty-four–hour urine collection for total protein and CrCl protein and CrCl


Biochemistry Biochemistry

Urea, electrolytes and creatinineUrea, electrolytes and creatinine

Calcium, phosphate and albuminCalcium, phosphate and albumin

Parathyroid hormoneParathyroid hormone

Lipids, glucose ± HbA1c Lipids, glucose ± HbA1c


ImagingImaging--

Renal ultrasound- Small echogenic Renal ultrasound- Small echogenic kidneys are observed in advanced renal kidneys are observed in advanced renal failure. Structural abnormalities, such as failure. Structural abnormalities, such as polycystic kidneys, also may be observed. polycystic kidneys, also may be observed. This is a useful test to screen for This is a useful test to screen for hydronephrosis.hydronephrosis.


Chest X-ray: heart size, pulmonary Chest X-ray: heart size, pulmonary oedemaoedema

ECG: if > 40 years or there are risk factors ECG: if > 40 years or there are risk factors for cardiac diseasefor cardiac disease

Renal artery imaging: if renovascular Renal artery imaging: if renovascular disease is suspected disease is suspected

Investigations Investigations

HistologyHistology- Renal biopsy.- Renal biopsy.

MicrobiologyMicrobiology-Hepatitis and HIV serology: -Hepatitis and HIV serology: if dialysis is needed (vaccination against if dialysis is needed (vaccination against hepatitis B if no previous infection; hepatitis B if no previous infection; isolation of dialysis machine if positive) isolation of dialysis machine if positive)


ImmunologyImmunology - - Group and saveGroup and save

Tissue typingTissue typing

Cytomegalovirus,Epstein-Barr virus, Cytomegalovirus,Epstein-Barr virus, varicella zoster virus varicella zoster virus


if transplantation is considered If diagnosis if transplantation is considered If diagnosis is not known-is not known-

Immunoglobulins and protein Immunoglobulins and protein electrophoresis electrophoresis

Urinary Bence Jones proteinUrinary Bence Jones protein

ComplementComplement


ANA: and dsDNA if ANA is positiveANA: and dsDNA if ANA is positive

ENA: if a connective tissue disorder is ENA: if a connective tissue disorder is suspectedsuspected

Rheumatoid factor ANCA: in all possible Rheumatoid factor ANCA: in all possible inflammatory renal diseaseinflammatory renal disease

Anti-GBM: in all possible inflammatory Anti-GBM: in all possible inflammatory renal diseaserenal disease

ManagementManagement

Once CRF has been diagnosed, the Once CRF has been diagnosed, the physician attempts to determine the cause physician attempts to determine the cause and, if possible, plan a specific treatment.and, if possible, plan a specific treatment.

Nonspecific treatments are implemented Nonspecific treatments are implemented to delay or possibly arrest the progressive to delay or possibly arrest the progressive loss of kidney function. loss of kidney function.


There are several aspects to the management of There are several aspects to the management of CRF: CRF: Identify the underlying renal disease. Identify the underlying renal disease. Look for reversible factors which are making Look for reversible factors which are making renal function worse renal function worse Attempt to prevent further renal damage. Attempt to prevent further renal damage. Attempt to limit the adverse effects of the loss of Attempt to limit the adverse effects of the loss of renal function. renal function. Institute renal replacement therapy (dialysis, Institute renal replacement therapy (dialysis, transplantation) when appropriate.transplantation) when appropriate.


Treatment of the underlying causeTreatment of the underlying cause- - some causes of CRF are amenable to some causes of CRF are amenable to treatment eg. Glomerulonephritis with treatment eg. Glomerulonephritis with immunosuppressive therapy.immunosuppressive therapy.


Retarding the progression of CRFRetarding the progression of CRF--

Control of blood pressureControl of blood pressure -control -control of blood pressure may retard deterioration of blood pressure may retard deterioration of GFR. Various target blood pressures of GFR. Various target blood pressures have been suggested: for example, 130/85 have been suggested: for example, 130/85 mmHg for CRF alone, lowered to 125/75 mmHg for CRF alone, lowered to 125/75 mmHg for those with proteinuria > 1 g/day. mmHg for those with proteinuria > 1 g/day.


ACE inhibitors have been shown to be more ACE inhibitors have been shown to be more effective at retarding the progression of renal effective at retarding the progression of renal failure than other therapies which lower failure than other therapies which lower systemic blood pressure to a similar degree . systemic blood pressure to a similar degree . This may be because they reduce glomerular This may be because they reduce glomerular perfusion pressure by dilating the efferent perfusion pressure by dilating the efferent arteriole. Angiotensin II receptor antagonists arteriole. Angiotensin II receptor antagonists also reduce glomerular perfusion pressure also reduce glomerular perfusion pressure and can be used.and can be used.


Diet -Diet -Restrict dietary proteinRestrict dietary protein,,Moderate Moderate restriction for a CRF patient is about 0.6 to restriction for a CRF patient is about 0.6 to 0.8 gm/kg/day(to 60 g protein per day) and 0.8 gm/kg/day(to 60 g protein per day) and this should be accompanied by an this should be accompanied by an adequate intake of calories to prevent adequate intake of calories to prevent malnutrition. malnutrition.


Limiting the adverse effects of CRF –Limiting the adverse effects of CRF –AnaemiaAnaemia -Anaemia is common; it -Anaemia is common; it

usually correlates with the severity of renal usually correlates with the severity of renal failure and contributes to many of the non-failure and contributes to many of the non-specific symptoms of CRF. specific symptoms of CRF.

Recombinant human erythropoietin is Recombinant human erythropoietin is effective in correcting the anaemia of CRF. effective in correcting the anaemia of CRF. The target haemoglobin is usually The target haemoglobin is usually between 100 and 120 g between 100 and 120 g


Fluid and electrolyte balance -Fluid and electrolyte balance - Due to Due to the reduced ability of the failing kidney to the reduced ability of the failing kidney to concentrate the urine, a relatively high concentrate the urine, a relatively high urine volume is needed to excrete urine volume is needed to excrete products of metabolism and a fluid intake products of metabolism and a fluid intake of around 3 litres/day is desirable. of around 3 litres/day is desirable.


Some patients with so-called 'salt-wasting' Some patients with so-called 'salt-wasting' disease may require a high sodium and water disease may require a high sodium and water intake, including supplements of sodium salts, to intake, including supplements of sodium salts, to prevent fluid depletion and worsening of renal prevent fluid depletion and worsening of renal function. This is most often seen in patients with function. This is most often seen in patients with renal cystic disease, obstructive uropathy, reflux renal cystic disease, obstructive uropathy, reflux nephropathy or other tubulo-interstitial diseases, nephropathy or other tubulo-interstitial diseases, and is not seen in patients with glomerular and is not seen in patients with glomerular disease. These patients benefit from taking 5-10 disease. These patients benefit from taking 5-10 g/day (85-170 mmol/day) of sodium chloride by g/day (85-170 mmol/day) of sodium chloride by mouth. mouth.


AcidosisAcidosis- The plasma bicarbonate should - The plasma bicarbonate should be maintained above 22 mmol/l by giving be maintained above 22 mmol/l by giving sodium bicarbonate supplements (starting sodium bicarbonate supplements (starting dose of 1 g 8-hourly, increasing as dose of 1 g 8-hourly, increasing as required). The increased sodium intake required). The increased sodium intake may induce hypertension or oedema;may induce hypertension or oedema;calcium carbonate (up to 3 g daily) is an calcium carbonate (up to 3 g daily) is an alternative that is also used to bind dietary alternative that is also used to bind dietary phosphate. phosphate.


Infection -Infection - they must be recognised and they must be recognised and treated promptly.treated promptly.Renal osteodystrophyRenal osteodystrophy- plasma calcium - plasma calcium and phosphate should be kept as near to and phosphate should be kept as near to normal as possible. normal as possible. Hypocalcaemia is corrected by giving 1α-Hypocalcaemia is corrected by giving 1α-hydroxylated synthetic analogues of hydroxylated synthetic analogues of vitamin D. The dose is adjusted to avoid vitamin D. The dose is adjusted to avoid hypercalcaemia. hypercalcaemia.


Hyperphosphataemia is controlled by dietary Hyperphosphataemia is controlled by dietary restriction of foods with high phosphate content restriction of foods with high phosphate content (milk, cheese, eggs) and the use of phosphate-(milk, cheese, eggs) and the use of phosphate-binding drugs administered with food (e.g. binding drugs administered with food (e.g. calcium carbonate and aluminium hydroxide). calcium carbonate and aluminium hydroxide).

Secondary hyperparathyroidism is usually Secondary hyperparathyroidism is usually prevented or controlled by these measures but, prevented or controlled by these measures but, in severe bone disease with autonomous in severe bone disease with autonomous parathyroid function, parathyroidectomy may parathyroid function, parathyroidectomy may become necessary. become necessary.


Renal replacement therapy (RRT)Renal replacement therapy (RRT) Early preparation is important. The health Early preparation is important. The health care team educates the patient about the care team educates the patient about the different procedures involved in RRT, different procedures involved in RRT, which include the following: which include the following: HemodialysisHemodialysis—removal of toxic elements —removal of toxic elements from the blood, which is filtered through a from the blood, which is filtered through a membrane while circulated outside of the membrane while circulated outside of the body body


Peritoneal dialysisPeritoneal dialysis—filtration through the —filtration through the lining membrane of the abdominal cavity; lining membrane of the abdominal cavity; fluid is instilled into the peritoneal space, fluid is instilled into the peritoneal space, then drained then drained

kidney transplantation.kidney transplantation.

Documents

Chronic renal failure Dr.H.N.Sarker FCPS(Medicine),MACP(USA), MRCP(UK),FRCP(GLASGO) Associate Professor. Medicine