WHAT IS CHRONIC RENAL FAILURE:

When the kidneys fail gradually over a period of several years due to slow destruction of normal kidney tissue, the condition  is called Chronic Renal Failure (CRF). Should the kidneys fail rapidly over a period of few days or weeks then it is called Acute Renal Failure (ARF).  As the CRF progresses, kidneys are unable to function normally. Therefore the following events occur with progressively increasing severity:

            1.    Various toxins, acids and other chemical waste materials are not cleared from the blood. Their levels increase in the blood. This changes the character of the blood, making it more acidic and alters the internal chemical environment.  Resulting adverse chemical internal environment interferes with the normal function of other organs.  Such a wide spread malfunction of organs and tissues cause numerous  symptoms.

            2.    Kidneys are unable to conserve much needed water and cause frequent urination and at times dehydration.  But as the kidneys progressively worsen further, then the excess water could not be eliminated and water retention occurs.  This causes body to swell.  Such a swelling is called 'edema.'  At times, water can accumulate in the lungs causing difficulty in breathing due to lung-edema (Pulmonary Edema).  When the heart is unable to cope with excess water, patients develop   Congestive Heart Failure (CHF).

            3.    Kidneys are unable to produce certain substances which counteract  blood-pressure increasing chemicals produced elsewhere in the body.  Kidneys also produce excess Renin which increases the blood-pressure.  Therefore, in most instances the blood pressure increases causing Hypertension. 

            4.    Kidneys are unable to produce certain hormones and chemical agents like Erythropoietin and Active-Vitamin-D.  Lack of Erythropoietin causes Anemia, as the Erythropoietin is essential for the bone marrow to produce red blood cells.  No amount of Iron and Vitamin B12 could compensate for it.  Lack of vitamin D reduces Calcium absorption from the intestines leading to low Calcium levels in the blood (hypocalcemia). This in turn causes bones to become brittle.

            5.    Kidneys are unable to eliminate Sodium, Potassium and Phosphorus.    Sodium retention causes blood pressure to be further elevated.  It also aggravates edema.  Potassium may accumulate in the body to dangerous levels.  High levels of Potassium in the blood (Hyperkalemia) causes irregular heart beats and in extreme cases could stop the heart altogether. High phosphorus in the blood (Hyperphosphatemia) makes the bones brittle and in extreme cases could spontaneously or with minor trauma break the bones.  In addition, the excess phosphorus combines with Calcium in the blood and is deposited in the walls of the blood vessels.  This in turn leads to poor circulation and gangrene.   Hyperphosphatemia also stimulates the glands called "Parathyroids" and  those glands produce excessive  hormones (Parathormone).  This in turn causes severe bone disease since Parathormone, apart from other deleterious effects, interferes with  proper maintenance of bone mineralization and strength.

HOW OFTEN DOES CRF HAPPEN?

          Fortunately kidneys failing and the patient requiring dialysis
            or transplantation is still less common.   But the numbers
            (in U.S.A.) are as follows:
                                1982            62,000 pts
                                1998          256,000 pts
                                2008          600,000 pts (estimated)
            250 to 400 new patients per million population

            Accurate number of those patients still not requiring dialysis but are in the state of mild to moderate renal failure is not available.  But is usually estimated as 4 to 6 times the number of those requiring dialysis and transplantation.

SYMPTOMS OF CHRONIC RENAL FAILURE:

            Usually there are no symptoms until at least 60 to 70% of the total kidney tissue is destroyed.  Most of the time the CRF is diagnosed on blood tests done on routine physical examination or done during evaluation of other medical problems.   When the symptoms do occur patient may notice one or more of the following:

        1.    General ill feeling (malaise) and tiredness with 'lack of energy'
        2.    Diminishing attention span / inability to concentrate
        3.    Insomnia and altered sleep pattern and headaches
        4.    Feeling cold all the time
        5.    Low back pain
        6.    More frequent urination and urinating several times during nights
        7.    Weight loss / Loss of appetite / Nausea and vomiting
        8.    Swelling (edema) of legs and face causing fluid weight gain
        9.    Tingling and numbness of hands and feet
      10.   Difficulty in breathing
      11.   Itching
      12.   Chest pain esp., when lying down
      13.   Convulsions and Coma.
      14.    Signs of Congestive Heart Failure, Hypertension, Anemia

UREMIA:

        When patients develop symptoms primarily due to high level of the various chemicals accumulating in the blood due to kidney failure, then the condition is called UREMIA.  If the patient has no symptoms and is  tolerating those high levels of chemicals (uremic toxins) then it is usually referred to as AZOTEMIA.

CAUSES OF CHRONIC RENAL FAILURE:

            1.   The most common causes of Chronic Renal Failure
                    are Diabetes Mellitus and Hypertension.
               2.   Chronic Nephritis (Chronic Glomerulo-Nephritis)

ABNORMAL BLOOD TESTS:

TREATMENT:
                            BEFORE REQUIRING DIALYSIS
                            DIALYSIS
                            TRANSPLANT

        BEFORE REQUIRING DIALYSIS TREATMENT:

            1.  Treatment of the cause of the kidney failure: This depends on the the actual cause of the kidney failure, and might involve suppressing the immune system with medications as listed in the treatment of proteinuria.

            2.  Control the progressive deterioration of the kidney function by the following measures:

                a.   Adequate control of the blood pressure, preferably with
                      ACE-Inhibitors or AT1- receptor blocker
                b.   Avoiding over the counter medications that are not kidney-friendly
                c.   Reducing the protein intake to 0.6 to 0.7 grams per kilogram
                     of body weight.  (An Ounce of Meat, Fish or Poultry has about 7 Grams of Protein)
                d.   Controlling the salt intake to about 2000 mgs of Sodium. (On rare occasion 
                     sodium control may not be advisable!)
                e.   Controlling the Phosphorus intake.
                f.    If there is Diabetes Mellitus, controlling the blood sugar adequately
                     and taking if feasible ACE-Inhibitors or AT1-receptor blockers 

         3.  Control anemia with Erythropoietin injections with careful
                 monitoring of the blood count, since over correction is dangerous
                 as well.

            4.   Nutritional management:  As mentioned above, restrict dietary
                 protein consumption (but need to be watched for
                 protein malnutrition)

            5. Preparation for eventual dialysis / kidney transplantation:
                This will involve
                        a.   Inserting an AV-Fistula when kidney function is
                             down to 20%, if the patient prefers Hemodialysis
                             instead of Peritoneal dialysis
                        b.   Initiating tests needed for listing the patient at a
                             transplant center when Creatinine is 5mgs% or above
                        c.   Preparing the family of the patient regarding changing
                             needs of the patient and his/her life on dialysis

RECOMMENDED READING:
"When Your Kidneys Fail"
Author: Mickie Hall Faris, MPH, MBA.
Publisher: 
         National Kidney Foundation
               of Southern California
         5777 W. Century Blvd, Suite 1450
         Los Angeles, CA  90045-7404
         Tel: (310) 641-8152