Chronic Renal Failure(CRF)

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Chronic Renal Failure(CRF)

• Shanghai Ruijin Hospital affiliated to Shanghai
  Second Medical University, Dept.of
  Nephrology
• Qian Ying

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CRF

• Definition
• final stage of numorous renal diseases
  resulting from progressive loss of glomerular,
  tubular and endocrine function in both kidneys.
  This leads to
• disturbed excretion of end products of metabolism
• disturbed elimination of electrolytes and water
• disturbed secretion of hormones(eg.
  Erythropoietin, renin, prostaglandins, active
  form of vitamin D)

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CRF

• Regional and racial incidence of CRF
• Britain 70-80/per million
• China 100/per million
• USA 60-70/per million

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CRF

• Etiology
• diabetic nephropathy,
• hypertensive glomerular sclerosis,
• chronic GN
• chronic GN,
• obstructive nephropathy,
• diabetic nephropathy

overseas
china
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CRF

• Pathogenesis (unknown)
• uremic toxins
• small molecular weight
• urea, creatinine, uric acid, guanidine,
  phenol, amines, indoles
• middle molecular weight PTH
• large molecular weight ?2-MG

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CRF

• Major hypothesis
• intact nephron hypothesis
• final common pathway
• (hemodynamically mediated glomerular injury)

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CRF
glomerular injury
adaptive single nephron hyperfiltration
?glomerular capillary plasma flow, ? hydraulic
pressure
Intact nephron hypertrophy and sclerosis
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CRF

• Trade-off hypothesis
• CRF ? Calcium? phostate? ?PTH ? ?SHPT ?
  bone,heart,blood,nerves injury
• Hypertension and compensatory hypertrophy of
  glomeruli
• Hypermetabolism of renal tubuli
• cytokines and lipid disturbances

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CRF

• Stage 1 the normal stage of renal function
• GFRgt70 ml/min, BUNlt6.5 mmol/L,
• Scrlt110 umol/L
• Stage 2imcompensation stage of renal
• GFR 50-70 ml/min, 6.5 ltBUNlt 9
  mmol/L,
• 110 ltScrlt 178 umol/L
• no any signs and symptoms except for the
  underlying disorders

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CRF

• Stage 3 azotemic stage
• GFRlt50 ml/min,BUNgt9 mmol/L
• Scrgt178 umol/L
• there may be slight fatigue,anorexia and
  anemia
• Stage 4 uremic stage
• GFRlt25 ml/min,BUNgt20 mmol/L
• Scrgt445 umol/L
• a constellation of uremic syndrome may appear
  in this stage

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CRFSigns and symptoms of uremia

• General
• Gastrointestinal tract
• Neuropathy
• Bone
• Blood
• Electrolyte disorders

• Heart
• Skin
• Muscles
• Infection
• Lung
• Endocrine and metabolic

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CRF
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CRF

• Cardiovascular disorders
• Hypertension 80
• Water and sodium retention
• Alterations of RAAS
• Glomerular capillary pressuregt systemic
  arterial pressure

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CRF

• Atherosclerosis

hypertriglycerid, hypercholesterolemia
vascular calcification
inadequate perfusion of the limbs
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CRF

• Pericarditis
• Uremic
• Dialysis associated
• Signs and symptoms
• Chest pain
• Friction rub
• Pericardial effusion and tamponade

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CRF

• Hematologic disorders
• Anemia, bleeding, granulocyte, platelet
  dysfunction
• Causes
• Relative deficiency of erythropoietin
• Decreased erythropoietin production
• Reduced red cell survival
• Increased blood loss
• Folate and Iron deficiency
• Hypersplenism

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CRF

• Neuropathy
• Central nervous system
• Tiredness, insomnia, agitation, irritability,
• depression, regression, rebellion
• Peripheral nervous system
• Restless leg syndrome the patients
  legs are
• jumpy during the night, painful paresthesis
  of extremities, twitching, loss of deep tendon
  reflexes , musclar weakness, sensory deficits

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CRF

• Renal osteodystrophy
• Type I high turn-over bone disease
• Type II low turn-over bone disease
• Type III mixture

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CRF

• Causes of renal osteodystrophy
• 1, 25(OH)2D3?
• calcium? phosphate ?
• SHPT
• malnutrition
• iron and aluminum overload

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CRF
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CRF

• Water, electrolyte and acid-base disturbances
• potassium ? sodium ?
• calcium? phosphate ?
• Metabolic acidosis
• magnesium ?

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CRF

• Diagnosis of hyperkalemia
• Plasma Kgt5.5mmol/L
• Plasma Kgt7.0mmol/L cardiac arrest

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CRF
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CRF

• Causes of hyperkalemia
• Increased intake rapid adminstration of K by
  mouth or intravenously
• Drugs containing K(chinese medical herbs)
• Impaired excretion
• Chronic renal failure(GFRlt15ml/min)

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CRF

• Causes of hyperkalemia
• Shift of K out of cells
• Metabolic acidosis
• Tissue breakdown
• Bleeding into soft tissues, GI tract or body
  cavities
• Hemolysis
• Catabolic states

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CRF

• Diagnosis
• Case history
• Physical examination
• Laboratory studies including
• urinalysis , renal function tests ,
  biochemical analysis of blood
• X-ray, ultrosound and radiorenogram

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CRF

• Treatment of CRF
• Non-dialysis
• dialysis

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CRF

• Non-dialysis
• Diet therapy
• Treatment of reversible factors
• Treatment of the underlying disease
• Treatment of complcations of uremia
• Chinese medical herbs

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CRF

• Diet therapy
• Protein restriction (0.5-0.8mg/kg/d)
• Adequte intake of calories(30-35kcal/kg/d)
• Fluid intakeurine volume 500ml
• Low phosphate diet(600-1000mg/d)
• Supplement of EAA(ketosteril)

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CRF

• Reversible factors in CRF
• Hypertension
• Reduced renal perfusion (renal artery stenosis,
  hypotension , sodium and water depletion, poor
  cardiac function)
• Urinary tract obstruction
• Infection
• Nephrotoxic medications
• Metabolic factors(calcium phosphate products ?)

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CRF

• Management of complications of uremia
• Hyperkalemia
• Identify treatable causes
• Inject 10-20ml 10 calcium gluconate
• 50 gluconate 50-100ml i.v.insulin 6-12u
• Infusion 250ml 5 sodium bicarbonate
• Use exchage resin
• Hemodialysis or peritoneal dialysis

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CRF

• Cardiac complications
• Diuretics
• Digitalis
• Treat hypertension
• dialysis

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CRF

• Antihypertensive therapy
• Target blood pressure 130/85mmHg
• ACE inhibitors
• Angiotension II receptor antagonists
• Calcium antagonists
• ?-blockers
• vesodialators

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CRF

• Treatment of anemia
• Recombinant human erythropoietin(rhEPO)
• 2000-3000u BIW H
• Target hemoglobin 10-12g/L
• hemotocrit 30-33

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CRF

• Side effects of rhEPO
• Hypertension
• Hypercoagulation
• Thrombosis of the AVF

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CRF

• rhEPO resistant
• Iron deficiency
• Active inflamation
• Malignancy
• Secondary hyperparathyroid
• Aluminum overload
• Pure red cell aplasia

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CRF

• Treatment of renal osteodystropy
• Low phosphate diet
• Calcium carbonate (1-6g/d)
• Vitamin D (0.25ug/d for prophylactic, 0.5ug/d for
  symptomatic, pulse therapy 2-4ug/d for severe
  cases)
• parathyroidectomy

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CRF

• Renal replacement therapy
• Hemodialysis
• Peritoneal dialysis
• Renal transplantation

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CRF

• Indications of HD
• GFRlt10ml/min
• the uremic syndrome
• hyperkalemia
• acidosis
• fluid overload

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Hemodialysis
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Hemodialysis
?? Diffussion
?? Dialysis
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Hemodialysis
?? Ultrofiltration
??
??
?? Conduction
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Contraindications of HD

• Shoke
• Severe caidioc complications
• Severe bleeding
• malignency , sepsis
• poor condition in vascular system

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CRF

• Indications of CAPD
• child
• old people with cardiovascular disease
• dibetic nephropathy
• trouble of AVF

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Choice of HD or CAPD
??
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CRF

• Indications of RT
• maitenance dialysis patients without
  contraindications of RT
• agelt60 years

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CRF

• Prognosis
• 5-year survival
• Home HD 80
• RT 60
• Hospital HD 60
• CAPD 50

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CRF

• Drug dosing in CRF
• Redused dose and adminstration interval
• Ccr(ml/min)(140-years old)body
  weight(kg)/72Scr(mg/dl)
• for female 0.85

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Acute heart failure in uremia (key treatment?)

• Diuretics
• Digitalis
• Treat hypertension
• dialysis

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Thank You!