Chronic Renal Failure(CRF)
Shanghai Ruijin Hospital affiliated to
Shanghai Second Medical University,
Dept.of Nephrology
Qian Ying
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)
CRF
Regional and racial incidence of CRF
• Britain 70-80/per million
• China 100/per million
• USA 60-70/per million
CRF
Etiology
overseas
diabetic nephropathy,
hypertensive glomerular sclerosis,
chronic GN
china
chronic GN,
obstructive nephropathy,
diabetic nephropathy
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
CRF
Major hypothesis
• intact nephron hypothesis
final common pathway
(hemodynamically mediated glomerular
injury)
CRF
glomerular injury
adaptive single nephron hyperfiltration
glomerular capillary plasma flow,  hydraulic pressure
Intact nephron hypertrophy and sclerosis
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
CRF
• Stage 1: the normal stage of renal function
GFR>70 ml/min, BUN<6.5 mmol/L,
Scr<110 umol/L
• Stage 2:imcompensation stage of renal
GFR 50-70 ml/min, 6.5 <BUN< 9 mmol/L,
110 <Scr< 178 umol/L
no any signs and symptoms except for the
underlying disorders
CRF
• Stage 3: azotemic stage
GFR<50 ml/min,BUN>9 mmol/L
Scr>178 umol/L
there may be slight fatigue,anorexia and anemia
• Stage 4: uremic stage
GFR<25 ml/min,BUN>20 mmol/L
Scr>445 umol/L
a constellation of uremic syndrome may appear in
this stage
CRF
Signs and symptoms of uremia
 General
 Gastrointestinal tract
 Neuropathy
 Bone
 Blood
 Electrolyte disorders






Heart
Skin
Muscles
Infection
Lung
Endocrine and
metabolic
CRF
CRF
Cardiovascular disorders
• Hypertension 80%
Water and sodium retention
Alterations of RAAS
Glomerular capillary pressure> systemic
arterial pressure
CRF
Atherosclerosis
hypertriglycerid, hypercholesterolemia
vascular calcification
inadequate perfusion of the limbs
CRF
Pericarditis
• Uremic
• Dialysis associated
Signs and symptoms
• Chest pain
• Friction rub
• Pericardial effusion and tamponade
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
CRF
Neuropathy
• Central nervous system
Tiredness, insomnia, agitation, irritability,
depression, regression, rebellion
• Peripheral nervous system
Restless leg syndrome
the patient’s legs are
jumpy during the night, painful paresthesis of
extremities, twitching, loss of deep tendon reflexes ,
musclar weakness, sensory deficits
CRF
Renal osteodystrophy
Type I: high turn-over bone disease
Type II: low turn-over bone disease
Type III: mixture
CRF
Causes of renal osteodystrophy
• 1, 25(OH)2D3
• calcium phosphate 
• SHPT
• malnutrition
• iron and aluminum overload
CRF
CRF
Water, electrolyte and acid-base disturbances
• potassium  sodium 
• calcium phosphate 
• Metabolic acidosis
• magnesium 
CRF
Diagnosis of hyperkalemia
• Plasma K>5.5mmol/L
• Plasma K>7.0mmol/L cardiac arrest
CRF
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(GFR<15ml/min)
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
CRF
Diagnosis:
•
Case history
•
Physical examination
•
Laboratory studies including
urinalysis , renal function tests ,
biochemical analysis of blood
•
X-ray, ultrosound and radiorenogram
CRF
Treatment of CRF
Non-dialysis
dialysis
CRF
Non-dialysis
• Diet therapy
• Treatment of reversible factors
• Treatment of the underlying disease
• Treatment of complcations of uremia
• Chinese medical herbs
CRF
Diet therapy
• Protein restriction (0.5-0.8mg/kg/d)
• Adequte intake of calories(30-35kcal/kg/d)
• Fluid intake:urine volume +500ml
• Low phosphate diet(600-1000mg/d)
• Supplement of EAA(ketosteril)
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 )
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
CRF
Cardiac complications
• Diuretics
• Digitalis
• Treat hypertension
• dialysis
CRF
Antihypertensive therapy
Target blood pressure 130/85mmHg
• ACE inhibitors
• Angiotension II receptor antagonists
• Calcium antagonists
• -blockers
• vesodialators
CRF
Treatment of anemia
• Recombinant human erythropoietin(rhEPO)
• 2000-3000u BIW H
• Target hemoglobin 10-12g/L
• hemotocrit 30-33%
CRF
Side effects of rhEPO
• Hypertension
• Hypercoagulation
• Thrombosis of the AVF
CRF
rhEPO resistant
• Iron deficiency
• Active inflamation
• Malignancy
• Secondary hyperparathyroid
• Aluminum overload
• Pure red cell aplasia
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
CRF
Renal replacement therapy
• Hemodialysis
• Peritoneal dialysis
• Renal transplantation
CRF
Indications of HD
• GFR<10ml/min
• the uremic syndrome
• hyperkalemia
• acidosis
• fluid overload
Hemodialysis
Hemodialysis
弥散 Diffussion
渗透 Dialysis
Hemodialysis
超滤 Ultrofiltration
正压
对流 Conduction
负压
Contraindications of HD
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•
•
•
•
Shoke
Severe caidioc complications
Severe bleeding
malignency , sepsis
poor condition in vascular system
CRF
Indications of CAPD
child
old people with cardiovascular disease
dibetic nephropathy
trouble of AVF
治疗
Choice of HD or CAPD
HD
PD
young
no
eldly
yes
Blood
No bleeding
Bleeding
Vascular condition
good
poor
Ecnomic situation
better
poor
Age
Cardiovascular disease
CRF
Indications of RT
• maitenance dialysis patients without
contraindications of RT
• age<60 years
CRF
Prognosis
5-year survival
Home HD 80%
RT 60%
Hospital HD 60%
CAPD 50%
CRF
Drug dosing in CRF
Redused dose and adminstration interval
 Ccr(ml/min)=[(140-years old)×body
weight(kg)]/[72×Scr(mg/dl)]
 for female: ×0.85
Acute heart failure in uremia
(key treatment?)
•
•
•
•
Diuretics
Digitalis
Treat hypertension
dialysis