Chronic Renal Failure
一、Introduction：
etiologies: CGN, DM, HTN, CIN, PKD, etc.
CLASSIFICATION OF CHRONIC KIDNEY DISEASE
Chronic Kidney Disease: A Clinical Action Plan
Stage
Description
GFR
(mL/min/1.73m2)
Action*
At increased
risk
90
(with CKD risk
factors)
Screening
CKD risk reduction
90
Diagnosis and treatment
Treatment of comorbid
conditions,
slowing progression,
CVD risk reduction
1.
Kidney
damage
with normal
or GFR
2.
Kidney
damage
with mild
GFR
60-89
Estimating progression
3.
Moderate
GFR
30-59
Evaluating and treating
complications
4.
Severe GFR
15-29
Preparation for kidney
replacement therapy
5.
Kidney Failure
<15
(or dialysis)
Replacement (if uremia
present)
1. Chronic kidney disease (CKD) is defined as either kidney damage or
GFR <60 mL/min/1.73 m2 for 3 months
2. Target Range of Ca, P, and iPTH in CKD (K/DOQI 2003)
CKD stage 3-4
P: 3-4.6 mg/dl
Ca: 8.4-9.5 mg/dl
iPTH: stage 3 - 35-70 pg/ml
stage 4 – 80-100 pg/ml
CKD stage 5
P: 3.5-5.5 mg/dl
Ca: 8.4-9.5 mg/dl
Ca*P product < 55
iPTH: 100-300 pg/ml
二、Exacerbating factors:
1.water or electrolyte imbalance: dehydration 、 hyponatremia 、
hypokalemia
2.hemodynamic impairment:CHF、shock、hepatorenal syndrome
3.infection: systemic/renal bacterial/viral infection
4.metabolic disease: hypercalcemia
5.nephrotoxic drugs: cephalosporin, aminoglycoside,
medium, amphotericin-B, NSAID, ACEI, cyclosporin
6.renovascular disease
7.obstructive nephropathy(benign/malignant)
contrast
三、Signs and symptoms of Uremia
1. General:
Fetor uremicus, uremic frost, pruritus, growth retardation,
susceptibility to drug overdose
2. Neurologic:
Metabolic encephalopathy (altered mental status, decreased memory
and attention), seizures, asterixis, myoclonus, peripheral neuropathy
3. Cardiovascular:
Uremic pericarditis, accelerated atherosclerosis, hyperlipidemia,
volume overload, hypertension, cardiomyopathy
4. Renal:
Hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis
5. Gastrointestinal:
Decreased appetite, metallic taste, nausea, vomiting
6. Hematologic:
Normocytic anemia(decreased erythropoietin), bleeding (uremic
platelet dysfunction)
7. Endocrine:
Decrease 1,25-OH-VitD, hyperphosphatemia → hypocalcemia→
secondary
hyperparathyroidism→
osteitis
fibrosa
cystica,
osteomalacia, fractures
8. Infections:
Increase susceptibility
四、Treatment：
1.Diet control:
(1)calories: 35Kcal/kg/day，carbohydrate 35-50%，protein 10%，
others: fat，unsaturated fatty acid 60%。
(2)protein: 0.6gm/kg/day in pre-dialysis patients ， 50-60% high
bioavailability. Post-dialysis 1.2gm/kg/day。
(3)Ca, P, VitD management to maintain Ca * P product < 70 to
prevent metastatic calcification. (target <55)
2.treat hypertension and hyperlipidemia(target <130/80; DM with
proteinuria< 125/75)
3.EPO if anemia and low EPO level
4.ACEI or/and ARB slow progression of DM and non-DM nephropathy
5.DDAVP for severe bleeding
6.Consider dialysis and transplantation
7. Indication for dialysis:
(1)Uremic symptoms:
a.CNS: confusion, coma, seizure
b.GI: obvious nausea, vomiting
c.Mostly BUN>100 mg/dl, Cr>7-8 mg/dl
d.others: pericarditis、pericardial effusion、bleeding tendency
(2)Water, electrolyte, acid-base imbalance:
a. volume overload: CHF、pulmonary edema、using TPN with
anuria
b. hyperkalemia:K>6.0 mEq/L，esp. EKG changes
c. refractory metabolic acidosis:pH<7.2
(3)others: drug intoxication、hypothermia、hypercalcemia
五、Admission Order in CRF：
1. Diet:
甲、 low renal protein 0.6 gm/kg/day if Ccr < 60 ml/min
乙、 Protein intake 1.2 gm/kg/day if p’t on HD
丙、 water limitation: depend on clinical condition and limit
1500cc/day if p’t on HD
丁、 low salt diet 3-5 gm/day
2. CBC/DC+PLT, MAR+ Ca, P, iPTH(若半年內無Data), PT, APTT,
Bleeding time(選擇性), stool OB, urinanalysis
3. 24 Hrs urine Ccr, protein loss, Na for FeNa(選擇性)
4. CXR, EKG, KUB(選擇性)
5. Renal echography
6. PES if PUD suspected
7. Cardiac echography if combined with heart failure sign or ischemic
change in EKG
8. NCV (sensory+ motor), upper and lower limbs if neuropathy
suspected
9. Record I/O or body weight QD
10. Consult plastic or CVS surgeon for AV shunt/fistula creation if p’t
wants to do HD in the future
11. Consult GS surgeon for CAPD tube implantation if p’t wants to do
CAPD in the future
12. Medication: avoid nephrotoxic drugs if possible, adjust dosage
according to Ccr.
13. Others depend on clinical needs