天 津 医 科 大 学 授 课 教 案
TEACHING PLAN OF TIANJIN MEDICAL UNIVERSITY
总页 Total page: 8
页 Page: 1
Course：
Nephrology
Topic of course
教师姓名：Jiang Jian-qing
Teacher’s Name
职称：Professor
Teacher’s Professional Position
Type of student ： Students of International
College of TMU
Teaching Manner：Multi media
：Chronic Renal Failure
教学日期：2013.3.12
Date of Teaching
Teaching Textbook：
《International
Medicine》
Teaching Hour：2
Number of student：80
Purpose &Requirement of Teaching in the Chapter：
At the end of the course the student will be able to:
1、 Master the diagnosis evidence and treatment principle, master the clinical manifestation
and pathogenesis of the uraemia.
2、 Master various theories of the pathogenesis of the uraemia, pathologic change, the stage of
the chronic renal failure.
3、 Know the importance of the prevention of renal failure and know the replacement therapy,
various dialysis and renal transplantation, etc.
授课主要内容及学时分配：Teaching Subject and Teaching Arrangement
Definition, etiology, pathogenesis，Clinical findings: 50 minutes
diagnosis and differential diagnosis，Treatment and prognosis: 50 minutes
Emphasis, Difficult Points and Requirements on Students
1. The definition of Chronic Renal Failure
2.Clinical manifestation ： General symptoms,
the symptoms of digestive,
respiratory, cardiovascular, hematologic, muscular and dermal systems, renal
osteopathy, endocrine and metabolic disturbances, fluid and electrolyte disorders,
acid-base disturbances, secondary infection
3. Treatment：Treat the primary disease and rectify the evocable factors, dietetic
therapy, rectify the fluid and electrolyte disorders, maintain the acid-base balance,
diuretic, control the blood pressure, treat the anemia, dialysis (include peritoneal
dialysis, hemodialysis, etc), traditional Chinese treatment, renal transplantation.
Medical terminology： Chronic Renal Failure 、Uraemia
Assistance of teaching： Classroom lecture by media mix, clinical practice, visit
ward. Show the typical cases and make the students have sensible
knowledge.
Questions：
1. How to treat the patient with chronic renal failure in diet 2. Show
the diagnosis stander of three stages in CRF patient 3 Hemodialysis
adaptions of CRF
Reference Material
《International Medicine》
《The Kidney》
Signature of Director：
Date：
天 津 医 科 大 学 授 课 教 案
（共 8 页、第 3 页）
CRF:
1 Definition
1.1 CRF a substantial and irreversible reduction in renal function over a period of months (>3
mos) to less than 20% of normal.
1.2 Azotemia: Elevated blood urea nitrogen (BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)
1.3 Uremia: azotemia with symptoms or signs of renal failure
1.4 End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis
1.5 Creatinine Clearance (CCr): rate of filtration of creatinine by the kidney (marker for
GFR)
1.6 CRF typically occurs in three stages:
1). Compensatory stage. 50ml/min<GFR<80ml/min, Cr<178umol/L(2mg/dl), BUN<9mmol/L
(25mg/dl), and no symptoms.
2). Decompensatory stage. 25ml/min<GFR<50ml/min, Cr>178umol/L, BUN>9mmol/L, lightly
gastrointestinal signs (anorexia, nausea, and vomiting) and anemia.
3). Uremic stage. GFR<25ml/min, Cr>445umol/L(5mg/dl), BUN>20mmol/L(55mg/dl), typical
uremic symptoms.
Stages of chronic Kidney disease
Stage
1
2
3
4
5
Description
GFR(ml/min/1.73m2)
Kidney damage with normal or GFR↑
Kidney damage with mild GFR↓
Moderate GFR↓
Severe GFR↓
Kidney failure
≥90
60-89
30-59
15-29
＜15(or dialysis)
From Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation, USA
2 Etiology
Causative diseases include:
glomerulonephritis of any type (one of the most common causes in Chinese, but in US, 10%)
Diabetes mellitus (In US, there are 50K cases of DN ESRD annually. Diabetes is the most
common contributor to ESRD, that is, >30% of ESRD cases attributed to Diabetes)
polycystic kidney disease, 5%
hypertension, (In US, CFR with Hypertension causes 23% of ESRD annually)
Alport syndrome,
reflux nephropathy, obstructive uropathy,
kidney stones and infection,.
Rapidly progressive glomerulonephrities (vasculitis): 2%
Renal Vascular Disease (i.e., renal artery stenosis)
Medications
Analgesic Nephropathy (progression after many years)
Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with
CRF
Prevalence of CKD and CRF by etiology and sex, Bajo Lempa, El Salvador
(n=775; 343 male, 432 female)
3 Pathogenesis
3.1 The Remaining Nephrons Theory and Maladaptation Mechanisms
3.2 Glomerular Hyperfiltration Theory
3.3 Renal Tubular Hypermetabolic Theory
4 Clinical Manifestations
4.1 Symptoms:
1) Initial symptoms (may be nonspecific):
unintentional weight loss
nausea, vomiting
general ill feeling
Fatigue
Headache
frequent hiccups
generalized itching (pruritus)
Sign
Tests
The Uremic Syndrome
Specific Manifestations of Uremia
2) Later symptoms
increased or decreased urine output, need to urinate at night
easy bruising or bleeding; may have blood in the vomit or in stools
decreased alertness, lethargy, coma, muscle twitching or cramps, seizures
increased skin pigmentation--skin may appear yellow or brown
uremic frost--deposits of white crystals in and on the skin
decreased sensation in the hands, feet, or other areas
4.2 Specific Manifestations of Uremia
Gastrointestinal Disease
Hematologic Effects
Cardiovascular Effects
Neurologic Manifestations
Dermatologic Manifestations
Musculoskeletal Manifestations
Endocrine Abnormalities
Metabolic Disorders
Hyperkalemia
Acid-base Disorders
5 Diagnosis and Differential Diagnosis
5.1 diagnosis is made based on present, past, and family history, serologic evaluation,
examination of the urine sediment, and ultrasound evaluation.
1) Diagnosis of the underlying etiology Biopsy is the most specific tool to reach definitive
diagnosis. This allows specific treatment of the underlying etiology, assessment of the
prognosis, and suitability of kidney transplantation. If the biopsy is not performed because of
small kidney size
2) Seeking the causes of deterioration of renal function
Table The Common Causes of Acute Deterioration of Renal Function
prerenal azotemia result from a decrease of renal blood flow
postrenal azotemia obstruction of urine flow
renal azotemia intrinsic renal parenchymal diseases
a. Acute tubular necrosis(ATN)
b. Intrinsic renal diseases
(1) Acute primary or secondary glomerulonephritis
(2) Tubulointerstitial nephritis
(3) Renal vasculitis
5.2 Differential Diagnosis
6 Prevention
Treatment of the underlying disorders may help prevent or delay development of chronic renal
failure. Diabetics should control blood sugar and blood pressure closely and should refrain
from smoking.
7 Treatment
7.1 Treatment focuses on:
controlling the symptoms
minimizing complications
slowing the progression of the disease
7.2 1. The treatment of underlying diseases and causes of deterioration of renal function
Associated diseases that cause or result from chronic renal failure must be controlled.
Hypertension, congestive heart failure, urinary tract infections, kidney stones, obstructions of
the urinary tract, glomerulonephritis, and other disorders should be treated as appropriate.
7.3 Diet
Recent evidence suggests the role of high protein intake in glomerular hyperfiltration and the
role of hyperlipidemia in mesangial proliferation and sclerosis.
The National Study of Dietary Modification in Renal Disease suggests a beneficial effect of
protein restriction at the level of 0.75 mg/kg/day in patients with GFR of 25 to 50 ml/min, and
with proper restriction of sodium, potassium, phosphorus intake. Enough calories should be
supplemented.
7.4 Essential amino acid therapy
The supplement of essential amino acid (EAA) could maintain the nitrogen balance and lower
the blood urea. But, these kinds of drugs are very expensive.
The common dosage of EAA is 0.1-0.2g/kg/day.
7.5 Chinese herbs therapy
7.6 Management of Complications of Uremia:
A. Water And Electrolyte Abnormalities.
B. Cardiovascular Abnormalities.
C. Hematologic Abnormalities.
D. Renal Osteodystrophy.
E. Infections..
7.7 Dialysis
The current criteria for initiation of dialysis is GFR ≤ 15 ml/min for diabetics and < 10
ml/min for nondiabetics.
Patients with volume overload resistant to diuretics, acidosis, persistent hyperkalemia,
intractable gastrointestinal symptoms, or encephalopathy should be started on dialysis even
though their creatinine clearance may exceed the previously set criteria.
Conservative
Treatment
Dialysis
Hemodialysis
Transplant
Peritoneal
Home
1）Hemodialysis
2）Peritoneal Dialysis
Related Donor
Center
Cadaver Donor
7.8 Transplantation
Additional Resources and Information from the Web
University Renal Research and Education Association (www.urrea.org)
National Institute of Diabetes & Digestive & Kidney Diseases (www.niddk.nih.gov)
National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)
(http://kidney.niddk.nih.gov/)
Life Options Rehabilitation Program (www.lifeoptions.org)
United Network for Organ Sharing (UNOS) (http://www.unos.org)
American Society of Nephrology (www.asn-online.org)
National Kidney Foundation (www.kidney.org)
JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html)
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