1. Chronic Renal Failure(CRF)
Shanghai Ruijin Hospital affiliated to Shanghai Second Medical University, Dept.of Nephrology
Qian Ying

2. 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)

3. CRF Regional and racial incidence of CRF Britain 70-80/per million
China /per million
USA /per million

4. CRF overseas china Etiology diabetic nephropathy,
hypertensive glomerular sclerosis,
chronic GN
chronic GN,
obstructive nephropathy,
diabetic nephropathy
overseas
china

5. 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

6. CRF Major hypothesis intact nephron hypothesis final common pathway
(hemodynamically mediated glomerular injury)

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

8. 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

9. 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 ml/min, 6.5 <BUN< 9 mmol/L,
110 <Scr< 178 umol/L
no any signs and symptoms except for the underlying disorders

10. 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

11. CRF Signs and symptoms of uremia
General
Gastrointestinal tract
Neuropathy
Bone
Blood
Electrolyte disorders
Heart
Skin
Muscles
Infection
Lung
Endocrine and metabolic

12. CRF

13. CRF Cardiovascular disorders Hypertension 80%
Water and sodium retention
Alterations of RAAS
Glomerular capillary pressure> systemic arterial pressure

14. CRF Atherosclerosis hypertriglycerid, hypercholesterolemia
vascular calcification
inadequate perfusion of the limbs

15. CRF Pericarditis Signs and symptoms Uremic Dialysis associated
Chest pain
Friction rub
Pericardial effusion and tamponade

16. CRF Hematologic disorders Causes:
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

17. 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

18. CRF Renal osteodystrophy Type I: high turn-over bone disease
Type II: low turn-over bone disease
Type III: mixture

19. CRF Causes of renal osteodystrophy 1, 25(OH)2D3 calcium phosphate 
SHPT
malnutrition
iron and aluminum overload

20. CRF

21. CRF Water, electrolyte and acid-base disturbances potassium  sodium 
calcium phosphate 
Metabolic acidosis
magnesium 

22. CRF Diagnosis of hyperkalemia Plasma K>5.5mmol/L
Plasma K>7.0mmol/L cardiac arrest

23. CRF

24. 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)

25. 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

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

27. CRF
Treatment of CRF
Non-dialysis
dialysis

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

29. 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( mg/d)
Supplement of EAA(ketosteril)

30. 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 )

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

32. CRF Cardiac complications Diuretics Digitalis Treat hypertension
dialysis

33. CRF Antihypertensive therapy Target blood pressure 130/85mmHg
ACE inhibitors
Angiotension II receptor antagonists
Calcium antagonists
-blockers
vesodialators

34. CRF Treatment of anemia Recombinant human erythropoietin(rhEPO)
u BIW H
Target hemoglobin 10-12g/L
hemotocrit 30-33%

35. CRF Side effects of rhEPO Hypertension Hypercoagulation
Thrombosis of the AVF

36. CRF rhEPO resistant Iron deficiency Active inflamation Malignancy
Secondary hyperparathyroid
Aluminum overload
Pure red cell aplasia

37. 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

38. CRF Renal replacement therapy Hemodialysis Peritoneal dialysis
Renal transplantation

39. CRF Indications of HD GFR<10ml/min the uremic syndrome hyperkalemia
acidosis
fluid overload

40. Hemodialysis

41. Hemodialysis
弥散 Diffussion
渗透 Dialysis

42. Hemodialysis
超滤 Ultrofiltration 负压 正压
对流 Conduction

43. Contraindications of HD
Shoke
Severe caidioc complications
Severe bleeding
malignency , sepsis
poor condition in vascular system

44. CRF Indications of CAPD child old people with cardiovascular disease
dibetic nephropathy
trouble of AVF

45. Cardiovascular disease治疗
Choice of HD or CAPD
poor
better
Ecnomic situation
good
Vascular condition
Bleeding
No bleeding
Blood
yes no
Cardiovascular disease
eldly
young
Age PD HD

46. CRF
Indications of RT
maitenance dialysis patients without contraindications of RT
age<60 years

47. CRF Prognosis 5-year survival Home HD 80% RT 60% Hospital HD 60%
CAPD 50%

48. 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

49. Acute heart failure in uremia (key treatment?)
Diuretics
Digitalis
Treat hypertension
dialysis

50. Thank You!