1
Chronic Renal Insufficiency
Lu Fuming
Division of Nephrology,Huashan Hospital,Fudan University
2
Chronic Renal Insufficiency
? Pathogen and pathogenesis
? Manifestation
? Laboratory examination
? Diagnosis and differential diagnosis
? Treatment
3
Etiology
? primary glomerular diseases
? hypertensive nephrosclerosis
? diabetic nephropathy
? chronic pyelonephritis
? multicystic kidney
? systemic lupus nephritis
4
Pathogenesis
? Mechanism associated with exacerbation of
renal function
? Mechanism associated with uremic symptom
5
Mechanism Associated With Exacerbation
of Renal Function
? Hyperfiltration theory
? Effect of proteinuria
? Trade-off hypothesis in acidosis
? Disturbance of lipid metabolism
? Tubulointerstitial injury
? Renal hypoxia
6
Mechanism Associated With Uremic Symptom
? Uremic toxins
? malnutrition
? trade-off hypothesis
? Endocrine dysfunction
7
Manifestation of the Uremic Syndrome
? Gastrointestinal
? Cardiovascular
? Hematologic
? Pulmonary
? Neurologic
? Dermatologic
? Endocrinologic
? ophthalmic
8
Gastrointestinal Manifestation
? Anorexia progressing to nausea and vomiting
? Stomatitis and gingivitis
? Parotitis
? Peptic ulcer diathesis
? Gastritis,duodenitis and enterocolitis
? Pancreatitis
? Ascites
9
Cardiovascular Manifestation
? Accelerated atherosclerosis
? Cardiomyopathy
? pericarditis
10
Hematologic Manifestation
? Anemia
? Altered neutrophilic chemotaxis
? Depressed lymphocyte function
? Platelet dysfunction
11
Pulmonary Manifestation
? Atypical pulmonary edema
? Pneumonitis
? Fibrinous pleuritis
12
Neurologic Manifestation
? Central
– Daytime drowsiness,a tendency to sleep,coma
– Decreased attentiveness
– Seizures
– Disorientation and confusion
? Peripheral
– Restless leg syndrome
– Sensorimotor peripheral neuropathy
– Increased muscle fatigability and muscle cramps
13
Dermatologic Manifestation
? Pruritus
? Dystrophic calcification
? Changes in skin pigmentation
14
Renal Osteodystrophy
? high bone turnover disease
? low bone turnover disease
? Mixed bone disease
15
Endocrinologic Manifestation
? Secondary hyperparathyroidism
? Insulin resistance
? Type IV hyperlipidemia
? Altered peripheral thyroxine metabolism
? Testicular atrophy
? Ovarian dysfunction
16
Disturbed Water,Electrolytes and Acid-
base Balance
? Water loss and water intoxication
? Hypo- or hyper-natremia
? Hypo- or hyper-kalemia
? Hypo- or hyper-calcemia
? Hypo- or hyper-phosphatemia
? metabolic acidosis
17
Experimental Test
? Urine test
? Blood test
? Renal function test
? Blood biochemical test
? Radiologic and ultrasonographic test
18
Diagnosis and Differential Diagnosis
? Diagnosis of chronic kidney disease
? Etiologic diagnosis
? Differential diagnosis
19
Stages of Renal Insufficiency
stage GFR SCr clinical manifestation
(ml/min) (umol/L)
compensated stage 50— 80 <133 asymptom
azotemia 25---50 <445 nycturia,anemia
renal failure 10---25 <800 nausea,anemia,acidosis
uremia <10 >800 obvious uremic symptom
20
Definition of Chronic Kidney Disease
? Renal injury,>3 months
– Decreased GFR,yes or no
– Renal injury,abnormal experimental tests
? GFR<60ml/min/1.73m2,>3 months
– Renal injury,yes or no
21
Stages of chronic kidney disease
stage description GFR management
0 high risk for CKD >90 find out the risk factors
1 Renal injury,normal GFR >90 diagnosis,treat complications
2 Lightly decreased GFR 60-89 evaluation of progressing
3 Moderately decreased GFR 30-59 treat complications
4 Severely decreased GFR 15-29 ready for renal replacement
5 uremia <15 renal replacement
22
? History
? Physical examination
? Experimental test
? Radiologic and ultrasonographic examination
? Renal biopsy
Etiologic diagnosis
23
Differential diagnosis
? With acute renal failure
– History, long or short
– Changes in urine volume
– Changes in Hb
– Dermatologic manifestation
– Bone disease
– Changes in SCr
– Length of the kidney
24
Treatment
? Etiologic treatment
? Treatment without dialysis
? Dialysis
? Renal transplant
25
Etiologic treatment
? Progress of primary disease
? hypoperfusion
? Heart failure
? hypertension
? hyperlipidemia
? infection
? Nephrotoxical drug
? Obstructed urinary tract
? stress
? Severe anemia
? Disorder of electrolytes
? High protein diet
26
Treatment without dialysis
? nutritional therapy
? Treat cardiovascular complications
? Treat anemia
? Treat renal osteodystrophy
? Keep the balance of water,electrolytes and acid-
base
27
Nutritional Therapy
? Energy intake
– 30--35 kcal/kg/day
? Protein intake
– 0.6g/kg/day
– Necessary amino-acid
? Vitamins
– VitC,VitB6
– VitD
28
Treat cardiovascular complications
? hypertension
? Heart failure
? pericarditis
29
Treatment of anemia
? Erythropoietin
– initial,100u/kg/week,divide in 2-3 dosage
– Increase 50% dosage,Hct increase < 2% per month
– Decrease 25% dosage,Hct increase > 8% per month
– target,Hct 33%--36% Hb 11— 12g/dl
? Iron supplement
– target,SF>100,saturated TRF > 20%
– oral,200mg iron/d
– Intra venous,100mg iron per HD,total 10 times
– target reached,25— 125mg iron per week
30
Treat renal osteodystrophy
? Treatment of hypocalcemia and
hyperphosphatemia
? Use of Vit D
? parathyriodectomy
31
Keep the balance of water,electrolytes
and acid-base
32
Renal Replacement
? Dialysis
– Hemodialysis
– Peritoneal dialysis
? Renal transplant
Chronic Renal Insufficiency
Lu Fuming
Division of Nephrology,Huashan Hospital,Fudan University
2
Chronic Renal Insufficiency
? Pathogen and pathogenesis
? Manifestation
? Laboratory examination
? Diagnosis and differential diagnosis
? Treatment
3
Etiology
? primary glomerular diseases
? hypertensive nephrosclerosis
? diabetic nephropathy
? chronic pyelonephritis
? multicystic kidney
? systemic lupus nephritis
4
Pathogenesis
? Mechanism associated with exacerbation of
renal function
? Mechanism associated with uremic symptom
5
Mechanism Associated With Exacerbation
of Renal Function
? Hyperfiltration theory
? Effect of proteinuria
? Trade-off hypothesis in acidosis
? Disturbance of lipid metabolism
? Tubulointerstitial injury
? Renal hypoxia
6
Mechanism Associated With Uremic Symptom
? Uremic toxins
? malnutrition
? trade-off hypothesis
? Endocrine dysfunction
7
Manifestation of the Uremic Syndrome
? Gastrointestinal
? Cardiovascular
? Hematologic
? Pulmonary
? Neurologic
? Dermatologic
? Endocrinologic
? ophthalmic
8
Gastrointestinal Manifestation
? Anorexia progressing to nausea and vomiting
? Stomatitis and gingivitis
? Parotitis
? Peptic ulcer diathesis
? Gastritis,duodenitis and enterocolitis
? Pancreatitis
? Ascites
9
Cardiovascular Manifestation
? Accelerated atherosclerosis
? Cardiomyopathy
? pericarditis
10
Hematologic Manifestation
? Anemia
? Altered neutrophilic chemotaxis
? Depressed lymphocyte function
? Platelet dysfunction
11
Pulmonary Manifestation
? Atypical pulmonary edema
? Pneumonitis
? Fibrinous pleuritis
12
Neurologic Manifestation
? Central
– Daytime drowsiness,a tendency to sleep,coma
– Decreased attentiveness
– Seizures
– Disorientation and confusion
? Peripheral
– Restless leg syndrome
– Sensorimotor peripheral neuropathy
– Increased muscle fatigability and muscle cramps
13
Dermatologic Manifestation
? Pruritus
? Dystrophic calcification
? Changes in skin pigmentation
14
Renal Osteodystrophy
? high bone turnover disease
? low bone turnover disease
? Mixed bone disease
15
Endocrinologic Manifestation
? Secondary hyperparathyroidism
? Insulin resistance
? Type IV hyperlipidemia
? Altered peripheral thyroxine metabolism
? Testicular atrophy
? Ovarian dysfunction
16
Disturbed Water,Electrolytes and Acid-
base Balance
? Water loss and water intoxication
? Hypo- or hyper-natremia
? Hypo- or hyper-kalemia
? Hypo- or hyper-calcemia
? Hypo- or hyper-phosphatemia
? metabolic acidosis
17
Experimental Test
? Urine test
? Blood test
? Renal function test
? Blood biochemical test
? Radiologic and ultrasonographic test
18
Diagnosis and Differential Diagnosis
? Diagnosis of chronic kidney disease
? Etiologic diagnosis
? Differential diagnosis
19
Stages of Renal Insufficiency
stage GFR SCr clinical manifestation
(ml/min) (umol/L)
compensated stage 50— 80 <133 asymptom
azotemia 25---50 <445 nycturia,anemia
renal failure 10---25 <800 nausea,anemia,acidosis
uremia <10 >800 obvious uremic symptom
20
Definition of Chronic Kidney Disease
? Renal injury,>3 months
– Decreased GFR,yes or no
– Renal injury,abnormal experimental tests
? GFR<60ml/min/1.73m2,>3 months
– Renal injury,yes or no
21
Stages of chronic kidney disease
stage description GFR management
0 high risk for CKD >90 find out the risk factors
1 Renal injury,normal GFR >90 diagnosis,treat complications
2 Lightly decreased GFR 60-89 evaluation of progressing
3 Moderately decreased GFR 30-59 treat complications
4 Severely decreased GFR 15-29 ready for renal replacement
5 uremia <15 renal replacement
22
? History
? Physical examination
? Experimental test
? Radiologic and ultrasonographic examination
? Renal biopsy
Etiologic diagnosis
23
Differential diagnosis
? With acute renal failure
– History, long or short
– Changes in urine volume
– Changes in Hb
– Dermatologic manifestation
– Bone disease
– Changes in SCr
– Length of the kidney
24
Treatment
? Etiologic treatment
? Treatment without dialysis
? Dialysis
? Renal transplant
25
Etiologic treatment
? Progress of primary disease
? hypoperfusion
? Heart failure
? hypertension
? hyperlipidemia
? infection
? Nephrotoxical drug
? Obstructed urinary tract
? stress
? Severe anemia
? Disorder of electrolytes
? High protein diet
26
Treatment without dialysis
? nutritional therapy
? Treat cardiovascular complications
? Treat anemia
? Treat renal osteodystrophy
? Keep the balance of water,electrolytes and acid-
base
27
Nutritional Therapy
? Energy intake
– 30--35 kcal/kg/day
? Protein intake
– 0.6g/kg/day
– Necessary amino-acid
? Vitamins
– VitC,VitB6
– VitD
28
Treat cardiovascular complications
? hypertension
? Heart failure
? pericarditis
29
Treatment of anemia
? Erythropoietin
– initial,100u/kg/week,divide in 2-3 dosage
– Increase 50% dosage,Hct increase < 2% per month
– Decrease 25% dosage,Hct increase > 8% per month
– target,Hct 33%--36% Hb 11— 12g/dl
? Iron supplement
– target,SF>100,saturated TRF > 20%
– oral,200mg iron/d
– Intra venous,100mg iron per HD,total 10 times
– target reached,25— 125mg iron per week
30
Treat renal osteodystrophy
? Treatment of hypocalcemia and
hyperphosphatemia
? Use of Vit D
? parathyriodectomy
31
Keep the balance of water,electrolytes
and acid-base
32
Renal Replacement
? Dialysis
– Hemodialysis
– Peritoneal dialysis
? Renal transplant
