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1、Chronic Renal Failure,陆福明复旦大学附属华山医院肾脏科,The importance of Chronic Renal Failure,Worldwide, the prevalence of CRF is increasing by more than 5% annuallyThe cost of renal replacement therapy has an increasing impact on health economics in both developed and developing countries,Plasma Creatinine and GF
2、R,Normal GFR 100-125ml/min/1.73m2GFR declines by about 1ml/min/1.73m2 /yearPlasma creatinine concentration can be used to monitor renal function when GFR50ml/minMass screening of plasma creatinine cannot provide early detection of renal diseases in the general population,Causes of CRF,Glomerular dis
3、eases account for 60% of CRF Diabetic nephropathy account for 10-15% of CRF (in USA about 50%)Hypertension: 10-15%Polycystic kidney diseases: 5%Obstructive uropathy: 3-4%Lupus nephropathy: 2-3%Undermined Origin: 5-10%,Evolution of CRF,Glomerular diseases will be decreasedDiabetic and hypertensive ne
4、phropathyChronic nephrotoxicity by environmental pollutants, drugs and herbsIncidence of ESRD: 100-200 per million,Clinic manifestation of CRF,Deterioration of renal function is invariable once GFR is reduced by more than 25%Serial plots of the reciprocal of cr vs. time follows a straight lineOften
5、remain asymptomatic when GFR=25%Uraemic syndrome,Clinical Diagnosis of CRF,Acute or chronic?Often presents acutely when GFR suddenly drops from 20% to 10% or lessTo assess the severity of renal impairmentTo elucidate the causes of renal failureTo ascertain whether the renal failure is acute, or acut
6、e-on-chronicTo assess the patient for renal replacement therapy,Clinical Investigations,The history should include a diligent search for potential nephrotoxic agentsA positive family may indicate heredofamilial diseasesPallor, scratch marks, peripheral oedema and palpable masses in the abdomenA full
7、 examination is important, especially in patients with diabetes,Common Investigations,Renal function profileUrinalysisQuantitation of proteinuriaDetermination of creatinine clearanceLiver function profileHepatitis B and C status,Common Investigations,Serological test such as anti-nuclear antibodies,
8、 complements, immunoglobulin levels, C-reactive protein and anti-neutrophil cytoplasm antibodiesLipid profileUltrasonogram of kidneys for measurement of kidney size and exclusion of structural abnormalitiesDoppler examination of renal arteries when indicated,Management of CRF,Treatment of primary di
9、seaseTreatment of hypertensionUsing ACEI or angiotensin-II receptor blockersAvoiding nephrotoxic agentsLow dietary protein intakePhosphate controlEarly correction of aneamia,Treatment of Hypertension,The target of blood pressure:130/80mmHgMultiple agents are requiredACEI,ARB,B-B,CCB,-B，diureticsBloo
10、d pressure controlled for 24hr,Using ACEI or ARB,ACEI can causes an unacceptable cough in a substantial number of patientsThe risk of hyperkalaemia is small though real.ARF can be happened in patients with severe renal artery stenosis.,Avoiding nephrotoxic Agents,Non-steroidal anti-inflammatory drug
11、s are used too liberallyHerbs: patients often resort to alternative medicine and ingest a wide combination of herbs which leads to a rapid demise of remaining kidney function.,Management of CRF,Urinary obstruction and infection should be treated promptlyFluids overloading should be avoided Early ref
12、erred to nephrologist (GFR30ml/min),Management of CRF,Phosphate binders are given with each meal to bind dietary phosphates in the gutCalcium supplementation is neededActive Vitamin D metabolites are prescribed when PTH is high,Management of CRF,Metabolic acidosis is corrected with sodium bicarbonat
13、eErythopoietin can corrects early anaemia, improves cardiovascular function and preserves residual renal function,Management of CRF,Protein restriction can slow down the progression of renal failure. However, severe malnutrition should be carefully avoided65% of the dietary protein intake should be
14、in the form of high biological value protein,Management of CRF,Vegetable protein may be beneficial in early stages of CRFSaturated fats must be avoidedLipid abnormalities must be given due attentionLow sodium dietary intake,Management of CRF,Cardiovascular mortality is the most important cause of de
15、athAnti-lipid treatment should be given early Aspirin will a beneficial impact on survival Smoking should be avoidedPotassium intake should be reduced when in ESRD,Renal Replacement Therapy,A thorough discussion involving the patient and his family on the different treatment options is mandatoryKidn
16、ey transplantation presents the best means of rehabilitation, especially when it is performed pre-emptively,Renal Replacement Therapy,Integrated approach in the overall management:Peritoneal dialysis can be considered as initial dialytic therapy, while haemodialysis is reserved for patients who are unable to perform PD, Prior to kidney transplantation,Renal Replacement Therapy,Incremental dialysis: the dose of dinlysis is decided based on the amount of residual renal function,THANKS！,
