|
|
(47 intermediate revisions by 7 users not shown) |
Line 1: |
Line 1: |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
| | __NOTOC__ |
| | |
| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
Line 10: |
Line 9: |
| ICDO = | | | ICDO = | |
| OMIM = | | | OMIM = | |
| MedlinePlus = | | | MedlinePlus = 000471| |
| }} | | }} |
|
| |
| {{Chronic renal failure}} | | {{Chronic renal failure}} |
| {{SI}} | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
|
| |
|
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} | | {{CMG}}; {{AE}} {{AN}} [[User:Sergekorjian|Serge Korjian]], [[User:YazanDaaboul|Yazan Daaboul]] ; {{FT}} |
|
| |
|
| | '''Synonyms and keywords''': Established chronic kidney disease; end-stage renal disease; end stage renal disease; ESRD; chronic kidney failure; chronic kidney disease; CKD; chronic renal insufficiency; CRI; renal failure, chronic; kidney failure, chronic; uremia; uremic syndrome |
| | |
| | ==[[Chronic renal failure overview|Overview]]== |
|
| |
|
| ==[[Chronic renal failure overview|Overview]]== | | ==[[Chronic renal failure definition|Definition]]== |
|
| |
|
| ==[[Chronic renal failure pathophysiology|Pathophysiology]]== | | ==[[Chronic renal failure pathophysiology|Pathophysiology]]== |
|
| |
|
| ==[[Chronic renal failure epidemiology and demographics|Epidemiology & Demographics]]== | | ==[[Chronic renal failure causes|Causes]]== |
|
| |
|
| ==[[Chronic renal failure natural history|Natural History, Complications & Prognosis]]== | | ==[[Chronic renal failure differential diagnosis|Differentiating Chronic renal failure from other Diseases]]== |
|
| |
|
| ==Diagnosis== | | ==[[Chronic renal failure epidemiology and demographics|Epidemiology and Demographics]]== |
|
| |
|
| :[[Chronic renal failure history and symptoms|History and symptoms]] | [[Chronic renal failure laboratory tests|Lab tests]] | [[Chronic renal failure electrocardiogram|Electrocardiogram]] | [[Chronic renal failure CT|CT]] | [[Chronic renal failure echocardiography or ultrasound|Echocardiograpgy or Ultrasound]] | [[Chronic renal failure other imaging findings|Other Imaging Findings]] | [[Chronic renal failure other diagnostic studies|Other Diagnostic Studies]]
| | ==[[Chronic renal failure risk factors|Risk factors]]== |
|
| |
|
| ==Causes== | | ==[[Chronic renal failure screening|Screening]]== |
| ===Common Causes===
| |
|
| |
|
| ===Causes by Organ System=== | | ==[[Chronic renal failure natural history|Natural History, Complications and Prognosis]]== |
| {|style="width:80%; height:100px" border="1"
| |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" |[[Malignant hypertension]], [[Systemic hypertension]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Chemical / poisoning'''
| |
| |bgcolor="Beige"| [[Arsenic]], [[Bismuth]], [[Mercury]], [[Lead]], [[Nitrosourea compounds]], [[Pentamidine]], [[Radiocontrast agents]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dermatologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Drug Side Effect'''
| |
| |bgcolor="Beige"|[[Acetominophen]], [[Acyclovir ]], [[Allopurinol]], [[Aminoglycosides]], [[Angiotensin-converting enzyme inhibitors]], [[Anticoagulants]], [[Aspirin]], [[bevacizumab]], [[Bismuth]], [[Cisplatin]], [[Carboplatin]], [[Carbon tetrachloride]], [[Carmustine]], [[Celecoxib]], [[Chloroquine]], [[Cimetidine]], [[Cocaine]], [[Cyclosporine]], [[Erythromycin]], [[Esomeprazole ]], [[Foscarnet]], [[Fenofibrate]], [[Furosemide]], [[Gentamicin]], [[Gemfibrozil]], [[Hydroxychloroquine]], [[Ibuprofen]], [[Indinavir]], [[Infliximab ]], [[Ifosphamide]], [[Isoniazid]], [[Lansoprazole ]], [[Laxatives]], [[Lithium]], [[Lomustine]], [[Methicillin]], [[Mitomycin C]], [[Mesalamine]], [[Naproxen]], [[Interferons]], [[Omeprazole ]], [[Pamidronate]], [[Pantoprazole ]], [[Penicillin-like drugs]], [[Phenytoin ]], [[Propylthiouracil]], [[Quinine]], [[Rabeprazole]], [[Rifampicin]], [[Sickle cell disease ]], [[Sulfa-containing antibiotics]], [[Sulfonamides]], [[Tacrolimus]], [[Tenofovir]], [[Thiazides]], [[Trimethadione ]], [[Vancomycin]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Ear Nose Throat'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Endocrine'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Environmental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Gastroenterologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Genetic'''
| |
| |bgcolor="Beige"| [[Alport's syndrome]], [[Balkan endemic nephropathy]], [[Adenine phosphoribosyltransferase deficiency]], [[Alström syndrome]], [[Barakat syndrome]], [[Bardet-Biedl syndrome]], [[Fabry's Disease]], [[Hereditary Nephritis]], [[Lecithin cholesterol acyltransferase deficiency]], [[Lesch-Nyhan syndrome]], [[Loken Senior syndrome]], [[Lowe syndrome]], [[Nail-Patella Syndrome]], [[Papillorenal syndrome]], [[Polycystic kidney disease]], [[Townes-Brocks syndrome]], [[X-linked recessive nephrolithiasis type 1]], [[Vesicoureteral reflux]], [[X-linked hypophosphatemia]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Hematologic'''
| |
| |bgcolor="Beige"|[[Acute intermittent porphyria]], [[Light chain disease]], [[Myeloma]], [[Normocytic normochromic anemia]], [[Renal vein thrombosis]], [[Thrombotic thrombocytopenic purpura]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Iatrogenic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Infectious Disease'''
| |
| |bgcolor="Beige"|[[Chronic pyelonephritis]], [[Schistosoma haematobium]], [[Tuberculosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Musculoskeletal / Ortho'''
| |
| |bgcolor="Beige"|[[Idiopathic multicentric osteolysis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Neurologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Nutritional / Metabolic'''
| |
| |bgcolor="Beige"|[[Calcium phosphate deposition]], [[cystinosis]], [[Diabetic nephropathy]], [[Fabry's disease]], [[Hyperkalemia]], [[Hyperlipidemia]], [[Hyperoxaluria]], [[Hyperphosphatemia]], [[Metabolic acidosis]], [[Oxalosis]], [[X-linked hypophosphatemia]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Obstetric/Gynecologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Oncologic'''
| |
| |bgcolor="Beige"| [[Metastatic prostate cancer]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Opthalmologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Overdose / Toxicity'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Psychiatric'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Pulmonary'''
| |
| |bgcolor="Beige"|[[Goodpasture’s syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Renal / Electrolyte'''
| |
| |bgcolor="Beige"| [[Analgesic nephropathy]], [[Alport's syndrome]], [[Balkan endemic nephropathy]], [[Chronic Glomerulonephritis]], [[Chronic Pyelonephritis]], [[Congenital Nephrotic Syndrome]], [[Diabetic nephropathy]], [[Goodpasture’s syndrome]], [[Focal glomerulosclerosis]], [[Glomerulosclerosis]], [[Hypertensive nephrosclerosis ]], [[Hereditary Nephritis]], [[IgA nephropathy]], [[Interstitial Nephritis]], [[Lupus nephritis]], [[Papillorenal syndrome]], [[Polycystic kidney disease]],[[Medullary cystic kidney disease]], [[Medullary sponge kidney]], [[Membranoproliferative Glomerulonephritis]], [[Membranous nephritis]], [[Nephrolithiasis]], [[Nephrosclerosis]], [[Obstructive uropathy]], [[Proteinuria]], [[Reflux nephropathy]], [[Renal artery stenosis]], [[Type IV renal tubular acidosis]], [[Vesicoureteral reflux]], [[Xanthogranulomatous pyelonephritis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Rheum / Immune / Allergy'''
| |
| |bgcolor="Beige"|[[Goodpasture’s syndrome]], [[Lupus nephritis]], [[Rheumatoid arthritis]], [[Scleroderma]], [[Systemic Lupus Erythematosus]], [[Systemic sclerosis]], [[Vasculitis]], [[Wegener's granulomatosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Sexual'''
| |
| |bgcolor="Beige"| [[Benign prostatic hyperplasia]], [[Denys-Drash syndrome]], [[Metastatic prostate cancer ]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Trauma'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Urologic'''
| |
| |bgcolor="Beige"| [[Obstructive uropathy]], [[Reflux nephropathy]], [[Hydronephrosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Miscellaneous'''
| |
| |bgcolor="Beige"|[[Amyloidosis]], [[Chronic inflammation]], [[Hemolytic uremic syndrome]]
| |
|
| |
| |-
| |
| |}
| |
| ===Causes in Alphabetical Order===
| |
| {{MultiCol}}
| |
| *[[Acetominophen]]
| |
| *[[Acute intermittent porphyria]]
| |
| *[[Acyclovir ]]
| |
| *[[Adenine phosphoribosyltransferase deficiency]]
| |
| *[[Allopurinol]]
| |
| *[[Alport's syndrome]]
| |
| *[[Alström syndrome]]
| |
| *[[Aminoglycosides]]
| |
| *[[Amyloidosis]]
| |
| *[[Analgesic nephropathy]]
| |
| *[[Angiotensin-converting enzyme inhibitors]]
| |
| *[[Anticoagulants]]
| |
| *[[Aspirin]]
| |
| *[[Balkan endemic nephropathy]]
| |
| *[[Barakat syndrome]]
| |
| *[[Bardet-Biedl syndrome]]
| |
| *[[Benign prostatic hyperplasia]]
| |
| *[[Bevacizumab]]
| |
| *[[Bismuth]]
| |
| *[[Calcium phosphate deposition]]
| |
| *[[Carbon tetrachloride ]]
| |
| *[[Carboplatin]]
| |
| *[[Carmustine]]
| |
| *[[Celecoxib]]
| |
| *[[Chloroquine]]
| |
| *[[Chronic Glomerulonephritis]]
| |
| *[[Chronic inflammation]]
| |
| *[[Chronic Pyelonephritis]]
| |
| *[[Cimetidine]]
| |
| *[[Cisplatin]]
| |
| *[[Cocaine]]
| |
| *[[Congenital Nephrotic Syndrome]]
| |
| *[[Cyclosporine]]
| |
| *[[Cystinosis]]
| |
| *[[Denys-Drash syndrome]]
| |
| *[[Diabetic nephropathy]]
| |
| *[[Erythromycin]]
| |
| *[[Esomeprazole ]]
| |
| *[[Fabry's Disease]]
| |
| *[[Fenofibrate]]
| |
| *[[Furosemide]]
| |
| *[[Focal glomerulosclerosis]]
| |
| *[[Foscarnet]]
| |
| *[[Gemfibrozil]]
| |
| *[[Gentamicin]]
| |
| *[[Glomerulosclerosis]]
| |
| *[[Goodpasture’s syndrome]]
| |
| *[[Hemolytic uremic syndrome]]
| |
| *[[Hereditary Nephritis]]
| |
| *[[Hydroxychloroquine]]
| |
| *[[Hyperkalemia]]
| |
| *[[Hyperlipidemia]]
| |
| *[[Hyperoxaluria]]
| |
| *[[Hyperphosphatemia]]
| |
| *[[Hypertensive nephrosclerosis ]]
| |
| *[[Ibuprofen]]
| |
| *[[Idiopathic multicentric osteolysis]]
| |
| *[[IgA nephropathy]]
| |
| *[[Indinavir]]
| |
| *[[Infliximab ]]
| |
| *[[Interstitial Nephritis]]
| |
| *[[Ifosphamide]]
| |
| *[[Isoniazid]]
| |
| *[[Jeune's thoracic dystrophy syndrome]]
| |
| *[[Lansoprazole ]]
| |
| *[[Laxatives]]
| |
| *[[Lead]]
| |
| *[[Lecithin cholesterol acyltransferase deficiency]]
| |
| *[[Lesch-Nyhan syndrome]]
| |
| *[[Light chain disease]]
| |
| *[[Lithium]]
| |
| {{ColBreak}}
| |
| *[[Loken Senior syndrome]]
| |
| *[[Lomustine]]
| |
| *[[Lowe syndrome]]
| |
| *[[Lupus nephritis]]
| |
| *[[Malignant hypertension]]
| |
| *[[Medullary cystic kidney disease]]
| |
| *[[Medullary sponge kidney]]
| |
| *[[Membranoproliferative Glomerulonephritis]]
| |
| *[[Membranous nephritis]]
| |
| *[[Metabolic acidosis]]
| |
| *[[Metastatic prostate cancer ]]
| |
| *[[Methicillin]]
| |
| *[[Mesalamine]]
| |
| *[[Mitomycin C]]
| |
| *[[Myeloma]]
| |
| *[[Nail-Patella Syndrome]]
| |
| *[[Naproxen]]
| |
| *[[Nephrolithiasis]]
| |
| *[[Nephrosclerosis]]
| |
| *[[Nitrosourea compounds]]
| |
| *[[Normocytic normochromic anemia]]
| |
| *[[Interferons]]
| |
| *[[Obstructive uropathy]]
| |
| *[[Omeprazole ]]
| |
| *[[Oxalosis]]
| |
| *[[Pamidronate]]
| |
| *[[Pantoprazole ]]
| |
| *[[Papillorenal syndrome]]
| |
| *[[Penicillin-like drugs]]
| |
| *[[Pentamidine]]
| |
| *[[Phenytoin ]]
| |
| *[[Polycystic kidney disease]]
| |
| *[[Propylthiouracil]]
| |
| *[[Proteinuria]]
| |
| *[[Quinine]]
| |
| *[[Rabeprazole]]
| |
| *[[Radiocontrast agents]]
| |
| *[[Reflux nephropathy]]
| |
| *[[Renal artery stenosis]]
| |
| *[[Renal vein thrombosis]]
| |
| *[[Rheumatoid arthritis]]
| |
| *[[Rifampicin]]
| |
| *[[Schistosoma haematobium]]
| |
| *[[Scleroderma]]
| |
| *[[Sickle cell disease ]]
| |
| *[[Sulfa-containing antibiotics]]
| |
| *[[Sulfonamides]]
| |
| *[[Systemic hypertension]]
| |
| *[[Systemic Lupus Erythematosus]]
| |
| *[[Systemic sclerosis]]
| |
| *[[Tacrolimus]]
| |
| *[[Tenofovir]]
| |
| *[[Thrombotic thrombocytopenic purpura]]
| |
| *[[Thiazides]]
| |
| *[[Townes-Brocks syndrome]]
| |
| *[[Trimethadione ]]
| |
| *[[Tuberculosis]]
| |
| *[[Type IV renal tubular acidosis]]
| |
| *[[Vancomycin]]
| |
| *[[Vasculitis]]
| |
| *[[Vesicoureteral reflux]]
| |
| *[[Wegener's granulomatosis]]
| |
| *[[Xanthogranulomatous pyelonephritis]]
| |
| *[[X-linked hypophosphatemia]]
| |
| *[[X-linked recessive nephrolithiasis type 1]]
| |
| {{EndMultiCol}}
| |
|
| |
|
| | ==[[Chronic renal failure diagnosis|Diagnosis]]== |
|
| |
|
| The most common causes of CRF are [[diabetic nephropathy]], [[hypertension]], and [[glomerulonephritis]]. Together, these cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy.
| | [[Chronic renal failure history and symptoms|History]] | [[Chronic renal failure physical examination|Physical Examination]] | [[Chronic renal failure laboratory tests|Laboratory Findings]] | [[Chronic renal failure electrocardiogram|Electrocardiogram]] | [[Chronic renal failure x ray|X ray]] | [[Chronic renal failure CT|CT]] | [[Chronic renal failure echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Chronic renal failure other imaging findings|Other Imaging Findings]] | [[Chronic renal failure other diagnostic studies|Other Diagnostic Studies]] |
|
| |
|
| Historically, kidney disease has been classified according to the part of the renal anatomy that is involved, as:
| | ==[[Chronic renal failure treatment|Treatment]]== |
| * Vascular, includes large vessel disease such as bilateral [[renal artery stenosis]] and small vessel disease such as ischemic nephropathy, [[hemolytic-uremic syndrome]] and [[vasculitis]]
| |
| * Glomerular, comprising a diverse group and subclassified into
| |
| ** Primary Glomerular disease such as [[focal segmental glomerulosclerosis]] and [[IgA nephropathy]]
| |
| ** Secondary Glomerular disease such as [[diabetic nephropathy]] and [[lupus nephritis]]
| |
| * Tubulointerstitial including [[polycystic kidney disease]], drug and toxin-induced chronic tubulointerstitial nephritis and [[reflux nephropathy]]
| |
| * Obstructive such as with bilateral [[kidney stone]]s and diseases of the [[prostate]]
| |
|
| |
|
| ==Treatment==
| | [[Chronic renal failure medical therapy|Medical Therapy]] | [[Chronic renal failure primary prevention|Primary Prevention]] | [[Chronic renal failure secondary prevention|Secondary Prevention]] | [[Chronic renal failure cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Chronic renal failure future or investigational therapies|Future or Investigational Therapies]] |
| The goal of therapy is to slow down or halt the otherwise relentless progression of CRF to ESRD. Control of [[blood pressure]] and treatment of the original disease, whenever feasible, are the broad principles of management. Generally, [[angiotensin converting enzyme inhibitor]]s (ACEIs) or angiotensin II receptor antagonists (ARBs) are used, as they have been found to slow the progression to ESRD.<ref>Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet. 1998 Oct 17;352(9136):1252-6. PMID 9788454.</ref><ref>Ruggenenti P, Perna A, Gherardi G, Garini G, Zoccali C, Salvadori M, Scolari F, Schena FP, Remuzzi G. Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuria. Lancet. 1999 Jul 31;354(9176):359-64. PMID 10437863.</ref>
| |
| | |
| Replacement of [[erythropoietin]] and [[vitamin D3]], two hormones processed by the kidney, is usually necessary, as is [[calcium]]. [[Phosphate binders]] are used to control the serum [[phosphate]] levels, which are usually elevated in chronic renal failure.
| |
| | |
| After ESRD occurs, renal replacement therapy is required, in the form of either [[dialysis]] or a [[Kidney_transplant|transplant]].
| |
| | |
| * '''Treatment of Reversible Exacerbants'''
| |
| *:* Volume Depletion
| |
| *:*:* May be subtle
| |
| *:*:* Autoregulation impaired with [[DM]], [[hypertension]], CRI--decreases GFR with mild volume depletion
| |
| *:*:* Careful trial of volume repletion may--return of baseline renal function
| |
| *:*:* (Increase dietary Na, reduce diuretic dosing)
| |
| *:* [[Nephrotoxin]]s
| |
| *:*:* NSAIDs
| |
| *:*:*:* Most toxic in setting of volume depletion, CHF, diuretic use
| |
| *:*:*:* Reduce [[prostaglandin]] (PG) synthesis--unopposed vasoconstriction with decreased GFR
| |
| *:*:*:* Can also cause ATN ([[acute tubular necrosis]])
| |
| *:*:* [[Aminoglycoside]]s
| |
| *:*:*:* Nonoliguric ARF typically occurs at 7-10 days
| |
| *:*:*:* Increased risk with older patients, prolonged therapy and greater total dose
| |
| *:*:* IV contrast
| |
| *:*:*:* ARF usually occurs within 24-48 hours of dye administration
| |
| *:*:*:* Peak Cr after 5-7 days with return to baseline at 10-14 days
| |
| *:*:*:* Risk ARF increased with DM and higher volume of dye
| |
| *:*:* Note: certain meds increase serum Cr (via inhibiting Cr secretion or interfering with assay) without changing GFR, e.g. cimetidine, trimethoprim (TMP), cefoxitin, flucytosine; BUN will not rise because GFR is preserved
| |
| *:* Urinary Tract Obstruction
| |
| *:*:* Most commonly due to prostatic hypertrophy in men
| |
| *:*:* Other causes:
| |
| *:*:*:* [[Nephrolithiasis]]
| |
| *:*:*:* [[Tumor]]
| |
| *:*:*:* [[Neurogenic bladder]]
| |
| *:*:* Results in reduced [[GFR]] and impaired tubular function
| |
| *:*:* Consider ultrasound, urologic evaluation
| |
| * '''Reduce Progression'''
| |
| *:* Protective therapy most effective if initiated '''early''', before Cr > 1.5-2.0 mg/dL
| |
| *:* Treat [[Hypertension]]
| |
| *:*:* Systemic [[hypertension]]--elevated intraglomerular pressure +/or glom hypertrophy
| |
| *:*:* Blood Pressue (BP) control shown in multiple trials to slow progression of renal disease
| |
| *:*:* Goal BP < 130/80-85; < 125/75 in patients with proteinuria > 1-2 g/d
| |
| *:*:* ACE inhibitors (ACEI) and Angiotensin II receptor blockers (ARB) preferred 1st line agents due to renoprotective effects
| |
| *:*:* Additional agents as needed, including diuretics if volume overload
| |
| *:* Restrict Dietary Protein
| |
| *:*:* Controversial – may decrease intraglomerular pressure
| |
| *:*:* Conflicting studies – some show benefit, others do not
| |
| *:*:* No significant adverse effects shown in large trial
| |
| *:*:* Recommendations
| |
| *:*:*:* No restriction (> 0.8 g/kg/d) if GFR 25-55 mL/min
| |
| *:*:*:* Limit protein to 0.8 g/kg/d if progression or uremic symptoms
| |
| *:*:*:* Limit to 0.6 g/kg/d if severe CRI (GFR 13-25 mL/min)
| |
| *:*:* Close follow-up by dietician given risk of malnutrition in CRI population
| |
| *:* Control blood sugar:
| |
| *:*:* Tight control (A1c < 7.0, FBS 70-120) reduces progression in DM I
| |
| *:*:* Unclear if as beneficial in DM II, but potentially helpful
| |
| * '''Treat complications'''
| |
| *:* Volume Overload
| |
| *:*:* Impaired excretion of Na/H2O due to decreased GFR +/- AII/aldo activation
| |
| *:*:* Restrict dietary Na to 1-2 g/d if hypertension or edema
| |
| *:*:* [[Diuretic]]s
| |
| *:*:*:* [[Thiazide]]s ineffective if [[GFR]] < 25 mL/min (~ Cr > 2-3)
| |
| *:*:*:* Switch to loop diuretic as Cr rises; may need bid dosing
| |
| *:*:*:* Addition of [[thiazide]] to loop diuretic can--additional diuresis
| |
| *:*:*:* Watch for excessive volume depletion
| |
| *:* [[Hyperkalemia]]
| |
| *:*:* K usually maintained until GFR < 15-20 mL/min
| |
| *:*:* Increased risk of [[hyperkalemia]] with oliguria, high [[K]] diet, ([[ACEI]] therapy)
| |
| *:*:* Increased risk with many meds: [[ACEI]], [[NSAID]]s, K-sparing diuretics, [[digoxin]], [[TMP]]
| |
| *:*:* Increased risk in diabetics with type IV RTA
| |
| *:*:* Management
| |
| *:*:*:* Low K diet (< 60 mEq/d) once GFR < 15 mL/min
| |
| *:*:*:* Avoidance of salt substitutes (may contain K salts)
| |
| *:*:*:* +/- [[loop diuretic]]
| |
| *:*:*:* Low dose Kayexelate (5 g with meals) if needed
| |
| *:* Ca/PO4 Abnormalities
| |
| *:*:* Reduced renal synthesis 1,25-(OH)2D--low serum Ca-- 2° [[hyperparathyroidism]]
| |
| *:*:*:* (Occurs when [[GFR]] < 40 mL/min)
| |
| *:*:* Reduced [[GFR]]--phosphate retention
| |
| *:*:* Elevated [[parathyroid hormone]] ([[PTH]])--mobilization of Ca from bone; increased excretion PO4
| |
| *:*:*:* Allows maintenance of normal Ca/PO4 while GFR > 30 mL/min
| |
| *:*:*:* Causes [[renal osteodystrophy]]
| |
| *:*:*:* Once [[GFR]] < 25-30 mL/min, [[hyperphosphatemia]] occurs
| |
| *:*:* Therapy goals = normalize Ca/PO4 and maintain [[parathyroid hormone]] (PTH)< 200 (2-3x uln)
| |
| *:*:*:* Ca/PO4 management should be initiated when Cr ~ 2
| |
| *:*:*:* CaxPO4 product should be < 60 to prevent met calcification
| |
| *:*:*:* Low PO4 diet: < 800 mg/d (challenging)
| |
| *:*:*:* Ca-based oral PO4 binders: Ca acetate or CaCO3 with meals
| |
| *:*:*:* Avoid Al-based PO4 binders except for acute therapy of hi CaxPO4 products
| |
| *:*:*:*:* (Al toxicity = [[osteomalacia]], [[anemia]], [[encephalopathy]])
| |
| *:*:*:* Avoid Ca citrate (increases gastrointestinal absorption of aluminum)
| |
| *:*:*:* RenaGel = new non-Ca/Al-containing PO4 binder (cationic polymer)
| |
| *:*:*:*:* (For patients who cannot tolerate CaCO3 or need additional agent)
| |
| *:*:*:* [[Calcitriol]] 0.125-0.25 mg/d improves Ca & PTH levels, decreases bone disease
| |
| *:*:*:*:* (Monitor Ca--reduce dose if hyercalcemic)
| |
| *:* [[Metabolic Acidosis]]
| |
| *:*:* Occurs when [[GFR]] < 25 mL/min due to inability to excrete H+ ions
| |
| *:*:* Underlying cause = impaired renal NH3 prodxn and HCO3 reabsorption
| |
| *:*:* Risk = bone buffering of acidosis--worsened osteodystrophy via Ca/PO4 loss
| |
| *:*:*:* Increased skeletal muscle breakdown--loss of lean body mass
| |
| *:*:* Therapy goal = HCO3 > 22 mEq/L via alkali therapy (NaHCO3 0.5-1 mEq/kg/d)
| |
| *:* [[Anemia]]
| |
| *:*:* Normocytic, normochromic, hypoproliferative anemia due to reduced erythropoietin production
| |
| *:*:* May be exacerbated by reduced rbc survival, coexistent Fe/folate deficiency, etc.
| |
| *:*:* Generally occurs when Cr > 2-3 mg/dL
| |
| *:*:* If untreated, [[hematocrit]] (Hct) usually stabilizes at ~ 25
| |
| *:*:* Therapy recommendations = erythropoietin if symptomatic anemia or Hgb < 10 g/dL (in pre-dialysis patients)
| |
| *:*:*:* Goal Hct 33-36
| |
| *:*:*:* Must replete Fe stores first (oral FeSO4)
| |
| *:*:*:* Initial dose ~ 150 U/kg sc weekly to increase Hct
| |
| *:*:*:* Maintenance dose ~ 75 U/kg weekly once Hct goal reached
| |
| *:*:*:* Improves symtoms and may reduce left ventricle (LV) mass (via improvemt of hyperdynamic state)
| |
| *:*:*:* Side effects = increased blood pressure (BP); may need to augment antihypertensive regimen
| |
| * '''Plan for Renal Replacement Therapy (RRT)'''
| |
| *:* Indications for Dialysis
| |
| *:*:* [[Malnutrition]]
| |
| *:*:* CrCl M 10-15 mL/min
| |
| *:*:* Symptoms of [[uremia]] related complications ([[pericarditis]], [[encephalopathy]])
| |
| *:*:* [[Hyperkalemia]], acidosis not responsive to medical therapy
| |
| *:*:* Volume overload / [[CHF]]
| |
| *:* RRT modalities
| |
| *:*:* [[Hemodialysis]]
| |
| *:*:* [[Peritoneal dialysis]]
| |
| *:*:* [[Renal transplant]]
| |
| *:* Access for [[hemodialysis]] should be established when [[GFR]] < 25 mL/min (estimated ESRD within 1 year)
| |
| *:* Diabetics tend to require dialysis sooner than non-diabetics because more symptomatic at given [[GFR]]
| |
| * Indications for referral to nephrologist
| |
| *:* Unclear etiology of new or chronic [[renal insufficiency]]
| |
| *:* For diagnostic evaluation, e.g. [[biopsy]]
| |
| *:* [[GFR]] < 50 mL/min: i.e. '''before''' vascular access/RRT required
| |
| | |
| ==Prognosis==
| |
|
| |
|
| ==See also== | | ==See also== |
| *[[Acute renal failure]] | | *[[Acute kidney injury]] |
| *[[Dialysis]] | | *[[Dialysis]] |
| *[[Hepatorenal syndrome]] | | *[[Hepatorenal syndrome]] |
| *[[Renal failure]]
| |
| *[[Artificial kidney]]
| |
|
| |
| ==References==
| |
| {{reflist|2}}
| |
|
| |
|
| ==External links== | | ==External links== |
|
| |
|
| *[http://www.kidney.org/ National Kidney Foundation] | | *[http://www.kidney.org/ National Kidney Foundation] |
| *[http://www.emedicine.com/emerg/topic501.htm Renal Failure, Chronic and Dialysis Complications] - emedicine.com
| |
| *[http://www.emedicine.com/med/topic374.htm Chronic Renal Failure] - emedicine.com
| |
| <br>
| |
|
| |
|
| {{Nephrology}} | | {{Nephrology}} |
|
| |
| [[Category:Kidney diseases]] | | [[Category:Kidney diseases]] |
| [[Category:Organ failure]] | | [[Category:Organ failure]] |
| [[Category:Nephrology]] | | [[Category:Nephrology]] |
|
| |
| [[de:Chronisches Nierenversagen]]
| |
| [[es:Insuficiencia renal crónica]]
| |
| [[id:Gagal ginjal kronis]]
| |
| [[it:Insufficienza renale]]
| |
| [[ja:慢性腎不全]]
| |
| [[pt:Insuficiência renal crônica]]
| |
| [[ru:Хроническая почечная недостаточность]]
| |
| [[sv:Kronisk njursvikt]]
| |
|
| |
|
|
| |
|
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |