Chronic renal failure primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]

Overview

Effective measures for the primary prevention of chronic renal failure include treatment of reversible exacerbants such as volume depletion, nephrotoxins, urinary tract obstruction and other causes.

Primary Prevention

Effective measures for the primary prevention of chronic renal failure include:

• 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)
  • Nephrotoxins
    • 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)
    • Aminoglycosides
      • 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