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