Nephrology Book

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Chronic Renal FailureAka: End Stage Renal Disease, Chronic Kidney Disease, Chronic Renal Insufficiency, ESRD, CRF

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  1. Epidemiology
    1. Incidence: 200 cases per 1 million persons U.S.
    2. Prevalence
      1. Chronic Kidney Disease
        1. Adults in U.S.: 19 million (11% of the adult population)
      2. End Stage Renal Diseases
        1. Actual 2002: 435,000 in U.S.
        2. Estimated 2010: 650,000 in U.S.
  2. Causes
    1. Diabetes Mellitus (28%)
      1. See Diabetic Nephropathy
      2. Glycemic control is critical to slow progression
      3. Type I Diabetes Mellitus
        1. Progresses to ESRD in 40% of patients
      4. Type II Diabetes Mellitus
        1. Progresses to ESRD in 20% of patients
        2. Type II Diabetes is 10 times as common as Type I
    2. Hypertension (24%)
    3. Glomerulonephritis (21%)
    4. Polycystic Kidney Disease
    5. Urologic disease
      1. Chronic Urinary Tract Infections (Pyelonephritis)
      2. Nephrolithiasis (obstruction)
    6. Vasculitis (e.g. Systemic Lupus Erythematosus)
    7. Drug toxicity
    8. Unknown (20%)
  3. Symptoms
    1. Weakness
    2. Fatigue
    3. Headaches
    4. Anorexia
    5. Nausea
    6. Vomiting
    7. Pruritus
    8. Polyuria
    9. Nocturia
  4. Signs
    1. Hypertension
    2. Congestive Heart Failure
    3. Pericarditis
    4. See Edema in Chronic Renal Failure
  5. Criteria: Chronic kidney disease
    1. Kidney damage for >3 months or
    2. GFR < 60 ml/min/1.73 m2 for >3 months or
      1. Men: Serum Creatinine >1.5 mg/dl
      2. Women: Serum Creatinine >1.3 mg/dl
    3. Significant Proteinuria for >3 months
      1. Urine Albumin >300 mg/24 hours or
      2. Urine Albumin to Creatinine Ratio 200 mg/gram
  6. Stages: NKF Classification System
    1. Stage 1: GFR >90 ml/min despite kidney damage
      1. Microalbuminuria present
    2. Stage 2: Mild reduction (GFR 60-89 min/min)
      1. GFR of 60 may represent 50% loss in function
      2. Parathyroid Hormone starts to increase
    3. Stage 3: Moderate reduction (GFR 30-59 ml/min)
      1. Calcium absorption decreases
      2. Malnutrition onset
      3. Anemia secondary to Erythropoietin deficiency
      4. Left Ventricular Hypertrophy
    4. Stage 4: Severe reduction (GFR 15-29 ml/min)
      1. Serum Triglycerides increase
      2. Hyperphosphatemia
      3. Metabolic Acidosis
      4. Hyperkalemia
    5. Stage 5: Kidney Failure (GFR <15 ml/min)
      1. Azotemia
    6. References
      1. (2002) Am J Kidney Dis 39:S1
      2. Snively (2004) Am Fam Physician 70:1921
  7. Labs: Screening for Chronic Kidney Disease
    1. Indications
      1. History or Family History of causes listed above
      2. All patients over age 60 years old
    2. Initial Screening Tests
      1. Serum Creatinine
      2. Urinalysis
    3. Assess Glomerular Filtration Rate (GFR)
      1. Estimations generally as accurate as 24 hour urine
        1. See Creatinine Clearance for exceptions
      2. Formyla
        1. Cockcroft-Gault equation or
        2. Modification of Diet in Renal Disease (MDRD)
    4. Assess for Proteinuria
      1. General
        1. First morning void spot urine is preferred sample
      2. Step 1: Standard Urine Dipstick for screening
      3. Step 2a: Urine Dipstick 1+ or greater
        1. Obtain protein to Creatinine ratio
        2. Ratio > 200 mg protein/gram Creatinine
          1. Evaluate Proteinuria
        3. Ratio > 200 mg protein/gram Creatinine
          1. Repeat protein to Creatinine ratio yearly
      4. Step 2b: Urine Dipstick negative or trace
        1. Obtain microalbumin to Creatinine ratio
        2. Ratio > 30 mg microalbumin/gram Creatinine
          1. Evaluate microalbuminuria
        3. Ratio < 30 mg microalbumin/gram Creatinine
          1. Repeat microalbumin to Creatinine ratio yearly
    5. Assess other urinary sediment on Urinalysis
      1. Hematuria
      2. Urine White Blood Cells
  8. Imaging: Initial presentation
    1. Renal ultrasound (indicated in most patients)
      1. Consider Doppler of renal arteries
    2. Consider CT or MRI of Kidneys and Liver
    3. Consider Voiding Cystourethrogram
  9. Labs: Findings in Chronic Kidney Disease Stages 3-4
    1. Anemia (Normochromic, Normocytic)
      1. Hematocrit decreases
        1. Serum Creatinine > 2-3
        2. Glomerular Filtration Rate <20-30
      2. Results from decreased Erythropoietin synthesis
    2. Azotemia
    3. Decreased Serum Protein
    4. Serum chemistry abnormalities
      1. Hyperkalemia or Hypokalemia
      2. Metabolic Acidosis
      3. Hypocalcemia
      4. Hyperphosphatemia
  10. Labs: Initial presentation
    1. Basic labs
      1. Basic metabolic panel
      2. Serum Calcium
      3. Serum Phosphorus
      4. Complete Blood Count (CBC)
    2. Additional labs as indicated
      1. Antinuclear Antibody (ANA)
      2. Serum Protein Electrophoresis
      3. HBsAg
      4. xHBC Antibody
      5. HIV Test
      6. ANCA
      7. ASO Titer
      8. Consider Anti-GBM Antibody
      9. Consider complement studies (C3, C4, CH50)
  11. Labs: Monitoring
    1. Labs to repeat every 3-12 months
      1. Serum Creatinine
      2. Serum electrolytes
      3. Serum Calcium
      4. Serum Phosphorus
      5. Serum Albumin
      6. Intact Parathyroid Hormone (iPTH)
    2. Labs to repeat every 12 months
      1. Quantitative measurement of Proteinuria
  12. Diagnostics: Renal Biopsy
    1. Indications
      1. Hematuria and low Creatinine Clearance or Proteinuria
      2. Nephrotic range Proteinuria
      3. Chronic Renal Failure with normal or large kidneys
      4. Acute Renal Failure of unknown cause
    2. Contraindications
      1. Renal length <9 cm
      2. Severe Hypertension
      3. Multiple large renal cysts
      4. Uncorrected bleeding tendency
      5. Hydronephrosis
      6. Acute infection
  13. Management: Secondary Prevention
    1. See Prevention of Kidney Disease Progression
    2. Referral to nephrology indications
      1. Chronic kidney disease with GFR <30 ml/minute
        1. Consider initial evaluation when GFR <60 ml/minute
      2. Chronic kidney disease with rapid progression
      3. Acute failure complicating chronic kidney disease
      4. Unclear etiology for Renal Failure
      5. Renal biopsy
  14. Management: End Stage Renal Disease
    1. Hemodialysis or peritoneal dialysis
      1. Absolute Dialysis Indications
        1. Uremic Symptoms
        2. Uremic Pericarditis
      2. Relative Dialysis Indications
        1. Hypervolemia
        2. Hyperkalemia or other electrolyte abnormalities
        3. Severe Metabolic Acidosis
        4. Creatinine Clearance <10 ml/min (15 in diabetics)
    2. Renal transplantation
      1. Less rejection if transplant before dialysis started
      2. Mange (2001) N Engl J Med 344:726
  15. Management: Erythropoietin (EPO)
    1. Study: EPO in pre-dialysis patients (n=83)
    2. Baseline Status
      1. Serum Creatinine 3 to 8
      2. Hematocrit <30%
    3. Post-EPO Status
      1. Hematocrit >36% in 79% of patients
      2. Improved energy
      3. Improved physical, cognitive, and social function
    4. References
      1. Renicki (1995) Am J Kidney Dis 25:548
  16. Complications
    1. Cardiovascular Disorders
      1. Coronary Artery Disease
      2. Peripheral Vascular Disease
      3. Cardiac arrhythmias
      4. Congestive Heart Failure
      5. Erectile Dysfunction
      6. Pericarditis
    2. Neurologic disorders
      1. Peripheral Neuropathy
      2. Restless Leg Syndrome
      3. Sleep Disorders
    3. Fluids, Electrolytes and Nutrition
      1. Metabolic Acidosis
      2. Muscle wasting and malnutrition
      3. Pseudogout
    4. Gastrointestinal disorders
      1. Chronic Constipation
      2. Gastritis
    5. Miscellaneous disorders
      1. Amenorrhea
      2. Pruritus
  17. Course: Major causes of death in ESRD
    1. Myocardial Infarction
    2. Cerebrovascular Accident
  18. Prognosis
    1. Annual mortality of ESRD: 24%
  19. References
    1. Golder (2003) AAFP Board Review, Seattle
    2. (2002) Am J Kidney Dis 39:s1
    3. Hood (1996) Postgrad Med 100(5):163
    4. Snyder (2005) Am Fam Physician 72(9):1723

Kidney Failure, Chronic (C0022661)

Definition (MSH)The end-stage of CHRONIC RENAL INSUFFICIENCY. It is characterized by the severe irreversible kidney damage (as measured by the level of PROTEINURIA) and the reduction in GLOMERULAR FILTRATION RATE to less than 15 ml per min (Kidney Foundation: Kidney Disease Outcome Quality Initiative, 2002). These patients generally require HEMODIALYSIS or KIDNEY TRANSPLANTATION.
Definition (CSP)irreversible and usually progressive reduction in renal function in which both kidneys have been damaged by a variety of diseases to the extent that they are unable to adequately remove the metabolic products from the blood and regulate the body's electrolyte composition and acid-base balance.
Definition (NCI)Chronic, irreversible renal failure.
Definition (NCI)An irreversible and usually progressive reduction in renal function in which both kidneys have been damaged by a variety of diseases to the extent that they are unable to adequately remove the metabolic products from the blood and regulate the body's electrolyte composition and acid-base balance. (from MSH98)
Definition (NCI)An irreversible and usually progressive reduction in renal function in which both kidneys have been damaged by a variety of diseases to the extent that they are unable to adequately remove the metabolic products from the blood and regulate the body's electrolyte composition and acid-base balance. (from MSH98)
ConceptsDisease or Syndrome (T047)
ICD9585.6, 585.9
EnglishChronic Kidney Failure, Chronic Renal Disease, Chronic renal failure, Chronic renal failure syndrome, CRF, End stage chronc renal failure, End stage chronic renal failure, END STAGE KIDNEY DIS, End Stage Kidney Disease, End Stage Kidney Failure, END STAGE RENAL DIS, End stage renal disease, End stage renal failure, ESRD, KIDNEY FAILURE CHRONIC, RENAL DIS END STAGE, RENAL FAILURE CHRONIC, RENAL FAILURE CHRONIC <UREMIA>, RENAL FAILURE CHRONIC UREMIA
Spanishenfermedad renal terminal, insuficiencia renal en estadio terminal
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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