1. Chronic Renal Failure Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University Jiang Zongpei

7. Renal pathologic change in CRF Normal Sclerosis

8. Stages of chronic kidney disease: A clinical action plan Replacement (if uremia is present) Preparation for kidney replacement therapy. Evaluating and treating complications Estimating progression Diagnosis and treatment. Treatment of basic diseases. Slowing of progression. Cardiovascular disease risk reduction. Action Uremic symptoms become prominent and usually the patients need to accept renal replacement therapy <15 Kidney failure 5 15-29 Severely↓GFR 4 clinical and laboratory complications of CKD become progressive 30-59 Moderately↓GFR 3 60-89 Kidney damage with mildly↓GFR 2 patients often remain free of symptom ≥ 90 Kidney damage with normal of ↑GFR 1 symptom GFR Description Stage

18. Decreased renal Function Decreased 1.25 (oh) 2 D 3 A1 3+ Intoxication Accumulation of β 2 microglobulin Hyperphosphatemia Decreased ionized Ca 2+ Hyperparathyroidism Decreased expression of calcium- sensing receptor Hyperplasia Of the parathyroid glands Osteitis fibrosa cystica (high-turnover bone disease) Osteomalacia Adynamic bone disease Dialysis-related amyloidosis Metabolic acidosis Excess Ca and vit D,PD,diabetes

34. Reversible causes of renal failure Physical examination, chest X-ray Congestive heart failure Blood pressure, chest X-ray Hypertension Drug history Nephrotoxic agents Serum electrolytes, calcium, phosphate uric acid Hypokalemia, hypercalcemia, and hy peruricemia(usually >15 mg/dL) Orthostatic blood pressure and pulse:↓blood pressure and ↑pulse upon sitting up from a supine position Extracellular fluid volume depletion Bladder catheterization, then renal ultrasound Obstruction Urine culture and sensitivity tests Infection Diagnostic clues Reversible factors

40. MANAGING COMPLICATIONS OF CHRONIC RENAL FAILURE Cardiovascular Disease Dialysis immediately Uremic Pericarditis Water and salt intake Diuretics Digoxin ACE inhibitors ARB Dialysis immediately Congestive Heart Failure Life-style changes Hyperlipidemia Hypertension CKD related risk factor Risk factor

42. Management guidelines for correction of anemia of chronic renal disease Iron 1. Monitor iron stores by percent transferrin saturation (TSat) and serum ferritin . 2. If patient is iron-deficient (Tsat <20%; serum ferritin<100 ug/L, administer iron, 50-100 mg IV twice per week for 5 weeks; if iron are still low, repeat the same course.) 3. If iron indices are normal yet Hb is still inadequate, administer IV iron as outlined above; monitor Hb, Tsat, and ferritin. 4. Withhold iron therapy when TSat >50% and/or ferritin >800 ng/mL(>800 ug/L). Increase Hb by 1-2 g/dL over 4-week period Optimal rate of correction ≤ 12 g/dL Target Hb: 0.45 ug/kg administered as a single IV or SC injection once weekly 0.75 ug/kg administered as a single IV or SC injection once every 2 Weeks Starting dosage: Darbepoetin alfa Increase Hb by 1-2 g/dL over 4-week period Optimal rate of correction 11-12 g/dL Target hemoglobin(Hb): 50-150 units/kg per week IV or SC (once, twice, or three times per week ) Starting dosage: Erythropoietin

45. Peritoneal dialysis is through a peritoneal catheter that allows infusion of a dialysate solution into the abdominal cavity, which allows transfer of solutes across the peritoneal membrane. Patients generally have the choice of performing their own exchanges (2-3 L of dialysate, 4-5 times during daytime hours) or using an automated device at night. The most common complication of peritoneal dialysis is peritonitis. MANAGING COMPLICATIONS OF CHRONIC RENAL FAILURE Peritoneal dialysis

46. Up to 50% of all patients with ESRD are suitable for kidney transplantation. The most common method for kidney transplantantion is put the graft in right side plevic cavity. Two-thirds of kidney transplants come from deceased donors, and the others from living related or unrelated donors. Immunosuppressive drugs developed very fast in these years. (Cyclosporine, MMF, tacrolimus and rapamycin.) MANAGING COMPLICATIONS OF CHRONIC RENAL FAILURE kidney transplantation.

48. Thanks for your attention!