Internal Diseases and Therapy · MU Sofia

121. Chronic renal failure – stages and clinical course

Covers chronic kidney failure as a gradual, irreversible loss of nephrons, listing its underlying causes and the diseases that lead to it, then the diagnostic criteria based on kidney damage and GFR. A five-stage table sets out GFR ranges, symptoms and serum creatinine for each stage. It goes on to describe blood pressure targets, anaemia, acidosis, lipid and renal bone complications with their drug treatments, and the indications for starting dialysis.

Inside: 2 sections · 2 labelled pictures · 1 table · 13 flashcards · 6 min

Topic 122 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 2 sections, about 701 words (6 min of reading), with 13 flashcards.

In this note

  1. Chronic renal failure - stages and clinical course
  2. Treatment in predialysis period of chronic renal failure and indications for dialysis

Chronic renal failure - stages and clinical course

⁵ Fractional excretion of sodium

Chronic renal failure is the gradual decline of renal function over a period of months or years. It is due to the irreversible and progressive destruction of the nephron, this can be due to:

  • Glomerular sclerosis
  • Interstitial fibrosis
  • Tubular atrophy
  • Or arteriolar hyalinosis

Various diseases that can cause CRI include:

  • Chronic glomerulonephritis
  • Diabetic nephropathy
  • Interstitial nephropathies
  • UTI, toxic nephropathies, metabolic disorders, immune disorders
  • Polycystic kidney diseases
  • Renal vascular diseases
  • Systemic vasculitis

We properly define chronic kidney diseases by one of the following two conditions:

  1. 1. Kidney damage >3 months with or without decreased GFR marked by
  2. a. Pathologic abnormalities or
  3. b. Markers of kidney damage including abnormal urinalysis or imaging tests
  4. 2. GFR <60mL/min for >3 months with or without additional kidney damage

There are five stages of chronic kidney damage, we have tabled them below:

⁶ Note, here stages 1 and 2 of chronic kidney failure are joined into the ‘first stage’ of chronic kidney injury for descriptive purposes, as symptomatically they are almost the same.

Elderly patients, or those with other comorbidities (e.g. diabetes, high BP, autoimmune diseases) are more likely to progress through the stages more rapidly, and have poorer outcomes for CRI.

Treatment of chronic kidney failure is centered around the following concepts:

  • Control of blood pressure
  • Action on renal haemodynamics
  • ACEI and AII type 1 receptor blockers
  • Low protein diet
  • Control of hyperlipidemia
  • Limitation of fibrosis

Take a look at the chart above, note how where there is a specific diagnosis (e.g. glomerulonephritis) treatment should first be targeted at that (e.g. corticosteroids). These treatments have been address in the questions above and will not be reexamined here. We are specifically interested in the more conservative treatment thats are designed at limiting damage to the kidneys and the reset of the body.

The most important thing to control in those with CKD is hypertension. The aim is to keep systolic below 140 mmHg and diastolic below 90 mmHg. Where ACR (albumin:creatinine ratio) >70mg.mmol then aim for below 130/80 mmHg. ACEIs should be included for pretty much all patients, while Angiotensin Receptor Blockers (ARBs) can be given as second line. This may lead to refractory hyperkalemia, in which case consider adding furosemide (loo diuretic) to compensate.

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