Chronic Renal Insufficiency Lu Fuming Division of Nephrology,Huashan Hospital,Fudan University Chronic Renal Insufficiency Pathogen and pathogenesis Manifestation Laboratory examination Diagnosis and differential diagnosis Treatment Etiology primary glomerular diseases hypertensive nephrosclerosis diabetic nephropathy chronic pyelonephritis multicystic kidney systemic lupus nephritis Pathogenesis Mechanism associated with exacerbation of renal function Mechanism associated with uremic symptom Mechanism Associated With Exacerbation of Renal Function Hyperfiltration theory Effect of proteinuria Trade-off hypothesis in acidosis Disturbance of lipid metabolism Tubulointerstitial injury Renal hypoxia Mechanism Associated With Uremic Symptom Uremic toxins malnutrition trade-off hypothesis Endocrine dysfunction Manifestation of the Uremic Syndrome Gastrointestinal Cardiovascular Hematologic Pulmonary Gastrointestinal Manifestation Anorexia progressing to nausea and vomiting Stomatitis and gingivitis Parotitis Peptic ulcer diathesis Gastritis , duodenitis and enterocolitis Pancreatitis Ascites Cardiovascular Manifestation Accelerated atherosclerosis Cardiomyopathy pericarditis Hematologic Manifestation Anemia Altered neutrophilic chemotaxis Depressed lymphocyte function Platelet dysfunction Pulmonary Manifestation Atypical pulmonary edema Pneumonitis Fibrinous pleuritis Neurologic Manifestation Central Daytime drowsiness,a tendency to sleep,coma Decreased attentiveness Seizures Disorientation and confusion Peripheral Restless leg syndrome Sensorimotor peripheral neuropathy Increased muscle fatigability and muscle cramps Dermatologic Manifestation Pruritus Dystrophic calcification Changes in skin pigmentation Renal Osteodystrophy high bone turnover disease low bone turnover disease Mixed bone disease  Endocrinologic Manifestation Secondary hyperparathyroidism Insulin resistance Type IV hyperlipidemia Altered peripheral thyroxine metabolism Testicular atrophy Ovarian dysfunction Disturbed Water, Electrolytes and Acid-base Balance Water loss and water intoxication Hypo- or hyper-natremia Hypo- or hyper-kalemia Hypo- or hyper-calcemia Hypo- or hyper-phosphatemia metabolic acidosis Experimental Test Urine test Blood test Renal function test Blood biochemical test Radiologic and ultrasonographic test Diagnosis and Differential Diagnosis Diagnosis of chronic kidney disease Etiologic diagnosis Differential diagnosis Stages of Renal Insufficiency stage GFR SCr clinical manifestation  (ml/min)  (umol/L) compensated stage 50—80 <133  asymptom azotemia  25---50 <445  nycturia , anemia renal failure 10---25 <800  nausea,anemia, acidosis uremia <10 >800  obvious uremic symptom  Renal Replacement Dialysis Hemodialysis Peritoneal dialysis Renal transplant * Neurologic Dermatologic Endocrinologic ophthalmic Definition of Chronic Kidney Disease Renal injury: >3 months Decreased GFR: yes or no Renal injury: abnormal experimental tests GFR<60ml/min/1.73m2 ：>3 months Renal injury: yes or no Stages of chronic kidney disease stage description GFR  management 0 high risk for CKD >90  find out the risk factors 1 Renal injury,normal GFR >90 diagnosis,treat complications 2 Lightly decreased GFR 60-89 evaluation of progressing 3 Moderately decreased GFR 30-59 treat complications  Severely decreased GFR 15-29 ready for renal replacement  uremia <15 renal replacement History Physical examination Experimental test Radiologic and ultrasonographic examination Renal biopsy Etiologic diagnosis Differential diagnosis With acute renal failure History : long or short Changes in urine volume Changes in Hb Dermatologic manifestation Bone disease Changes in SCr Length of the kidney Treatment Etiologic treatment Treatment without dialysis Dialysis Renal transplant Etiologic treatment Progress of primary disease hypoperfusion Heart failure hypertension hyperlipidemia infection Nephrotoxical drug Obstructed urinary tract stress Severe anemia Disorder of electrolytes High protein diet Treatment without dialysis nutritional therapy Treat cardiovascular complications Treat anemia Treat renal osteodystrophy Keep the balance of water,electrolytes and acid-base Nutritional Therapy Energy intake 30--35 kcal/kg/day Protein intake 0.6g/kg/day Necessary amino-acid Vitamins VitC 、VitB6 VitD Treat cardiovascular complications hypertension Heart failure pericarditis * * *