Management of Chronic Renal Failure

1. Treat underlying cause(s)

2. Renoprotection

Goals of treatment

BP <>

Proteinuria <>

Treatment

Patients with chronic renal failure and proteinuria > 1 g/24 hours:

ACE inhibitor increasing to maximum dose

Add angiotensin receptor antagonist if goals are not achieved

Add diuretic to prevent hyperkalaemia and help to control BP

Add calcium-channel blocker (verapamil or diltiazem) if goals not achieved

Additional measures

Statins to lower cholesterol to <>

Stop smoking (threefold higher rate of deterioration in CRF)

Treat diabetes (HbA1c <>

Normal protein diet (0.8-1 g/kg bodyweight)

3. Correction of complications

Hyperkalaemia

Dietary restriction of potassium intake

Stop drugs causing potassium retention

Ion-exchange resins to remove potassium in gastrointestinal tract (e.g. Sodium polystyrene sulfonate)

Acidosis

Sodium bicarbonate supplements

Hypocalcaemia

Calcium carbonate supplements

Calcitrol or Vitamin D analogue (e.g. alfacalcidol)

Hyperphosphataemia

Oral calcium carbonate / acetate reduces absorption of dietary phosphate

Sevelamar used as gut phosphate binder

Nicotinamide to block intestinal sodium/phosphate cotransporter

Anaemia

Synthetic human erythropoietin

Male erectile dysfunction

Oral phosphodiesterase inhibitor (e.g. sildenafil, tadalafil, vardenafil)

4. Renal replacement therapy

Haemodialysis

Blood from patient pumped through array of semi-permeable membranes

Blood comes in close association with dialysate and substances are filtered down their concentration gradients

Approximately 4-5 hours’ treatment 3 times a week

All patients anticoagulated (e.g. heparin)

Haemofiltration

Removal of plasma water and dissolved constituents across semi-permeable membrane

Replacement with solution of desired biochemical composition

22L exchange 3 times a week

Peritoneal dialysis

Utilizes the peritoneal membrane as a semi-permeable membrane

Tube placed into peritoneal cavity and dialysate run into cavity

Dissolved substances pass into dialysate down concentration gradients

Fluid changed regularly to repeat process

Transplantation

Surgical anastomosis of human kidney on to iliac vessels of recipient

Donor ureter placed into recipient’s bladder

Immunosuppressive treatment needed (e.g. corticosterioids, azathioprine, ciclosporin)

Sources: Kumar and Clark, Clinical Medicine