Chronic renal failure natural history
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Chronic renal failure can be complicated by the development of disorders such as hyperuricemia, myopathy, congestive heart failure, pallor, nausea, anorexia, and peptic ulcers amongst other disorders. The prognosis of the disease is poor if mismanaged. If untreated, patients will develop symptoms and signs of uremia (accumulation of uremic solutes), and chronic renal failure (CRF) will progress to end-stage renal disease, which has a high morbidity rate.
If left untreated, patients progressively lose renal function and develop signs and symptoms associated with extracellular fluid overload, ion concentration derangements, and uremia. Patients with chronic kidney disease eventually reach end stage renal disease (ESRD) when GFR is below < 15 mL/min/1.73m2Usually and eventually necessitate renal replacement (either dialysis or transplantation) for survival. Usually, the time frame of progression to ESRD is very variable among individuals. Older age, male gender, and African American ethnicity are all associated with higher risk of progression. Tight blood pressure and glycemic control are essential to decrease the risk of development of ESRD in patients with pre-existing renal insufficiency. A population-based study of a Swedish cohort of with pre-existing stage 4 or 5 CKD showed that 80% of patients would progress to require RRT within 5 years, with a mortality rate of up to 39%. Half of the cohort was on renal replacement by 18 months follow up.
Early stage CKD
The cardiovascular system is closely related to renal function. Studies have shown that even minor decreases in GFR (60-89 ml/min per 1.73 m2) can double the risk of myocardial infarction and stroke compared to patients with normal GFR. The risk of adverse cardiovascular events also tends to increase with decreasing GFR. This underlines the impact of cardiovascular disease being the leading cause of mortality in patients with renal disease.
ESRD & Dialysis
The prognosis of patients with chronic kidney disease is guarded as epidemiological data has shown that all cause mortality (the overall death rate) increases as kidney function decreases. The leading cause of death in patients with chronic kidney disease is cardiovascular disease, regardless of whether there is progression to ESRD.
While renal replacement therapies can maintain patients indefinitely and prolong life, the quality of life of the patient is severely affected. Renal transplantation increases the survival of patients with ESRD significantly when compared to other therapeutic options; however, it is associated with an increased short-term mortality (due to complications of the surgery). Transplantation aside, high intensity home hemodialysis appears to be associated with improved survival and a greater quality of life when compared to the conventional thrice weekly hemodialysis and peritoneal dialysis.
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