Transcript Conservative Management of Chronic Renal Failure

Dr. Sham Sunder
 Kidney damage for >= 3months ,
as defined by structural / functional abnormalities of
kidney
with or without decreased GFR,
and manifest by either :
 Pathologic abnormalities
 Markers of kidney damage, including abnormalities in
composition of blood / urine or abnormalities on imaging
 GFR < 60 ml/min/1.73m2 for >=3 months,
with / without kidney damage
 By Radiology – USG / CT / MRI etc…
 By Histology – Renal Biopsy
 Microalbuminuria
 Proteinuria
 Hematuria esp associated with proteinuria
 Casts ( with cellular elements )
Cockcroft-Gault formula
Ccr (ml/min) = (140-age) x weight *0.85 if female
72 x Scr
MDRD Study equation
GFR (ml/min/1.73 m2) = 186 x (Scr)-1.154 x (age)-.203 x
(0.742 if female) x (1.210 if African American)
STAGE
DESCRIPTION
GFR ( ml/min/1.73m2 )
1
Kidney damage with
normal / increased GFR
>=90
2
Kidney damage with
mildly decreased GFR
60 – 89
3
Moderately decreased GFR
30 – 59
4
Severely decreased GFR
15 – 29
5
Kidney failure
< 15 / dialysis
STAGE
ACTION PLAN
1
DIAGNOSIS AND TREATMENT
SLOW PROGRESSION
2
ESTIMATE PROGRESSION
3
EVALUATE AND TREAT
COMPLICATIONS
4
PREPARE FOR RENAL
REPLACEMENT THERAPY
5
RENAL REPLACEMENT
 Diagnosis
 Measures to slow progression
 Estimate Progression
 Evaluation and Treatment of Complications
 Preparation for Renal Replacement Therapy
 History
 Physical Examination
CLINICAL FACTORS
SOCIODEMOGRAPHIC FACTORS
DIABETES MELLITUS
OLDER AGE
HYPERTENSION
EXPOSURE TO CERTAIN CHEMICALS
/ ENVIRONMENTAL CONDITIONS
AUTOIMMUNE DISEASES
LOW INCOME / EDUCATION
SYSTEMIC INFECTIONS
URINARY TRACT INFECTIONS
URINARY STONES
LOWER URINARY TRACT
OBSTRUCTION
NEOPLASIA
FAMILY HISTORY OF CKD
RECOVERY FROM AKI
REDUCTION IN KIDNEY MASS
DRUGS
LOW BIRTH WEIGHT
Tests & Diagnostics
Significance / Goal
Blood Pressure
< 130 / 80 mm Hg ; Use ACEI /ARB
Serum Creatinine
To estimate GFR;
Historical values assist in determining
acuity and progression of disease
Urinalysis with microscopy
Presence of RBCs / RBC casts and or
Proteinuria – further work up
Serum Electrolytes ( Na+, K+ )
Useful as crude surrogate of renal disease
Help to guide antihypertensives
Help to identify patients in need of
medical nutrition education
Calcium, Phosphorus, PTH, ALP,
25-OH VITAMIN D
Assists in treatment of metabolic bone
disease
Complete Blood Count
Peripheral Blood Smear
Evaluate for anemia
TSAT , S.Ferritin
Useful in evaluation of iron stores
Tests & Diagnostics
Significance / Goals
Renal Ultrasound with or without Arterial
Doppler
Characterize Kidney number and size
Echogenicity of kidneys
Rule out presence of obstruction
Rule out renovascular disease
Cholesterol panel
Especially useful for patients with
nephrotic range proteinuria
Random urine protein
Random urine creatinine
Ratio approximate values obtained by
24 hour collection
Hepatitis Serology
Negative Hep B testing mandates
vaccination
Serum Protein Electrophoresis
Urine Protein Electrophoresis
In adults with renal disease to rule out
Myeloma
Antinuclear antibody
Warranted for adults with proteinuria /
evidence for SLE
HIV
Warranted in selected population
Renal Biopsy
Indicated in pts with hematuria and /
proteinuria and lack of evidence of
systemic disease
 Protein Restriction
 Reducing Intraglomerular Hypertension
 Reducing Proteinuria
 Control of Blood Glucose
 Control of Blood Pressure
 Reduces symptoms associated with uremia
 Slows the rate of decline in renal function at earlier stages of
renal diseases
 K/DOQI clinical practice guidelines recommend
daily protein intake between 0.60 – 0.75 g / Kg per day
 50 % of protein intake should be of high biological value
 As patient approaches CKD Stage V,
spontaneous protein intake decreases & patient enter a state of
Protein – Energy Malnutrition . Recommended protein intake is
0.9 g / Kg per day
 Increased intraglomerular filtration pressure & glomerular
hypertrophy - a response to loss of nephron number
 It promotes ongoing decline of kidney function even if the inciting
process has been treated.
 ACEI & ARBs
 Inhibit angiotensin induced vasoconstriction of efferent arteriole
 Reduces intraglomerular filtration pressure and proteinuria
 If monotherapy is not effective , combined therapy with
both ACEI & ARB can be tried
 2nd line drugs : Calcium Channel Blockers
Diltiazem , Verapamil
 Especially - Diabetic Nephropathy & Glomerular diseases
 Leading cause of Chronic Kidney Disease
 Control of Blood Glucose : excellent glycemic control
reduces the risk of kidney disease & its progression in
both Type 1 & 2 Diabetes Mellitus
 Recommendations : FBS : 90 – 130 mg/dl
HbA1C < 7%
 Control of Blood Pressure & Proteinuria : ACEI & ARBs
 Hypertension : sodium and water retention
renin angiotensin system activation
 Control of BP : to slow progression of CKD
to prevent extrarenal complications
( cardiovascular disease / stroke )
 Goal : BP < 130 / 80 mm Hg
BP < 125 / 75 mm Hg ( DM / Proteinuria > 1g/day )
 Salt Restriction
 Diuretics
 Loop Diuretics : Furosemide 40 mg BD
Bumetanide 1mg BD
 Thiazides : less efficacious gfr < 30 – 40 ml/min
 Both ameliorate hyperkalemia seen with ACEI / ARB
 ACEI / ARB
 Check S.Creat & S.K+ within 1 -2 weeks
 Upto 30 % increase in creatinine is acceptable
 Beta blockers / CCB / Alpha blockers / Vasodilators
 Anemia
 Bone Disorders
 Dyslipidemia
 Cardiovascular disease
 Defined as Hemoglobin < 13.5 g/dl in males
< 12 g/dl in females
 Normocytic normochromic anemia –
as early as in Stage III CKD or
universally by Stage IV CKD
 Primary cause : insufficient production of Erythropoetin
 Additional factors : iron deficiency
folate / vit B12 deficiency
chronic inflammation
hyperparathyroidism / bm fibrosis
 Target Hb : 11 g/dl
 Target Iron status : TSAT : lower limit > = 20
S.Ferritin : ng/ml
lower limit : 200 – HD CKD
100 – Non HD CKD
> 500 not routinely recommended
 Check Hb monthly while on ESAs
 Iron studies monthly when started on ESA
 On stable ESA Therapy : Iron studies can be done 3 monthly
 Ferrous sulphate 325 mg bid – tid
 IV Iron Dextran
 IV Iron Sucrose
 IV Sodium Ferric Gluconate Complex
 Folic acid and Vitamin B 12 supplements
 Erythropoetin Stimulating Agents : Epoetin alfa
Epoetin beta
Darbepoetin alfa
 Epoetin alfa / beta : 50 -100 IU / Kg SC per week
 Darbepoetin alfa : 40 mcg SC every 2 weeks
 Osteitis Fibrosa Cystica
 Osteomalacia
 Secondary


 Adynamic bone disease


 Mixed osteodystrophy

Hyperparathyroidism
Vitamin D deficiency
Acidosis
Aluminium accumulation
Osteoporosis in elderly
Osteopenia caused by
steroids
 Renal bone disease – significantly increase mortality in
CKD patients
 Hyperphosphatemia – one of the most important risk
factors associated with cardiovascular disease in CKD
patients
 K/DOQI recommends :
 CKD Stage III & IV : S.Phosphorus : 2.7 - 4.6 mg / dl
 CKD Stage V : S.Phosphorus : 3.5 - 5.5 mg / dl
CKD STAGE
GFR RANGE
INTACT PTH ( pg/ml )
3
30 – 59
35 – 70
4
15 – 29
70 – 110
5
< 15 / Dialysis
150 – 300
CKD STAGE
GFR RANGE
PTH LEVELS
S.Calcium &
S.Phosphorus
3
30 -59
Every 12 months
Every 12 months
4
15-29
Every 3 months
Every 3 months
5
< 15 / dialysis
Every 3 months
Every month
 Reduce dietary phosphate intake
 Phosphate binders : calcium carbonate
calcium acetate
aluminium hydroxide
magnesium carbonate ( rarely used )
sevelamer hydrochloride
lanthanum carbonate
 The use of calcium salts is limited by development of
hypercalcemia
 Calcium acetate poses a less problem as less calcium is
absorbed
 Calcimimetics – Cinacalcit :
 Agent that increase calcium sensitivity of the calcium
sensing receptor expressed by parathyroid gland
 Down regulating the parathyroid hormone secretion
 Reduce hyperplasia of parathyroid gland
 Calcitriol 0.25 mcg OD
 Paricalcitol 1 mcg daily or 2mcg 3 times a week
 Vitamin D deficiency :
 < 5 ng/ml – Ergocalciferol 50000 IU orally weekly for
12 weeks and then monthly thereafter
 5 – 15 ng/ml – Ergocalciferol 50000 IU orally weekly for
4 weeks and then monthly thereafter
 16 – 30 ng/ml – Monthly Ergocalciferol
 Acidosis : K/DOQI – total Co2 >=22 mEq/L
Sodium bicarbonate 650 – 1300 mg bid – tid
 A major risk factor for cardiovascular morbidity &
mortality
 Prevalence of hyperlipidemia increases as renal functions
diminish
 All patients with CKD must be evaluated for
Dyslipidemia
 Fasting lipid profile – annually
 Stage V CKD patients with dyslipidemia should always be
evaluated for secondary causes :
 Nephrotic syndrome
 Hypothyroidism
 Diabetes mellitus
 Excessive alcohol consumption
 Liver disease
 Drugs : oral contraceptives , haart etc…
 Goal : LDL – Cholesterol < 100 mg / dl
 LDL : 100 – 129 mg/dl : Lifestyle changes
Not responded : Low dose statin
 LDL >= 130 mg/dl : Lifestyle changes + Statins
 TG >= 200 mg/dl : Lifestyle changes + Statins
 Control BP : ACEI / ARB
 Treat dyslipidemia : Lifestyle changes + Statins
 Good Glycemic control
 Treat anemia
 Correct hyperphosphatemia
 Treat hyperparathyroidism
 Correct hyperkalemia
 Hepatitis B vaccination : 3 doses (0,1,2 months )
higher dose ( 40 mcg / ml )
 Pneumococcal vaccination : single dose
one time revaccination 5 yrs
after initial vaccination
 Influenza vaccination : recommended annually for adults
> 50 yrs age
 Patients of CKD Stage IV approaching Stage V should be referred
for
 Vascular access if hemodialysis is preferred
 Peritoneal dialysis catheter placement if peritoneal dialysis is
preferred




AVF is most preferred access for HD patients
Ideally created 6 months prior to start of HD
Non dominant upper extremity
And that arm is to be preserved – no iv lines
 AVG : 3-6 weeks prior to start of HD
 PD Catheter : 2 weeks prior to start of HD
 GFR not below 15 ml/min.1.73m2 but in presence of
 Intractable volume overload
 Hyperkalemia
 Hyperphosphatemia
 Hypercalcemia / Hypocalcemia
 Metabolic acidosis
 Anemia
 Uremic encephalopathy
 Uremic pericarditis
 Severe hypertension , acute pulmonary edema