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Conservative Management of Chronic Renal Failure

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  1. Conservative Management of Chronic Renal Failure Dr. Sham Sunder

  2. Definition – CKD • 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

  3. Pathologic Abnormalities : • By Radiology – USG / CT / MRI etc… • By Histology – Renal Biopsy

  4. Markers of kidney damage : • Microalbuminuria • Proteinuria • Hematuria esp associated with proteinuria • Casts ( with cellular elements )

  5. GFR Estimating Equations 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)

  6. NKF – K/DOQI Stages of CKD

  7. Action Plan according to CKD - Stage

  8. Conservative Management • Diagnosis • Measures to slow progression • Estimate Progression • Evaluation and Treatment of Complications • Preparation for Renal Replacement Therapy

  9. Diagnosis • History • Physical Examination

  10. Tests & Diagnostics

  11. Slowing the Progession of CKD

  12. Protein Restriction • Reducing Intraglomerular Hypertension • Reducing Proteinuria • Control of Blood Glucose • Control of Blood Pressure

  13. Protein Restriction • 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

  14. Reducing Intraglomerular Hypertension & Proteinuria • 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

  15. 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

  16. Slowing Progression of Diabetic Renal Disease • 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

  17. Control of Blood Pressure • Hypertension : sodium and water retention reninangiotensin 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 )

  18. 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

  19. Estimate Progression

  20. Evaluation & Treatment of Complications

  21. Anemia • Bone Disorders • Dyslipidemia • Cardiovascular disease

  22. Anemia • Defined as Hemoglobin < 13.5 g/dl in males < 12 g/dl in females • Normocyticnormochromic 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

  23. Anemia - goals • 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

  24. Anemia – treatment options • 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 : Epoetinalfa Epoetin beta Darbepoetinalfa • Epoetinalfa / beta : 50 -100 IU / Kg SC per week • Darbepoetinalfa : 40 mcg SC every 2 weeks

  25. Bone Disorders Causative factors • Osteitis Fibrosa Cystica • Osteomalacia • Adynamic bone disease • Mixed osteodystrophy • Secondary Hyperparathyroidism • Vitamin D deficiency • Acidosis • Aluminium accumulation • Osteoporosis in elderly • Osteopenia caused by steroids

  26. Renal bone disease – significantly increase mortality in CKD patients • Hyperphosphatemia – one of the most important risk factors associated with cardiovascular disease in CKD patients

  27. Treatment goals • 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

  28. Frequency of testing

  29. Treatment • 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

  30. Treatment • 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

  31. Vitamin D deficiency : • < 5 ng/ml – Ergocalciferol 50000 IU orally weekly for 12 weeks and then monthly thereafter • 5 – 15 ng/ml – Ergocalciferol50000 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

  32. Dyslipidemia • 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

  33. Dyslipidemia • 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

  34. Dyslipidemia • 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

  35. Cardiovascular Disease

  36. Treatment • Control BP : ACEI / ARB • Treat dyslipidemia : Lifestyle changes + Statins • Good Glycemic control • Treat anemia • Correct hyperphosphatemia • Treat hyperparathyroidism • Correct hyperkalemia

  37. Immunization • 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

  38. Preparation for Renal Replacement Therapy • 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

  39. Look for reversibility !

  40. Mangement for CKD patients according to Stage

  41. 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

  42. Thank You !