Title: Preventing%20Progression%20and%20Complications%20of%20Renal%20Disease
1(No Transcript)
2Recent Advances in Management of CRF
- Yousef Boobess, M.D.
- Head, Nephrology Division
- Tawam Hospital
3What is chronic renal failure ? Definitions
- Azotemia
- Elevated blood urea and creatinine
- Chronic renal failure
- The irreversible, substantial, and usually
long-standing (gt3 months) loss of renal function. - Uremia
- Azotemia with symptoms or signs of renal failure
- End-stage renal disease (ESRD)
- The degree of CRF that without renal replacement
treatment would result in death.
4STAGES OF Chronic Kidney Disease (CKD)
Urinary abnormalities (GFR ? 90 ml/min)
Mildly impaired (GFR 60 - 89 ml/min)
Moderate CRF (GFR 30 - 59 ml/min)
Severe CRF (GFR 15 - 29 ml/min)
ESRD (GFR lt 15 ml/min)
5Epidemiology
- The number of ESRD patients is increasing
rapidly, with very costly treatment -
- Early recognition of renal disease and
appropriate interventions may decrease - Human suffering
- Financial costs associated with ESRD
6Dialysis Sessions in Tawam
7Incidence Rates of ESRD Therapy
300 250 200 150 100 50
Rate per Million Population
1982 1984 1986
1988 1990 1992
1994 1995 Years
U.S. Renal Data System, (1997)
8Causes of ESRD in USA
1999 USRDS Report
9Team Approach Primary Helth Care (PHC)
Physician and Nephrologist in CKD
- PHC Physician
- Early recognition of renal disease
- PHC Physicians treat patients with DM, HTN
- Timely referral to a Nephrologist
- Collaboration with a Nephrologist to provide long
term care - Patient education
- Nephrologist
- Diagnose and assess patients
- Assist in developing strategic guidance
- Recommend and implement patient care
- Provide role-specific patient education
10Principles of Management of CKD Patients
- Early recognition of CKD
- Estimate the severity of CKD
- What is the cause of CKD?
- Detection and correction of any reversible cause.
Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
11Principles of Management of CKD Patients
- Early recognition of CKD
- Estimate the severity of CKD
- What is the cause of CKD?
- Detection and correction of any reversible cause.
Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
12Recognizing Renal Failure,Clinical Features
- Mild to Moderate renal failure
- Usually no symptoms
- Severe renal failure non specific
- Pale, fatigueability shortness of breath
- Hypertension, headaches
- Polyuria/nocturia
- Body itch
- Poor appetite, nausea, vomiting
- Hyperventilation
- Swelling of the face and legs
13Recognizing Renal Failure,Clinical Features
- Mild to Moderate renal failure
- Usually no symptoms
- Severe renal failure non specific
- Pale, fatigueability shortness of breath
- Hypertension, headaches
- Polyuria/nocturia
- Body itch
- Poor appetite, nausea, vomiting
- Hyperventilation
- Swelling of the face and legs
14Hyperventilation
- 13 y-o-f, came to ER with hyperventilation
- ER physician examined her ? psychosis ? valium,
reassured the family DC - No improvement ? taken to another hospital ?
Blood Chemistry ABGs - ? ESRD with very severe metabolic acidosis
(Bicarbonate 2.7 mmol/l)
15Recognizing Renal Failure,Investigations
- Urinalysis
- Urine dipstick microscopic exam
- gt Ptu, Htu, pyuria, glycosuria
- Blood chemistry
- s.Creatinine, urea (or BUN)
- Electrolytes (Na, K, CO2, Ca, Ph--)
- GFR
- Estimated or measured
- Ultrasound
- Morphologic evaluation
16s.Creatinine Concentration
- Normal values
- lt115 umol/L in males (1.3 mg/dL)
- lt90 umol/L in females (1 mg/dL)
- Changes in its level are more important
- an increase from 55 to 110 umol/L represents a
50 decline in renal function - Limitations
17High s.Creatinine with Normal GFR
- Spurious elevation
- Cephalosporin
- DKA
- Alcohol intoxication
- Blocking tubular secretion
- Cimetidine or trimethoprim
- Increased creatinine production
- Exogenous ingestion of large quantities of
cooked meat - Endogenous Muscular disorders, or increases in
muscular mass
18Normal s.Creatinine with CRF
- Poor production of creatinine
- Severely malnourished patients
- Elderly
- Small children
- Ladies of small size
19Glomerular Filtration Rate GFR
- Normal values
- In males 120 ? 20 mL/minute
- In females 115 ? 20 mL/minute.
- Creatinine Clearance (24-h urine collection)
- Creatinine Clearance in Severe CKD
- Overestimate GFR due to the tubular secretion
- To correct this overestimation
- Take the average of urea and creatinine
clearances - Or give oral cimetidine 1200 mg, 3h before
collection
20Estimation of Creatinine Clearance
Creat. Cl 1.23 x weight x(140-age)/(s.creat)
In Male
In Female
1.03
Cockcroft, Nephron, 1976 16 31-41
21Determine the cause of CKD
- A specific diagnosis is needed
- To consider specific TRT
- obstructive uropathy, analgesic NP, drug-related
IN, RPGN, SLE, vasculitis, accelerated HTN,
tuberculosis, myeloma, amyloid, .. - To be aware of potential complications
- SLE, DM..
- To advise the family
- PKD or other familial renal disease.
22Principles of Management of CKD Patients
- Early recognition of CKD
- Estimate the severity of CKD
- What is the cause of CKD?
- Detection and correction of any reversible cause.
Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
23Correcting any Reversible Cause
24Correction a Reversible CauseSarcoidosis
25Volume Depletion
- Causes
- Diarrhea, vomiting, iatrogenic (surgery,
overzealous use of diuretics) - Renal loss
- Worsening renal arterial stenosis, cholesterol
emboli - Volume repletion
- Restores renal function promptly
- Some degree of transient or permanent damage may
occur
26Principles of Management of CKD Patients
- Early recognition of CKD
- Estimate the severity of CKD
- What is the cause of CKD?
- Detection and correction of any reversible cause.
Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
27Slowing the Rate of Progression
The earlier we alter factors that damage the
kidneys, the better
28Successful Intervention
Therapeutic Intervention
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Months, follow-up
Rashed M., Tawam 125991
29InterventionRenal Diet
- Protein Restriction
- High calories
- Law potassium
- Law salt
- Law phosphate
30InterventionControlling BP in CKD
- Target BP
- CKD lt130/85 mm Hg
- If proteinuria lt125/75 mm Hg
- Benefits
- Slows the progression of CKD, especially if
proteinuria - Reduces the cardiovascular complications
Zabetakis PM, Nissenson AR. Am J Kid Dis.
200036(suppl)S31-S38.
31BP Control and GFR Decline
- Parving HH et al. Br Med J 1989 Moschio G et al.
NEJM 1996 - Viberti GC et al. JAMA 1993
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33Prevalence of LV Disorders at Start of Dialysis
Echocardiograms of 413 incident hemodialysis
patients
Parfrey PS, et al.. Nephrol Dial Transplant.
1996111277-1285
34Consequences of CKD (LVH)
- LVH is an independent predictor of cardiac death
in dialysis patients. - Hypertension, anemia and diabetics are modifiable
predictors of LVH - Increase in LVH risk For each
- ? Ccr of 25 mL/min gt 3 increased risk of LVH.
- ? Systolic BP by 5 mm Hg gt 3 increased risk.
- ? Hemoglobin by 1 g/dl gt 6 increased risk of LVH
Levin A, et al. Am J Kid Dis. 199627347-354.
35BP is Poorly Controlled in CKD
Coresh J, et al. Arch Intern Med.
20011611207-1216.
36Blood Pressure Control
- Several classes of drugs are available
- Some can slow the decline of GFR
- First-line treatment
- ACE inhibitors angiotensin receptor blockers
- There's still a great reluctance by PHC
physicians to use them for fear that they will
damage the kidneys rather than preserve function.
- Diuretics in combination with ACE inhibitors.
JNC VI. Arch Intern Med. 19971572413-2446.
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38Reno-protective Effect of ACEis
- ACEis (independent of their antihypertensive
action) - Decrease proteinuria
- Delay the progression of renal disease
- Mechanisms
- Dilatation of EA gtreducing intra-glomerular
pressure - Restoration of glomerular perm-selectivity in
proteinuric NPs - ? Effect on the GH like of AII
39Adverse Effects of ACEis
- Acute worsening of renal function
- if bilateral renal artery stenosis or if
decreased effective circulating volume - advices
- monitor renal function after initiation of ACEi
- in high risk patients renal scan with captopril
test - adjust the dose according to the renal function
- Hyperkalemia
- same considerations apply
40Glycemic Control in Diabetics
- Tight control of blood glucose HbA1C lt7
- Delay the onset of microalbuminuria
- Decrease or stabilize protein excretion in
patients who already had microalbuminuria - ACE inhibitors, and ARBs
- Delay the progression of kidney dysfunction.
Zabetakis PM, Nissenson AR. Am J Kid Dis.
200036(suppl)S31-S38. The Diabetes Control and
Complications Trial, long-term Sweden study,
Japanese study
41RENAAL Primary Components
ESRD
Risk Reduction 28
P
p0.002
with event
L
Doubling of Serum Creatinine
Risk Reduction 25
p0.006
Months
P ( CT)
762
715
610
347
42
L ( CT)
751
714
625
375
69
with event
ESRD or Death
Risk Reduction 20
p0.010
P
with event
L
Months
762
689
554
295
P ( CT)
36
L ( CT)
751
692
583
329
52
Brenner BM et al New Engl J Med
2001345(12)861-869.
Months
P ( CT)
762
715
610
347
42
L ( CT)
751
714
625
375
69
42Hyperlipidemia
- In CRF
- Mainly hypertriglyceridemia
- gt Increases glomerulosclerosis by
- Increasing mesangial proliferation and matrix
production - Altering glomerular hemodynamics
- Increasing local inflammation
43Smoking Cessation
- All patients with renal disease should be
encouraged to quit smoking - DM is 3 to 4 times more common in smokers than in
nonsmokers - Smoking increases the relative risk for
progression of CRF in nondiabetics - Former smokers have an intermediate risk
44Principles of Management of CKD Patients
- Early recognition of CKD
- Estimate the severity of CKD
- What is the cause of CKD?
- Detection and correction of any reversible
causes. Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
45Fluid and electrolyte disorders Sodium and Water
- Most often
- Impaired Na excretion gt Edema, HTN, CHF
- TRT
- Moderate Na restriction
- Loop diuretics
- In some patients
- Salt wasting gt volume depletion gt worsening of
CRF - TRT
- Na replacement
46Fluid and Electrolyte DisordersPotassium Balance
- Hyperkalemia
- Develops in advanced CRF
- Can occur earlier in patients with
- Tubulointerstitial disease
- Diabetic NP and hyporeninemic hypoaldosteronism
- Drugs as ACEis, A2 antagonist, b- blockers,
NSAIDs, K sparing diuretics, trimethoprim, salt
substitutes.. - TRT
- Dietary K restriction,
- loop diuretics,
- K exchange resins..
47Fluid and Electrolyte DisordersAcid-Base
Disorders
- Metabolic acidosis
- Occurs relatively early
- Treatment
- Decrease protein intake
- Alkali supplementation if bicarbonate lt 17mEq/L
- Na bicarbonate or Na citrate, 1 mEq/kg/day
- This will prevent
- Excessive bone loss
- Muscle breakdown
- Tubulointerstitial inflammation
48Hypocalcemia Hyperphosphatemia
- Hypocalcemia
- Deficiency in Vit.D, Hyperphosphatemia
- Hyperphosphatemia
- Early in renal failure Ph-- clearance gt
Ph-- gt PTH gt Ph-- clearance - Frank hyperphosphatemia occur if GFR lt 30 mL/min
- Management
- Dietary phosphate restriction
- Phosphate binders Ca carbonate, Renalgel,..
- Vit D Rocaltrol, One Alpha,..
49Anemia
- Present when GFR lt 30-35 mL/min
- Causes
- Reduced EPO production
- Others iron deficiency, rapid destruction of
RBC,.. - Anemia is an independent risk factor for death in
CHF - Studies of Left Ventricular Dysfunction (SOLVD)
7000 patients - 1 lower Hct was associated with 1 higher risk
of mortality
Al Ahmad. et al. J Am Coll Cardiol.
200138955-962.
50Independent Risk of a Fall in Mean Hb of 1 g/dL
in Dialysis Patients
Odds ratio P
LV Dilation 1.42 0.02
De novo cardiac failure 1.28 0.02
Recurrent cardiac failure 1.20 0.05
IHD NA
Death 1.14 0.02
Foley PS, et al. Am J Kidney Dis. 19962853-61.
51Cardio - Renal - Anemia Syndrome
Vicious Circle of Destruction
CKD
CHF
Anemia
52Cardio - Renal - Anemia Syndrome
- CHF is a common and crucial contributor to the
progression of CKD. (new concept) - Treatment of anemia in patients with CHF may
improve both the cardiac and the renal function - gt To save the heart and the kidney, treat the
anemia
53Treatment of Anemia
- Target Hgb 11 to 12 g/dL
- Epoetin
- Dose 50 U/kg/inj, iv or sc
- 1-3 times/week
- IV Iron Sucrose
- Target
- Serum ferritin 100 - 500 ng/mL
- Transferrin saturation 20 50.
- Dose 100 mg/session X 10, then reevaluate
54Principles of Management of CRF Patients
- Early recognition of CRF
- Estimate the severity of CKD
- What is the cause of CRF?
- Detection and correction of any reversible cause.
Avoidance of additional renal injury - Institution of interventions to delay progression
- Treatment of complications
- Planning for renal replacement therapy
55Planning for Renal Replacement Therapy
- Options of RRT should be discussed
- Difference modalities of dialysis
- HD, PD
- Transplantation
- Possibility of preemptive Tx
- Outcomes are optimal when RRT is initiated in a
planned manner - HD gt need for A-V fistula (4-6 months)
- Tx work-up
56TRADITIONAL DIALYSIS START
57Timely Dialysis Start
58EARLY DIALYSIS START
- Early dialysis start (CrCl gt 10 ml/min) vs late
dialysis start (CrCl lt 4 ml/min) - gt higher 12 yr survival (85 vs 51)
- Bonomini et al Kidney Int 17S57 1985
-
- gt improved quality of life at 6 months post
initiation of RRT - Korevaar et al AJKD Jan 2002
59Conclusion, 1
- Early recognition of renal disease
- Early referral to Nephrologist
- Detect and correct any reversible cause
- Avoid any additional renal injury
- Use ACE inhibitors whenever it is indicated
- Lipid-lowering drugs
60Conclusion, 2
- Avoid
- Nephrotoxic drugs
- NSAIDs, aminoglycosides, radiocontrast
- In moderate to severe CRF
- Diuretic therapy often necessary
- Dietary potassium restriction
- Potassium exchange resins if hyperkalemia
- Alkali supplementation if CO2 lt 16-17 mEq/L
- Phosphate binders, Vit D
- EPO, Iron