Preventing%20Progression%20and%20Complications%20of%20Renal%20Disease - PowerPoint PPT Presentation

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Preventing%20Progression%20and%20Complications%20of%20Renal%20Disease

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Head, Nephrology Division. Tawam Hospital. What is chronic renal failure ? Definitions ... Primary Helth Care (PHC) Physician and Nephrologist in CKD. PHC Physician ... – PowerPoint PPT presentation

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Title: Preventing%20Progression%20and%20Complications%20of%20Renal%20Disease


1
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2
Recent Advances in Management of CRF
  • Yousef Boobess, M.D.
  • Head, Nephrology Division
  • Tawam Hospital

3
What 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.

4
STAGES 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)
5
Epidemiology
  • 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

6
Dialysis Sessions in Tawam
7
Incidence 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)
8
Causes of ESRD in USA
1999 USRDS Report
9
Team 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

10
Principles 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

11
Principles 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

12
Recognizing 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

13
Recognizing 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

14
Hyperventilation
  • 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)

15
Recognizing 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

16
s.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

17
High 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

18
Normal s.Creatinine with CRF
  • Poor production of creatinine
  • Severely malnourished patients
  • Elderly
  • Small children
  • Ladies of small size

19
Glomerular 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

20
Estimation 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
21
Determine 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.

22
Principles 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

23
Correcting any Reversible Cause
24
Correction a Reversible CauseSarcoidosis
25
Volume 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

26
Principles 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

27
Slowing the Rate of Progression
The earlier we alter factors that damage the
kidneys, the better
28
Successful Intervention
Therapeutic Intervention

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Months, follow-up
Rashed M., Tawam 125991
29
InterventionRenal Diet
  • Protein Restriction
  • High calories
  • Law potassium
  • Law salt
  • Law phosphate

30
InterventionControlling 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.
31
BP Control and GFR Decline
  • Parving HH et al. Br Med J 1989 Moschio G et al.
    NEJM 1996
  • Viberti GC et al. JAMA 1993

32
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33
Prevalence of LV Disorders at Start of Dialysis
Echocardiograms of 413 incident hemodialysis
patients
Parfrey PS, et al.. Nephrol Dial Transplant.
1996111277-1285
34
Consequences 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.
35
BP is Poorly Controlled in CKD
Coresh J, et al. Arch Intern Med.
20011611207-1216.
36
Blood 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.
37
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38
Reno-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

39
Adverse 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

40
Glycemic 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
41
RENAAL 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
42
Hyperlipidemia
  • In CRF
  • Mainly hypertriglyceridemia
  • gt Increases glomerulosclerosis by
  • Increasing mesangial proliferation and matrix
    production
  • Altering glomerular hemodynamics
  • Increasing local inflammation

43
Smoking 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

44
Principles 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

45
Fluid 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

46
Fluid 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..

47
Fluid 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

48
Hypocalcemia 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,..

49
Anemia
  • 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.
50
Independent 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.
51
Cardio - Renal - Anemia Syndrome
Vicious Circle of Destruction
CKD
CHF
Anemia
52
Cardio - 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

53
Treatment 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

54
Principles 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

55
Planning 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

56
TRADITIONAL DIALYSIS START
57
Timely Dialysis Start
58
EARLY 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

59
Conclusion, 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

60
Conclusion, 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
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