Dr. Sham Sunder

Conservative Management of Chronic Renal Failure

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 imagingGFR < 60 ml/min/1.73m2 for >=3 months,

with / without kidney damage

Definition – CKD

By Radiology – USG / CT / MRI etc…

By Histology – Renal Biopsy

Pathologic Abnormalities :

Microalbuminuria

Proteinuria

Hematuria esp associated with proteinuria

Casts ( with cellular elements )

Markers of kidney damage :

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)

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

NKF – K/DOQI Stages of CKD

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

Action Plan according to CKD - Stage

Diagnosis

Measures to slow progression

Estimate Progression

Evaluation and Treatment of Complications

Preparation for Renal Replacement Therapy

Conservative Management

History

Physical Examination

Diagnosis

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 antihypertensivesHelp 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

Tests & Diagnostics Significance / Goals

Renal Ultrasound with or without Arterial Doppler

Characterize Kidney number and sizeEchogenicity of kidneysRule 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 ElectrophoresisUrine 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

Slowing the Progession of CKD

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

Protein Restriction

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

Reducing Intraglomerular Hypertension & 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

Slowing Progression of Diabetic Renal Disease

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 )

Control of Blood Pressure

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 acceptableBeta blockers / CCB / Alpha blockers / Vasodilators

Estimate Progression

Evaluation & Treatment of Complications

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

Anemia

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 recommendedCheck Hb monthly while on ESAsIron studies monthly when started on ESA On stable ESA Therapy : Iron studies can be done 3 monthly

Anemia - goals

Ferrous sulphate 325 mg bid – tid IV Iron Dextran IV Iron SucroseIV Sodium Ferric Gluconate ComplexFolic acid and Vitamin B 12 supplementsErythropoetin Stimulating Agents : Epoetin alfa

Epoetin beta

Darbepoetin alfaEpoetin alfa / beta : 50 -100 IU / Kg SC per week Darbepoetin alfa : 40 mcg SC every 2 weeks

Anemia – treatment options

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

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

Treatment goals

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

Frequency of testing

Reduce dietary phosphate intakePhosphate 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

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

Treatment

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

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

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

Dyslipidemia

Cardiovascular Disease

Control BP : ACEI / ARB

Treat dyslipidemia : Lifestyle changes + Statins

Good Glycemic control

Treat anemia

Correct hyperphosphatemia

Treat hyperparathyroidism

Correct hyperkalemia

Treatment

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

Immunization

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

Preparation for Renal Replacement Therapy

Look for reversibility !

Mangement for CKD patients according to Stage

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

Thank You !