ckd pre dialysis management
TRANSCRIPT
CKD-PRE DIALYSIS MANAGEMENT
Shruthi K
Chronic kidney disease
Global health problem Rising incidence – doubled in last 15 years In India – 0nly 10% of patients with ESRD have
access to RRT
CKD-definition
GFR ≤ 60ml/min/1.73m that is present for ≥ 3months with or without evidence of kidney damage
OR Evidence of kidney damage with or without decreased
GFR that is present for ≥ 3months as evidenced by Microalbuminuria Proteinuria Glomerular haematuria Pathological abnormalities (e.g. abnormal biopsy) Anatomical abnormalities (e.g. scarring seen on imaging or
polycystic kidneys)
Pre dialysis management – Why?
Optimal pre-dialysis care improve
Morbidity Mortality Dialysis and transplantation outcome
CKD Predicts CVD
2.113.65
11.29
21.8
36.6
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5
10
15
20
25
30
35
40
≥ 60 45-59 30-44 15-29 < 15
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Estimated GFR (mL/min/1.73 m2)
Early Treatment Makes a Difference
Brenner, et al., 2001
Goal
To establish diagnosis Rule out reversible causes Slow down progression Evaluate and treat complications Treat co-morbidities Reduce cardiovascular risk Prepare for replacement therapy Select & start renal replacement therapy at
appropriate time
Management
Treatment of reversible causes Preventing or slowing the progression of disease Treatment of the complications Identification and adequate preparation of the
patient in whom renal replacement therapy will be required
Treatment of reversible causes
Decreased renal perfusion Hypovolemia (such as vomiting, diarrhea, diuretic use,
bleeding) Hypotension (due to myocardial dysfunction or
pericardial disease) Infection /sepsis Drugs which lower the GFR
Urinary tract obstruction
Slowing the rate of progression
Proteinuria < 1 gm/day or at least 60% of baseline values Optimal level of protein intake
Not been determined 0.8 to 1.0 g/kg/day
ACEI/ARB Smoking cessation
Blood pressure <130/80mmHg <125/75mmHg if proteinuria >1g/day Salt restriction Antihypertensives
ACE,diuretics,CCB
Exercise
Treatment of complications
Volume overload
Salt restriction
Loop diuretics
Hyperkalemia Develops in the patient who is oliguric or who has an
additional problem such as a high potassium diet, increased tissue breakdown, or hypoaldosteronism
Low K+ diet – 40 to 70meq / day
Avoid NSAIDs
Metabolic acidosis Due to
Decreased ability to regenerate bicarbonate Reduced ammonia production Decreased hydrogen ion secretion Decreased filtration of titrable acids – sulphate,
phosphate, urate, hippurates Decreased proximal tubular re-absorption of
bicarbonate
Treatment of academia is desirable Bicarbonate supplementation may slow the progression
of CKD Bone buffering of the some of the excess hydrogen ion
is associated with the release of calcium and phosphate from bone, contributing to worsening of renal osteodystrophy
Uremia acidosis can increase skeletal muscle breakdown and diminish albumin synthesis leading to loss of lean body mass and muscles weakness- contributing to malnutrition
Therapy is targeted to maintain serum bicarbonate concentration above 23 mEq/Lit
Drug of choice : sodium bicarbonate < 0.5-1.0 mEq/kg/day
Hyperphosphatemia Diet restriction : 800mg/day GFR<25 to 30 ml/min: oral phosphate binders Stage 3 & 4 : between 2.7 and 4.6 mg/dL Stage 5 : between 3.5 and 5.5 mg/dL
Renal osteodystrophy High phosphate load and hypocalcemia stimulate
PTH secretion Leads to sec hyper parathyroidism which increases
bone resorption
Treatment
Control serum phosphate CKD stage-specific target levels of intact PTH
CKD stage 3: treat elevated PTH to target 35-70pg/ml
CKD stage 4 to target 70-110 pg/ml CKD stage 5 to target 150-300 pg/ml
Next step is assessment of 25-(OH)D levels and replacement with vitamin D (ergocalciferol) if levels are lower than 30 ng/mL.
If the intact PTH level is elevated and the serum 25-(OH)D level is higher than 30 ng/mL, treatment with an active form of vitamin D is indicated
Available options Calcitriol Alfacalcidol Doxecalciferol
Cinacalcet Calcimimetic Used if elevated phosphorus/Ca limit use of vit D
Hypertension
Cause and complication of CKD Target <130/80 or <125 /75 mmHg if proteinuria is >1
gm /day or diabetes is + Non pharmacological
Lifestyle modification Salt restriction Exercise,weight reduction Diet Smoking cessation etc….
Pharmacological May require 3 or more drugs Diabetes & proteinuria : treat with ACEI /ARB as 1st line
therapy Monitor Creatinine & K+ on day 3 ,7 &weekly Loop and thiazide diuretics as an adjunct therapy CVD: beta blockers CCBs Alpha blockers : prazosin,doxazosin followed by direct
vascular smooth muscle relaxant minoxidil is considered
Anemia
Caused by insufficient erythropoietin production ,short life span of RBCs , iron deficiency
Target Hb: 10 to 12gm% Correct iron deficiency EPO : 80 to 120units/kg/wk Alternative : darbepoietin alfa Longer acting agent Dose: 0.45µg/kg s/c once a week
Preparation for RRT
Counselling HD,peritoneal dialysis / renal transplant If not for transplant : vascular access should be
created in preferably native AV fistula in CKD stage 4
Venous preservation should start from stage 2 or 3 Vaccinate against hep B, pneumococcal and H
influenza infection Drug dosage according to eGFR, avoid contrast