Diagnostic and Therapeutic Approach to Kidney PatientDiagnostic and Therapeutic Approach to Kidney Patient

S. Ossareh- M.D.

HKC-IUMS

S. Ossareh- M.D.

HKC-IUMS

Nephrotic Syndrome/GNNephrotic Syndrome/GN• Lab:

– CBC, ESR– BUN, Cr, Na, K (daily?!!)– PPD– VDRL– Lipid profile– FBS? – Uric acid– Protein, Albumin– HBsAg, HCV Ab, HIV Ab – Immunologic: ANA, ANCA, C3, C4, CH50,antiGBM Ab?– Urinalysis, Urine sediment– 24 hour urine collection for protein, creatinine– PTT, PT

• Sonography• KUB

• Lab:– CBC, ESR– BUN, Cr, Na, K (daily?!!)– PPD– VDRL– Lipid profile– FBS? – Uric acid– Protein, Albumin– HBsAg, HCV Ab, HIV Ab – Immunologic: ANA, ANCA, C3, C4, CH50,antiGBM Ab?– Urinalysis, Urine sediment– 24 hour urine collection for protein, creatinine– PTT, PT

• Sonography• KUB

ESRD patientsESRD patients

ParaclinicParaclinic

• LAB:– CBC,ESR– BUN, Cr (daily?!!)– Na, K (daily?!!)– Ca, P, ALP,PTH– Lipid profile– Fe, Ferritin,TIBC– Retic, Coombs,S/E, – HBsAg, HCV Ab, HIV Ab – Sonography

• X-Rays as needed

• LAB:– CBC,ESR– BUN, Cr (daily?!!)– Na, K (daily?!!)– Ca, P, ALP,PTH– Lipid profile– Fe, Ferritin,TIBC– Retic, Coombs,S/E, – HBsAg, HCV Ab, HIV Ab – Sonography

• X-Rays as needed

Erythropoetin(Eprex, PD Poetin, Epocin)

Erythropoetin(Eprex, PD Poetin, Epocin)

• Hb/Hct goal:

– 11/33% for women

– 12/36% for men & post-menopausal

women

• Start Eprex with 50-100 unit/kg/wk

• Hb>13 → Reduce Eprex dose

• Hb> 13.5 → Stop Eprex for 1 month

• Hb/Hct goal:

– 11/33% for women

– 12/36% for men & post-menopausal

women

• Start Eprex with 50-100 unit/kg/wk

• Hb>13 → Reduce Eprex dose

• Hb> 13.5 → Stop Eprex for 1 month

Iron supplement(Venofer, ferrous sulfate)

Iron supplement(Venofer, ferrous sulfate)

• Iron status goal: – Ferritin> 200 and Fe/TIBC> 20%

• Give IV Venofer 300 mg/wk till you reach the goal

• Then reduce Venofer dose to 100 mg/wk to keep iron profile within the expected range

• If ferritin > 500 → reduce Venofer dose• If ferritin > 800 &/or Fe/TIBC> 50% →

Stop Venofer

• Iron status goal: – Ferritin> 200 and Fe/TIBC> 20%

• Give IV Venofer 300 mg/wk till you reach the goal

• Then reduce Venofer dose to 100 mg/wk to keep iron profile within the expected range

• If ferritin > 500 → reduce Venofer dose• If ferritin > 800 &/or Fe/TIBC> 50% →

Stop Venofer

Calcium supplement(Calcium Carbonate, Ca-D)Calcium supplement(Calcium Carbonate, Ca-D)

• Goal: Keep Ca between 8.4 to 9.5 mg/dl

• Maximum maintenance dose of Ca:

2 grams of elemental Calcium

• Keep P between 4-5.5 mg/dl with 1.5-2

grams of elemental Calcium Carbonate

• P < 4 mg/dl → CaCO3 between meals

• Goal: Keep Ca between 8.4 to 9.5 mg/dl

• Maximum maintenance dose of Ca:

2 grams of elemental Calcium

• Keep P between 4-5.5 mg/dl with 1.5-2

grams of elemental Calcium Carbonate

• P < 4 mg/dl → CaCO3 between meals

Calcium supplement(Calcium Carbonate, Ca-D)Calcium supplement(Calcium Carbonate, Ca-D)

• P: 4-5.5 mg/dl → CaCO3 3 tabs/day

(with meals)

• P:5.5-7 mg/dl → CaCO3 4-6 tabs/day for

a limited period (with meals)

• P > 7 mg/dl or Ca P >55 → Stop

Calcium and use Al(OH)3 for a limited

period (30 ml tid for 3-4 weeks)

• P: 4-5.5 mg/dl → CaCO3 3 tabs/day

(with meals)

• P:5.5-7 mg/dl → CaCO3 4-6 tabs/day for

a limited period (with meals)

• P > 7 mg/dl or Ca P >55 → Stop

Calcium and use Al(OH)3 for a limited

period (30 ml tid for 3-4 weeks)

Rocaltrol (Calcitriol)Rocaltrol (Calcitriol)

• If P < 5.5 mg/dl, and Ca < 9.5 and CaP

<55 start Rocaltrol to keep PTH level

between 150-300 pg/ml

• PTH: 300-600 → 2-6 pearls/qod

• PTH: 600-1000 → 4-16 pearls/qod

• PTH> 1000 → 12-28 pearls/qod

• If P < 5.5 mg/dl, and Ca < 9.5 and CaP

<55 start Rocaltrol to keep PTH level

between 150-300 pg/ml

• PTH: 300-600 → 2-6 pearls/qod

• PTH: 600-1000 → 4-16 pearls/qod

• PTH> 1000 → 12-28 pearls/qod

Vitamin SupplementsVitamin Supplements

• Folic Acid: 5 mg Bid

• B-Complex: 1 tab/ day

• B6: 1 tab/day

• Folic Acid: 5 mg Bid

• B-Complex: 1 tab/ day

• B6: 1 tab/day