Your SlideShare is downloading. ×
0
Chronic Kidney Disease Joel Reynolds, MD, FASN Chief, Nephrology Service
Objectives <ul><li>Epidemiology of CKD </li></ul><ul><li>How to measure GFR and when to refer </li></ul><ul><li>Mechanisms...
Defining Chronic Kidney Disease <ul><li>Kidney damage  > 3 mo regardless of GFR </li></ul><ul><ul><li>Biopsy </li></ul></u...
Stages of CKD <ul><li>1 Kidney damage with normal or high  GFR ( > 90cc/min) </li></ul><ul><li>2 Kidney damage with mild d...
Estimating GFR <ul><li>Glomerular filtration rate </li></ul><ul><ul><li>Rate of blood filtration through glomeruli </li></...
Measuring CrCl <ul><li>24-hour urine collection </li></ul><ul><ul><li>Inaccurate due to timed nature of collection </li></...
Measuring CrCl <ul><li>CG vs MDRD </li></ul><ul><ul><li>CG adjusts for (lean) body size </li></ul></ul><ul><ul><li>MDRD st...
Measuring Proteinuria <ul><li>24 hour urine collection </li></ul><ul><ul><li>Always order creatinine with any 24 hr urine ...
Defining Proteinuria <ul><li>Proteinuria:  </li></ul><ul><ul><li>>300mg/24 hours </li></ul></ul><ul><ul><ul><li>NOTE: CHCS...
Epidemiology <ul><li>USRDS data system on all Medicare dialysis patients </li></ul><ul><li>340,000 dialysis patients in 19...
Epidemiology   NHANES study (’88-’94) <ul><li>6.2 million w/ SCr  > 1.5mg/dL </li></ul><ul><li>800,000 w/ SCr  > 2.0mg/dL ...
Differential of CKD <ul><li>Diabetic Nephropathy:  </li></ul><ul><ul><li>Microalbuminuria after at least 5 years </li></ul...
Differential of CKD <ul><li>Paraproteinemias: SPEP/UPEP, older, anemia, back pain </li></ul><ul><li>Cystic diseases: FHx, ...
Work-Up of CKD <ul><li>Make sure it’s chronic and stable </li></ul><ul><li>BP, chemistry for GFR and lytes, quantify prote...
Risks of Progression to ESRD <ul><li>*Proteinuria > 1gm/24 hrs </li></ul><ul><ul><li>>3gm/24 hrs: best response to RAS blo...
Health Implications of ESRD <ul><li>>20% annual mortality </li></ul><ul><li>Lifespan: </li></ul><ul><ul><li>7.1-11.5yrs if...
CKD Under-Diagnosed <ul><li>Among diabetics: </li></ul><ul><ul><li>63% had UTP measured </li></ul></ul><ul><ul><ul><li>33%...
At Initiation of Dialysis  <ul><li>52% had Hct <28 </li></ul><ul><li>54% did not have permanent access </li></ul><ul><li>3...
Mortality in 5 yrs <ul><li>Stage CKD Rate to ESRD Mortality </li></ul><ul><li>1 1.1% 19.5% </li></ul><ul><li>2 1.3 24.3 </...
CV Disease <ul><li>All levels of CKD have increased risks of CAD, cerebral vascular disease and PVD </li></ul><ul><li>Ever...
CV Disease in CKD <ul><li>DM and tobacco classic risk factors </li></ul><ul><li>Other RF’s (HLP, HTN) less predictive </li...
CV Disease in CKD <ul><li>Increased severity of CAD, rates of reversible ischemia </li></ul><ul><li>Worse prognosis in ACS...
Anemia in CKD <ul><li>Direct correlation between GFR and Hb when GFR<60cc/min </li></ul><ul><li>Major factor is decreased ...
Anemia in CKD <ul><li>CBC if GFR <60cc/min </li></ul><ul><li>Full anemia work-up as appropriate </li></ul><ul><ul><li>Don’...
Epogen <ul><li>Start at ~100U/kg (5000-10000U) qwk subQ </li></ul><ul><li>Monitor BP, Hb and iron every 2-4 weeks while ad...
Hypertension in CKD <ul><li>Present in most CKD patients </li></ul><ul><li>Primary risk for progression of CKD </li></ul><...
HTN in CKD <ul><li>ACEI and ARB have beneficial effects in most renal diseases  </li></ul><ul><ul><li>Regardless of degree...
HTN in CKD Summary <ul><li>ACEI and ARB should be part of first-line therapy for HTN in CKD </li></ul><ul><li>COOPERATE: 1...
HTN in CKD <ul><li>Thiazides better than loops for HTN control </li></ul><ul><ul><li>Loop requires bid dosing for any BP c...
Hyperlipidemia <ul><li>CKD considered a CAD equivalent </li></ul><ul><li>Target LDL<100 </li></ul><ul><ul><li>(now <70) </...
Renal Osteodystrophy: ( aka Secondary Hyperparathyroidism) <ul><li>Processes causing parathyroid stimulation with resultan...
Renal Osteodystrophy So What? <ul><li>Treating pre-HD associated w/ 38% decreased 1 yr mortality after HD initiated </li><...
Monitoring PTH <ul><li>PTH, Ca, phos measurement: </li></ul><ul><ul><li>Every 6-12 months in stage 3 CKD </li></ul></ul><u...
Treating hyperPTH <ul><li>Dietary phosphorus restriction </li></ul><ul><li>Switch MVI to nephrocap </li></ul><ul><li>Stop ...
Phosphate binders <ul><li>Bind phosphorus from food in gut and retain in stool </li></ul><ul><ul><li>Not as a calcium supp...
Phosphate binders <ul><li>Renagel (Sevelamer) </li></ul><ul><ul><li>Non-calcium, non-aluminum phos binder </li></ul></ul><...
Phosphate binders <ul><li>Aluminum hydroxide (Amphojel) </li></ul><ul><ul><li>Very effective therapy to acutely lower phos...
Acidosis <ul><li>Early HCMA: impaired ammoniagenesis </li></ul><ul><li>Later AGMA: retained sulfur and phosphate anions </...
Nutrition in CKD <ul><li>Start avoiding phosphorus in stage 3 CKD </li></ul><ul><li>Start avoiding potassium in stage 4 CK...
Referral to Nephrologist <ul><li>GFR >60cc/min: if evidence of renal dz </li></ul><ul><li>GFR 40-60cc/min: seen 1-2x/year ...
Preparation for Dialysis <ul><li>When GFR~30cc/min, discussion regarding ESRD and therapies: PD, HD and transplant </li></...
Preparation for Dialysis <ul><li>Gortex graft ready in 2-6 weeks  </li></ul><ul><ul><li>Much higher thrombosis rate  </li>...
Preparation for Dialysis <ul><li>DM: Initiate when GFR <15cc/min and initial symptoms </li></ul><ul><li>Non-DM: Initiate w...
Summary <ul><li>Understand how to interpret Cr in different patients </li></ul><ul><li>Use the MDRD equation in CHCS </li>...
Questions????
Upcoming SlideShare
Loading in...5
×

Chronic kidney disease

1,138

Published on

Published in: Education
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,138
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
56
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Transcript of "Chronic kidney disease"

  1. 1. Chronic Kidney Disease Joel Reynolds, MD, FASN Chief, Nephrology Service
  2. 2. Objectives <ul><li>Epidemiology of CKD </li></ul><ul><li>How to measure GFR and when to refer </li></ul><ul><li>Mechanisms of CKD progression </li></ul><ul><li>Slowing progression of CKD </li></ul><ul><li>Health implications of CKD </li></ul><ul><li>Special medical issues in CKD </li></ul><ul><li>ESRD issues </li></ul>
  3. 3. Defining Chronic Kidney Disease <ul><li>Kidney damage > 3 mo regardless of GFR </li></ul><ul><ul><li>Biopsy </li></ul></ul><ul><ul><li>Abnormal blood, urine or radiographic tests </li></ul></ul><ul><li>GFR <60cc/min/1.73m 2 for > 3 mo regardless of evidence of kidney damage </li></ul><ul><li>Normal decline in CrCl 1cc/min/yr >30yo </li></ul>
  4. 4. Stages of CKD <ul><li>1 Kidney damage with normal or high GFR ( > 90cc/min) </li></ul><ul><li>2 Kidney damage with mild decrease in GFR (60-89cc/min) </li></ul><ul><li>3 Moderate decrease in GFR (30-59cc/min) </li></ul><ul><li>4 Severe decrease in GFR (15-29cc/min) </li></ul><ul><li>5 Kidney failure / ESRD (GFR<15cc/min or on RRT) </li></ul>AM J Kidney Dis 39[Suppl 1]: S1-S266, 2002
  5. 5. Estimating GFR <ul><li>Glomerular filtration rate </li></ul><ul><ul><li>Rate of blood filtration through glomeruli </li></ul></ul><ul><ul><li>Inulin clearance gold standard </li></ul></ul><ul><li>Creatinine clearance estimates GFR </li></ul><ul><ul><li>Produced at constant rate </li></ul></ul><ul><ul><li>Filtered by glomerulus </li></ul></ul><ul><ul><li>Effected by body mass, age, gender, race, diet, meds (serum Cr very misleading on its own) </li></ul></ul>
  6. 6. Measuring CrCl <ul><li>24-hour urine collection </li></ul><ul><ul><li>Inaccurate due to timed nature of collection </li></ul></ul><ul><ul><li>Poor method even in formal studies </li></ul></ul><ul><ul><li>Rarely used by nephrologists anymore </li></ul></ul><ul><li>Calculations using SCr </li></ul><ul><ul><li>Cockcroft Gault: (140-age)(wt)/72(Scr) </li></ul></ul><ul><ul><ul><li>Gives actual CrCl but requires precise knowledge of lean body weight </li></ul></ul></ul><ul><ul><li>MDRD: </li></ul></ul><ul><ul><ul><li>Complex equation, adults only </li></ul></ul></ul><ul><ul><ul><li>Only weakness: normal renal function </li></ul></ul></ul>
  7. 7. Measuring CrCl <ul><li>CG vs MDRD </li></ul><ul><ul><li>CG adjusts for (lean) body size </li></ul></ul><ul><ul><li>MDRD standardized to 1.73m 2 BSA </li></ul></ul><ul><ul><ul><li>Underestimates GFR in very large (lean) people </li></ul></ul></ul><ul><ul><ul><li>Overestimates GFR in very small people </li></ul></ul></ul><ul><li>Why use MDRD? </li></ul><ul><ul><li>GFR >60cc/min without evidence of renal disease is not considered CKD </li></ul></ul>
  8. 8. Measuring Proteinuria <ul><li>24 hour urine collection </li></ul><ul><ul><li>Always order creatinine with any 24 hr urine </li></ul></ul><ul><ul><li>Creatinine index </li></ul></ul><ul><ul><ul><li>15-20mg/kg females, 20-25mg/kg males </li></ul></ul></ul><ul><ul><li>Same inaccuracies as for all 24 hour urines </li></ul></ul><ul><li>Protein/Creatinine ratio (gm/24hr) * </li></ul><ul><ul><li>Spot urine, much easier, accurate </li></ul></ul><ul><ul><li>Good for trending and categorizing proteinuria </li></ul></ul><ul><li>Alb/cr ratio </li></ul><ul><ul><li>Useful only in screening for microalbuminuria </li></ul></ul>
  9. 9. Defining Proteinuria <ul><li>Proteinuria: </li></ul><ul><ul><li>>300mg/24 hours </li></ul></ul><ul><ul><ul><li>NOTE: CHCS reports protein as mg/L, must divide by 10 </li></ul></ul></ul><ul><li>Microalbuminuria </li></ul><ul><ul><li>30-300mg/24 hours </li></ul></ul>
  10. 10. Epidemiology <ul><li>USRDS data system on all Medicare dialysis patients </li></ul><ul><li>340,000 dialysis patients in 1999 </li></ul><ul><li>651,000 projected for 2010 </li></ul><ul><ul><li>Mostly from older, comorbid patients </li></ul></ul>
  11. 11. Epidemiology NHANES study (’88-’94) <ul><li>6.2 million w/ SCr > 1.5mg/dL </li></ul><ul><li>800,000 w/ SCr > 2.0mg/dL </li></ul><ul><li>70% of these had HTN </li></ul><ul><ul><li>Only 75% of these were treated </li></ul></ul><ul><ul><li>27% had BP<140/90 </li></ul></ul><ul><ul><li>11% had BP<130/85 </li></ul></ul><ul><li>Persistent albuminuria in 3% of US population w/ GFR>60cc/min </li></ul>
  12. 12. Differential of CKD <ul><li>Diabetic Nephropathy: </li></ul><ul><ul><li>Microalbuminuria after at least 5 years </li></ul></ul><ul><ul><li>Proteinuria and  SCr after at least 7 years </li></ul></ul><ul><ul><li>Not likely if no proteinuria, no retinopathy or new onset DM </li></ul></ul><ul><li>HTN: long-term, poorly treated </li></ul><ul><li>Renovascular disease: CV risk factors </li></ul><ul><li>Glomerulonephritis: Hx, UA, serology </li></ul>
  13. 13. Differential of CKD <ul><li>Paraproteinemias: SPEP/UPEP, older, anemia, back pain </li></ul><ul><li>Cystic diseases: FHx, US </li></ul><ul><li>Persistence of ARF: </li></ul><ul><ul><li>Glomerulosclerosis: healing scar </li></ul></ul><ul><ul><li>Chronic prerenal state (often reversible) </li></ul></ul>
  14. 14. Work-Up of CKD <ul><li>Make sure it’s chronic and stable </li></ul><ul><li>BP, chemistry for GFR and lytes, quantify proteinuria </li></ul><ul><li>UA for SG, blood, pH, protein </li></ul><ul><li>Renal US </li></ul><ul><ul><li>Obstruction, chronicity and amenability to Bx </li></ul></ul><ul><li>Refer to Nephrology </li></ul><ul><ul><li>All w/ GFR<60cc/min </li></ul></ul><ul><ul><li>Higher GFR’s with other evidence of renal dz </li></ul></ul>
  15. 15. Risks of Progression to ESRD <ul><li>*Proteinuria > 1gm/24 hrs </li></ul><ul><ul><li>>3gm/24 hrs: best response to RAS blockade and highest risk to progress </li></ul></ul><ul><li>TI disease on biopsy </li></ul><ul><li>*Lipids: low HDL, high total Cholesterol </li></ul><ul><li>*DM </li></ul><ul><li>*HTN </li></ul><ul><li>*Smoking, African American race, Genetics </li></ul>
  16. 16. Health Implications of ESRD <ul><li>>20% annual mortality </li></ul><ul><li>Lifespan: </li></ul><ul><ul><li>7.1-11.5yrs if 40-44yo </li></ul></ul><ul><ul><li>2.7-3.9yrs if 60-64yo </li></ul></ul><ul><li>Mean 15 hospital days per year </li></ul><ul><li>Lower QOL </li></ul><ul><li>1998: $16.7 billion (5% of Medicare budget) </li></ul><ul><li>Catching and stabilizing CKD early can prevent adverse outcomes </li></ul>
  17. 17. CKD Under-Diagnosed <ul><li>Among diabetics: </li></ul><ul><ul><li>63% had UTP measured </li></ul></ul><ul><ul><ul><li>33% of proteinuric patients on ACEI </li></ul></ul></ul><ul><ul><li>97% had creatinine measured </li></ul></ul><ul><ul><ul><li>32% w/ CKD on ACEI </li></ul></ul></ul><ul><li>Among HTN CKD: </li></ul><ul><ul><li>59% had UTP measured </li></ul></ul><ul><ul><ul><li>13% of proteinuric patients on ACEI </li></ul></ul></ul><ul><ul><li>91% had creatinine measured </li></ul></ul><ul><ul><ul><li>26% w/ CKD on ACEI </li></ul></ul></ul>
  18. 18. At Initiation of Dialysis <ul><li>52% had Hct <28 </li></ul><ul><li>54% did not have permanent access </li></ul><ul><li>39% were referred to Nephrologist within 3 months of initiation </li></ul><ul><li>24% were initiated at GFR’s<5cc/min </li></ul><ul><li>First 3 associated with increased morbidity and mortality on dialysis. </li></ul>
  19. 19. Mortality in 5 yrs <ul><li>Stage CKD Rate to ESRD Mortality </li></ul><ul><li>1 1.1% 19.5% </li></ul><ul><li>2 1.3 24.3 </li></ul><ul><li>3 19.9 45.7 </li></ul>
  20. 20. CV Disease <ul><li>All levels of CKD have increased risks of CAD, cerebral vascular disease and PVD </li></ul><ul><li>Every 10cc/min drop in GFR = 5% increase risk CVD (MDRD) </li></ul><ul><li>40% increased risk in “minor” CKD (HOPE) </li></ul><ul><li>100X CV mortality under 45yo in ESRD </li></ul><ul><li>Account for 50% of deaths in ESRD </li></ul><ul><li>Higher prevalence of DM, CHF, anemia and metabolic syndrome </li></ul>
  21. 21. CV Disease in CKD <ul><li>DM and tobacco classic risk factors </li></ul><ul><li>Other RF’s (HLP, HTN) less predictive </li></ul><ul><li>Chronic inflammation has major role </li></ul><ul><li>Homocysteine not related </li></ul><ul><li>Excessive vascular calcification </li></ul>
  22. 22. CV Disease in CKD <ul><li>Increased severity of CAD, rates of reversible ischemia </li></ul><ul><li>Worse prognosis in ACS/AMI </li></ul><ul><li>Decreased survival post-PCI </li></ul>
  23. 23. Anemia in CKD <ul><li>Direct correlation between GFR and Hb when GFR<60cc/min </li></ul><ul><li>Major factor is decreased epo synthesis </li></ul><ul><li>Normochromic, normocytic </li></ul><ul><li>Associated with higher hospitalization rates, CV dz, cognitive dysfunction, LVH and mortality </li></ul>
  24. 24. Anemia in CKD <ul><li>CBC if GFR <60cc/min </li></ul><ul><li>Full anemia work-up as appropriate </li></ul><ul><ul><li>Don’t measure epo levels </li></ul></ul><ul><li>Epo is mainstay of therapy </li></ul><ul><ul><li>Improves Hb (decreased transfusions) </li></ul></ul><ul><ul><li>Prevents LVH </li></ul></ul><ul><ul><li>Improves survival </li></ul></ul><ul><ul><li>Start when Hct 30-33 </li></ul></ul>
  25. 25. Epogen <ul><li>Start at ~100U/kg (5000-10000U) qwk subQ </li></ul><ul><li>Monitor BP, Hb and iron every 2-4 weeks while adjusting dose </li></ul><ul><li>Increase frequency of dose to tiw </li></ul><ul><ul><li>Don’t use 40,000U sq qwk </li></ul></ul><ul><ul><li>Will deplete iron stores and require IV iron </li></ul></ul><ul><li>Goal Hb: 11-12 (Hct: 33-36) </li></ul><ul><li>HTN w/ too much epo </li></ul>
  26. 26. Hypertension in CKD <ul><li>Present in most CKD patients </li></ul><ul><li>Primary risk for progression of CKD </li></ul><ul><ul><li>Reducing BP to <140/90 slows progression </li></ul></ul><ul><ul><li>No threshold effect </li></ul></ul><ul><ul><li>Most significant if UTP>1gm/24hrs </li></ul></ul><ul><li>JNC VI: </li></ul><ul><ul><li>Target BP in CKD:<130/85 </li></ul></ul><ul><ul><li>If >1gm UTP: <125/75 </li></ul></ul>
  27. 27. HTN in CKD <ul><li>ACEI and ARB have beneficial effects in most renal diseases </li></ul><ul><ul><li>Regardless of degree of proteinuria </li></ul></ul><ul><ul><li>Beyond effects on BP </li></ul></ul><ul><li>Slow progression of CKD, decrease proteinuria and in some cases improve mortality </li></ul><ul><li>Diabetic and non-diabetic renal disease </li></ul>
  28. 28. HTN in CKD Summary <ul><li>ACEI and ARB should be part of first-line therapy for HTN in CKD </li></ul><ul><li>COOPERATE: 1/2 dose ACEI + 1/2 dose ARB better than full dose either </li></ul><ul><ul><li>Slowed progression, improved renal survival </li></ul></ul><ul><li>ALLHAT: ACEI alone not enough to control BP in most cases </li></ul><ul><ul><li>Thiazide diuretic usually needed </li></ul></ul>
  29. 29. HTN in CKD <ul><li>Thiazides better than loops for HTN control </li></ul><ul><ul><li>Loop requires bid dosing for any BP control </li></ul></ul><ul><ul><li>HCTZ loses efficacy around GFR 30cc/min </li></ul></ul><ul><ul><li>Switch to metolazone, start 5mg tiw </li></ul></ul><ul><ul><li>Watch for ARF and hypoNa </li></ul></ul><ul><li>Multiple meds often required </li></ul>
  30. 30. Hyperlipidemia <ul><li>CKD considered a CAD equivalent </li></ul><ul><li>Target LDL<100 </li></ul><ul><ul><li>(now <70) </li></ul></ul><ul><li>Often require lipitor </li></ul><ul><ul><li>Lipitor more effective than zocor with decreased side effects </li></ul></ul><ul><ul><ul><li>Actually cheaper in civilian market </li></ul></ul></ul>
  31. 31. Renal Osteodystrophy: ( aka Secondary Hyperparathyroidism) <ul><li>Processes causing parathyroid stimulation with resultant bone disease </li></ul><ul><li>Decrease in 1,25-(OH) 2 Vit D (GFR <60cc/min) </li></ul><ul><ul><li>Decreased 1 α -hydroxylase: low renal mass </li></ul></ul><ul><li>Retention of phosphates (GFR<40cc/min) </li></ul><ul><ul><li>Stimulation of PTH </li></ul></ul><ul><li>Uremia causes bone resistance to PTH </li></ul>
  32. 32. Renal Osteodystrophy So What? <ul><li>Treating pre-HD associated w/ 38% decreased 1 yr mortality after HD initiated </li></ul><ul><li>Bone pain, fractures </li></ul><ul><ul><li>Osteitis fibrosa cystica (high turnover) from sustained hyperPTH, </li></ul></ul><ul><ul><li>Adynamic bone disease from oversuppression of PTH </li></ul></ul><ul><li>Extraskeletal calcification </li></ul><ul><li>Tertiary hyperPTH requiring surgery </li></ul>
  33. 33. Monitoring PTH <ul><li>PTH, Ca, phos measurement: </li></ul><ul><ul><li>Every 6-12 months in stage 3 CKD </li></ul></ul><ul><ul><li>Every 3mo if GFR<30cc/min </li></ul></ul><ul><li>Target PTH: </li></ul><ul><ul><li>Stage 3 CKD: 35-70 </li></ul></ul><ul><ul><li>Stage 4 CKD: 70-110 </li></ul></ul><ul><ul><li>Stage 5 CKD: 200-300 </li></ul></ul>
  34. 34. Treating hyperPTH <ul><li>Dietary phosphorus restriction </li></ul><ul><li>Switch MVI to nephrocap </li></ul><ul><li>Stop OTC Vit D preparations </li></ul><ul><li>Calcitriol 0.25mcg po tiw </li></ul><ul><ul><li>Limited by hyperphos and hyperCa </li></ul></ul><ul><li>Phosphate binder </li></ul><ul><li>Keep phos bet. 2.7-4.6 in Stage 3/4 CKD </li></ul><ul><li>Target Serum Ca <10.2 </li></ul>
  35. 35. Phosphate binders <ul><li>Bind phosphorus from food in gut and retain in stool </li></ul><ul><ul><li>Not as a calcium supplement </li></ul></ul><ul><li>Ca Carbonate (Oscal) </li></ul><ul><ul><li>No efficacy while on PPI </li></ul></ul><ul><li>Calcium Acetate (Phoslo) </li></ul><ul><ul><li>Use w/ PPI </li></ul></ul><ul><li>Ca-based binders associated with coronary calcification </li></ul>
  36. 36. Phosphate binders <ul><li>Renagel (Sevelamer) </li></ul><ul><ul><li>Non-calcium, non-aluminum phos binder </li></ul></ul><ul><ul><li>Not as effective solo </li></ul></ul><ul><ul><li>Can cause metaboic acidosis </li></ul></ul><ul><ul><li>First line if hypercalcemic or known calcific vascular disease </li></ul></ul>
  37. 37. Phosphate binders <ul><li>Aluminum hydroxide (Amphojel) </li></ul><ul><ul><li>Very effective therapy to acutely lower phos </li></ul></ul><ul><ul><li>Indicated if phos >7mg/dL </li></ul></ul><ul><ul><li>Aluminum toxicity: dialysis dementia and adynamic bone disease </li></ul></ul><ul><ul><li>For short-term uses only </li></ul></ul><ul><li>Calcimimetics (new and upcoming) </li></ul><ul><ul><li>Not a phos binder </li></ul></ul>
  38. 38. Acidosis <ul><li>Early HCMA: impaired ammoniagenesis </li></ul><ul><li>Later AGMA: retained sulfur and phosphate anions </li></ul><ul><li>Chronic acidosis leads to bone leeching </li></ul><ul><li>Goal bicarb >20-22 mEq/dL </li></ul><ul><li>Treat with oral Na-Bicarb </li></ul><ul><li>Avoid-citrate based therapies </li></ul><ul><ul><li>Increases passive aluminum absorption </li></ul></ul>
  39. 39. Nutrition in CKD <ul><li>Start avoiding phosphorus in stage 3 CKD </li></ul><ul><li>Start avoiding potassium in stage 4 CKD or earlier if hyperK </li></ul><ul><li>Malnutrition very common in ESRD </li></ul><ul><li>Difficult to balance nutrition and phos restriction </li></ul>
  40. 40. Referral to Nephrologist <ul><li>GFR >60cc/min: if evidence of renal dz </li></ul><ul><li>GFR 40-60cc/min: seen 1-2x/year </li></ul><ul><li>GFR 20-40cc/min: seen 2-4x/year </li></ul><ul><li>GFR<20cc/min: seen as needed, often monthly </li></ul><ul><li>Why? </li></ul><ul><ul><li>Treat anemia, HLP, HTN, renal osteodystrophy and prepare for dialysis </li></ul></ul>
  41. 41. Preparation for Dialysis <ul><li>When GFR~30cc/min, discussion regarding ESRD and therapies: PD, HD and transplant </li></ul><ul><li>Can be listed for transplant at GFR 20cc/min </li></ul><ul><ul><li>Pre-emptive transplant better prognosis </li></ul></ul><ul><li>Referral to vascular surgery for evaluation for fistula ~6 months before estimated need for HD </li></ul><ul><ul><li>Best form of access </li></ul></ul>
  42. 42. Preparation for Dialysis <ul><li>Gortex graft ready in 2-6 weeks </li></ul><ul><ul><li>Much higher thrombosis rate </li></ul></ul><ul><ul><li>~ 50% 1-2yr failure rate </li></ul></ul><ul><li>Central line </li></ul><ul><ul><li>Last choice </li></ul></ul><ul><ul><li>Highest infection and thrombosis rate </li></ul></ul><ul><li>1/cr plot w/ GFR calculator to help estimate time to ESRD </li></ul>
  43. 43. Preparation for Dialysis <ul><li>DM: Initiate when GFR <15cc/min and initial symptoms </li></ul><ul><li>Non-DM: Initiate when GFR <10cc/min and initial symptoms </li></ul><ul><li>Epo has helped delay onset of uremic symptoms </li></ul>
  44. 44. Summary <ul><li>Understand how to interpret Cr in different patients </li></ul><ul><li>Use the MDRD equation in CHCS </li></ul><ul><li>Referring to Nephrology earlier (GFR<60cc/min) decreases progression to ESRD and will help with comorbidities </li></ul><ul><li>Treat LDL to <70 </li></ul><ul><li>Treat BP to <125-130/75-80 </li></ul>
  45. 45. Questions????
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×