The document defines chronic kidney disease (CKD) and provides guidelines for evaluating and managing CKD according to the KDIGO 2012 Clinical Practice Guideline. It defines CKD based on glomerular filtration rate (GFR) and albuminuria categories. It recommends evaluating CKD severity annually and monitoring for progression. It provides guidance on managing complications of CKD like anemia, bone disease, and cardiovascular risk. It also addresses medication management, specialist referral indications, and timing the initiation of renal replacement therapy.
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Management of coronary disease in diabetes - Is it different?Dr Vivek Baliga
The management of diabetes and coronary artery disease go hand in hand. This presentation by Dr Vivek talks on whether it varies from usual management.
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Management of coronary disease in diabetes - Is it different?Dr Vivek Baliga
The management of diabetes and coronary artery disease go hand in hand. This presentation by Dr Vivek talks on whether it varies from usual management.
Diabetic nephropathy considered one of the most common complications of DM. This presentation answer the question are some diabetic patient immune to diabetic nephroapthy
Diabetic nephropathy considered one of the most common complications of DM. This presentation answer the question are some diabetic patient immune to diabetic nephroapthy
Calcium channel blockers are useful treatments in the management of hypertension. In this presentation by Dr Vivek Baliga, we look at the added benefits of newer types of CCBs in treating high blood pressure. Read more from Dr Baliga here - http://drvivekbaliga.net
Dyslipidemia management an evidence based approachDr Vivek Baliga
In this presentation by Dr Vivek Baliga, he discusses the different available statins and how you can choose the right one in different clinical situations. See articles from Dr Baliga on http://drvivekbaliga.net
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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3. INTRODUCTION
The Kidney Disease Improving Global Outcomes (KDIGO) 2012
Clinical Practice Guideline for the Evaluation and Management of
Chronic Kidney Disease (CKD) serves to update the 2002 KDOQI
Clinical Practice Guideline includes definition, an enhanced
classification frame work.
It also elaborates on the identification and prognosis of CKD;
management of progression and complications and expands on
the continuum of CKD care: timing of specialist referral, timing
of the initiation of dialysis, and finally the implementation of a
treatment program which includes comprehensive conservative
management.
4. Definition Of CKD
CKD is defined as abnormalities of kidney structure or
function, present for>3 months, with implications for
health .
CKD is classified based on cause, GFR category, and
albuminuria category (CGA).
5. Criteria For CKD (Either Of The Following
Present For >3 Months)
Markers of kidney damage (one or more)
- Albuminuria (AER <30 mg/24 hours; ACR <30 mg/g [<3
mg/mmol])
-Urine sediment abnormalities
-Electrolyte and other abnormalities due to tubular
disorders
-Abnormalities detected by histology
-Structural abnormalities detected by imaging
-History of kidney transplantation
Decreased GFR
GFR <60 ml/min/1.73 m2
6. GFR Categories In CKD
GFR Category GFR (ml/min/1.73
m2)
Terms
G1 ≥90 Normal or high
G2 60–89 Mildly decreased
G3a 45–59 Mildly to moderately
decreased
G3b 30–44 Moderately to severely
decreased
G4 15–29 Severely decreased
G5 <15 Kidney failure
9. Evaluation Of CKD
Evaluation Of Chronicity:
If duration is >3 months, CKD is confirmed.
If duration is not >3 months or unclear, not confirmed. Patients
may have CKD or acute kidney diseases or both and tests should
be repeated accordingly.
Evaluation Of Cause:
Evaluate the clinical context, including personal and family
history, social and environmental factor, medications, physical
examination, laboratory measures, imaging, and pathologic
diagnosis to determine the causes of kidney disease.
10. Contd.
Evaluation of GFR:
Using serum creatinine and a GFR estimating equation for
initial assessment.
Using additional tests (such as cystatin C or a clearance
measurement) for confirmatory testing in specific
circumstances when eGFR based on serum creatinine is less
accurate.
Measuring cystatin C in adults when eGFRcreat is 45–59
ml/min/1.73 m2 & who do not have markers of kidney
damage if confirmation of CKD is required .
If eGFRcys/eGFRcreat-cys is also <60 ml/min/1.73 m2, the diagnosis of CKD is
confirmed.
If eGFRcys/eGFRcreat-cys is ≥60 ml/min/1.73 m2, the diagnosis of CKD is not confirmed.
11. Contd.
Evaluation Of Albuminuria:
Using the following measurements for initial testing of
proteinuria ( in all cases an early morning urine sample is
preferred):
1) urine albumin-to-creatinine ratio (ACR);
2) urine protein-to-creatinine ratio (PCR);
3) reagent strip urinalysis for total protein with automated
reading;
4) reagent strip urinalysis for total protein with manual
reading.
12. Suggested protocol for the further investigation of an individual demonstrating a positive
reagent strip test for albuminuria/proteinuria or quantitative albuminuria/proteinuria test.
13. Predicting Prognosis Of CKD
In predicting risk for outcome of CKD, identify the fol variables:
1) cause of CKD
2) GFR category
3) albuminuria category
4) other risk factors and co morbid conditions such as age,
sex, race/ethnicity, elevated BP, hyperglycemia, dyslipidemia,
smoking, obesity, history of cardiovascular disease, ongoing
exposure to nephrotoxic agents.
In populations with CKD, group GFR and albuminuria categories
with similar relative risk for CKD outcomes into risk categories .
14.
15. Definition And Identification Of CKD
Progression
CKD Progression based on one of more of the following :
1) Decline in GFR category . A certain drop in eGFR is
defined as a drop in GFR category accompanied by a 25% or
greater drop in eGFR from baseline.
2) Rapid progression is defined as a sustained decline in
eGFR of more than 5 ml/min/1.73 m2/yr.
3) The confidence in assessing progression is increased with
increasing number of serum creatinine measurements and
duration of follow-up.
16. Contd.
Assess GFR and albuminuria at least annually in people with
CKD.
Assess GFR and albuminuria more often for individuals at
higher risk of progression or where measurement will impact
therapeutic decisions
17.
18. Management Of Progression And
Complications Of CKD
Prevention Of CKD Progression:
1)BP Interruption:
Individualize BP targets and agents according to age, coexisting cvs
disease and other co morbidities.
Recommend that in both diabetic and non-diabetic adults with CKD
and urine albumin excretion <30 mg/24 hrs whose office BP is
consistently >140/90mm Hg , maintain a BP that is consistently
≤140/90mm Hg .
If urine albumin excretion is >30mg/24hrs then target BP is ≤130/80
mm Hg.
19. Contd.
ARB or ACE-I can be used in diabetic adults with CKD where
AER is 30–300 mg/24 hrs.
Recommended that an ARB or ACE-I be used in both
diabetic and non-diabetic adults with CKD and urine
albumin excretion >300 mg/24 hour
In children with CKD, BP-lowering treatment is started
when BP is consistently above the 90th percentile for age,
sex, and height.ARB or ACE-I be used as BP-lowering drugs ,
irrespective of the level of proteinuria.
ARB or ACE-I can cause an acute increase in S-Cr &/or K,
continue medication if increase is< 30%.Monitor RFT & K
levels with initiation & with each dosages change every 1-2
wks until values return to baseline.
20. Contd.
CKD And Risk Of AKI:
Recommended that all people with CKD are considered to
be at increased risk of AKI.
Protein Intake: lowering protein intake to 0.8 g/kg/day in
adults with or without diabetes.
Glycemic Control:
i. Recommended a target HbA1c approx 7.0% to prevent or
delay progression of the microvascular complications of
diabetes.
ii. Recommended not treating to an HbA1c target of <7.0%
in patients at risk of hypoglycemia. Here target HbA1c
must be extended above 7.0% .
21. Contd.
Lifestyle Modification:
Recommended that people with CKD be encouraged to
undertake physical activity (at least 30minutes 5 times per
week) and stop smoking.
Salt Intake:
Lowering salt intake to <90mmol (o2 g) per day in adults.
Additional Dietary Advice:
Individuals with CKD receive expert dietary advice and
information in the context of an education program and the
need to intervene on salt, phosphate, potassium, and protein
intake where indicated.
22. Complications Associated With Loss Of
Kidney Function
Anaemia:
Definition and identification of anemia in CKD:
In adults and children >15 years with CKD when the Hb concentration is
<13.0 g/dl in males and <12.0 g/dl in females.
In children with CKD if Hb concentration
o <11.0 g/dl in 0.5–5 years,
o <11.5 g/dl in children 5–12 years, and
o <12.0 g/dl in 12-15 years.
To identify anemia in people with CKD, measure Hb concentration
1. clinically indicated in G1-G2
2. at least annually in G3a-G3b
3. at least twice per yr in G4-G5
23. Contd.
Metabolic Bone Disease:
Includes renal osteodystrophy and extraskeletal (vascular)
calcification related to abnormalities of bone mineral
metabolism. Renal osteodystrophy is quantified through
bone biopsy histomorphometry and includes osteitis fibrosa,
osteomalacia, and adynamic bone disease.
Recommended measuring serum levels of calcium,
phosphate, PTH, and Alkaline Phosphatase activity at least
once if GFR is <45ml/min/1.73m2 to determine baseline
values.
Not to perform bone mineral density testing routinely in
those with eGFR <45 ml/min/1.73m2, as information may be
misleading or unhelpful.
24. Contd.
In people with CKD stage 3b-5 suggest maintaining
serum phosphate concentrations in the normal range.
In people with GFR <45 ml/min/1.73 m2 (GFR categories
G3b-G5) the optimal PTH level is not known.
Suggested that people with levels of intact PTH above the
upper normal limit of the assay are first evaluated for
hyperphosphatemia, hypocalcemia, and vitamin D
deficiency.
25. Contd.
Vitamin D Supplementation And Bisphosphonates:
Suggested not to routinely prescribe vitamin D
supplements or vitamin D analogs, in the absence of
suspected or documented deficiency, to suppress
elevated PTH concentrations in people with CKD not on
dialysis.
Suggested not to prescribe bisphosphonate treatment in
people with CKD stage 4-5 without a strong clinical
rationale
26. Contd.
Acidosis: declining renal function is assosiated with metabolic
acidosis .
In people with CKD and serum bicarbonate conc. <22 mmol/l
treatment with oral bicarbonate supplementation to maintain
bicarbonate within the normal range.
Risk of CVD:
Recommended that all people with CKD should be considered at
increased risk for CVS disease.
Suggested that adults with CKD at risk for atherosclerotic events
should get treatment with antiplatelet agents unless there is an
increased bleeding risk .
.
27. Condt.
CKD And Risk Of Infections:
Recommended that all adults with CKD are offered annual
vaccination with influenza vaccine.
Adults with GFR categories G4-G5 and at high risk of
pneumococcal infection receive polyvalent pneumococcal
vaccine and revaccination within 5 yrs.
All adults who are at high risk of progression of CKD should
be immunized against hep B .
Consideration of live vaccine should include an appreciation
of the patient’s immune status and should be in line with
recommendations from official or governmental bodies.
28. Contd.
Risk factors for infection in people with CKD:
1) Advanced age
2)High burden of coexisting illnesses such as DM
3) Hypoalbuminemia
4)Immunosuppressive therapy
5)Nephrotic syndrome
6)Uremia
7)Anemia and malnutrition
8)High prevalence of functional disabilities
29. Contd.
Drug Toxicity: Altered pharmacokinetics of drugs excreted
by the kidney and an increased risk of drug-interactions are
common and require adjustment in the dosage of many
drugs.
30. Medication Management And Patient Safety In
CKD
Recommended that prescribers should take GFR into
account when drug dosing.
Temporary discontinuation of potentially nephrotoxic and
renally excreted drugs in people with CKD stage 3a-5 who
have serious intercurrent illness that increases the risk of
AKI. These agents include ACE-Is, ARBs, aldosterone
inhibitors, direct renin inhibitors, diuretics, NSAIDs,
metformin, lithium, and digoxin.
Not using herbal remedies in people with CKD.
31. Contd.
Metformin can be continued in G1-G3a; its use should be
reviewed in G3b; and it should be discontinued in G4-G5.
People with CKD should not be denied therapies for other
conditions such as cancer but there should be appropriate
dose adjustment of cytotoxic drugs according to knowledge
of GFR.
32. Cautionary Notes For Prescribing In People
With CKD
Agents Cautionary notes
1. Antihypertensives
ACE-Is,ARBs,
aldosterone antagonists
-Avoid in people with suspected functional renal artery
stenosis
- Start at lower dose in people with GFR <45 ml/min/1.73
m2
- Assess GFR and measure serum potassium within 1 week
of starting or following any dose increase
- Temporarily suspend during intercurrent illness, planned
IV radiocontrast administration,bowel preparation, or prior
to major surgery
- Do not routinely discontinue in people with GFR <30
ml/min/1.73 m2 as they are nephroprotective
2.Beta-blockers Reduce dose by 50% in people with GFR <30 ml/min/1.73
m2
3.Digoxin Reduce dose based on plasma concentrations
33. Condt.
Agents Cauti0nary note
4.Analgesics
NSAIDS
- Avoid in people with GFR <30 ml/min/1.73 m2
- Prolonged therapy is not recommended in people with
GFR <60 ml/min/1.73 m2
- Avoid in people taking RAAS blocking agents
5. Antimicrobials
Penicillin
Risk of crystalluria when GFR <15 ml/min/1.73 m2 with high
doses
6. Macrolides Reduce dose by 50% when GFR <30 ml/min/1.73 m
7.Aminoglycosides -Reduce dose and/or increase dosage interval when GFR
<60 ml/min/1.73 m2
- Avoid concomitant ototoxic agents such as furosemide
8.Antifungals -Avoid amphotericin unless no alternative when GFR <60
ml/min/1.73 m2
- Reduce maintenance dose of fluconazole by 50% when
GFR <45 ml/min/1.73 m2
9. Lipid-lowering drugs
Statin
Fenofibrate
No increase in toxicity for simvastatin dosed at 20 mg / day
Increases SCr by approximately 0.13 mg/dl
34. Referral To Specialists
KDIGO recommendation is in the following circumstances
1) AKI or abrupt sustained fall in GFR;
2) GFR <30 ml/min/1.73 m2 (GFR categories G4-G5)
3) consistent finding of significant albuminuria (ACR >300
mg/g [>30 mg/mmol]
4) progression of CKD
5)urinary red cell casts, RBC >20 per high power field
sustained and not readily explained
6) CKD and hypertension refractory to treatment with 4 or
more antihypertensive agents
7) persistent abnormalities of serum potassium;
8) recurrent or extensive nephrolithiasis.
9) hereditary kidney disease
35. Care Of The Patient With Progressive CKD
KDIGO suggested that people with progressive CKD should
be managed in a multidisciplinary care setting.
The multidisciplinary team should include or have access to
dietary counseling, education and counseling about different
RRT modalities, transplant options, vascular access surgery;
ethical, psychological, and social care.
36. Timing The Initiation Of RRT
Suggested that dialysis to be initiated when one or more of
the fol are present:
1) Symptoms or signs attributable to kidney failure
(serositis, acid-base or electrolyte abnormalities, pruritus)
2) Inability to control volum status or blood pressure
3) Progressive deterioration in nutritional status
refractory to dietary intervention
4) Cognitive impairment
This often but not invariably occurs in the GFR range between
5 -10 ml/min/1.73 m2.
37. Contd.
Living donor preemptive renal transplantation in adults
should be considered when the GFR is <20 ml/min/1.73 m2,
and there is evidence of progressive and irreversible CKD
over the preceding 6–12 months.
38. Structure And Process Of Comprehensive
Conservative Management
Conservative management for people who choose not to
pursue RRT and should be supported by a comprehensive
management program.
All CKD care providers should be able to deliver advance
care for people , recognized as end-of-life care.
Coordinated end-of-life care should be available to people
and families through either primary care or specialist care.
39. Contd.
This program should include protocols for symptoms and
pain management, psychological care, spiritual care, and
culturally sensitive care for the dying patient and their family
whether at home or in a hospital setting.