The document discusses chronic kidney disease (CKD) prognosis and factors that impact it, including cause of CKD, glomerular filtration rate (GFR) category, albuminuria category, and comorbidities. It also discusses guidelines for initiating renal replacement therapy (RRT), specifically dialysis, noting that recent evidence suggests late initiation may be safe for some patients and associated with improved survival compared to early initiation. The document outlines RRT modality options including transplantation, hemodialysis, peritoneal dialysis, and discusses preserving residual renal function for dialysis patients.
Guidelines for the prevention of stroke in patientsNeurologyKota
This document provides guidelines for preventing stroke in patients who have had a stroke or transient ischemic attack (TIA). It discusses risk factors like hypertension, diabetes, dyslipidemia, lifestyle factors, and recommends treatments and lifestyle changes to reduce risk. For hypertension, it recommends blood pressure management and provides evidence from clinical trials supporting treatment. It also recommends statin therapy and lifestyle changes to manage dyslipidemia and other risk factors.
Stroke prevention in patients with atrial fibrillationMgfamiliar Net
This document summarizes a webinar on stroke prevention in patients with atrial fibrillation. It reviews the evidence for using novel oral anticoagulants (NOACs), provides a clinical guide on how to use NOACs in practice, and discusses strategies to reduce ischemic and bleeding risks using real-world cases. The document also includes a quiz on the clinical use of NOACs and summarizes key advantages of NOACs over warfarin. Real-world cases demonstrate the impact of NOAC introduction on optimizing anticoagulation and reducing strokes in atrial fibrillation patients.
Rivaroxaban is an oral anticoagulant used to treat and prevent blood clots. It works by selectively inhibiting factor Xa. It is administered as tablets in doses of 2.5 mg, 10 mg, 15 mg, or 20 mg once or twice daily depending on the indication. Adverse reactions include hematoma, back pain, wound secretion and abdominal pain. Rivaroxaban is contraindicated in patients with hypersensitivity or active pathological bleeding. Dosage adjustments are required for patients with renal or hepatic impairment. Drug interactions can occur with strong CYP3A4 inhibitors or NSAIDs.
This document discusses sodium glucose cotransporter-2 inhibitors (SGLT2i) across the spectrum of renal diseases. It begins with an overview of renal glucose handling and the role of the SGLT2 channel. It then reviews the rationale for SGLT2 inhibition in diabetic and non-diabetic kidney diseases and basic SGLT2i pharmacology. Finally, it examines clinical outcomes data from trials demonstrating the cardiovascular, renal, and heart failure benefits of SGLT2is across levels of renal function and in diabetic and non-diabetic patients.
The DCCT trial showed that intensive diabetes management reduced the risk of eye, kidney, and nerve complications compared to standard management. Intensive therapy aimed for blood glucose levels between 70-120 mg/dl, while standard therapy aimed to avoid symptoms of high or low blood glucose. The risks of intensive therapy were increased hypoglycemia and weight gain. The follow up EDIC study found metabolic memory effects, with long term benefits of early intensive control.
Intensive glycemic control aimed at maintaining blood glucose between 80-110 mg/dl in adult ICU patients does not reduce mortality and significantly increases the risk of hypoglycemia compared to conventional control between 140-180 mg/dl. Multiple large randomized controlled trials found no benefit to intensive control and post-hoc analyses determined hypoglycemia independently increases mortality. Current guidelines recommend insulin therapy only for blood glucose over 180 mg/dl and targeting 140-180 mg/dl range to minimize hypoglycemia risk while avoiding hyperglycemia's harmful effects.
This document summarizes key information about the drug Empagliflozin. It belongs to the sodium glucose co-transporter 2 inhibitor class, which works by inhibiting glucose reabsorption in the kidney and increasing glucose excretion. The document outlines Empagliflozin's pharmacodynamics, pharmacokinetics, adverse reactions, dosage and administration, current status, and references. It provides an overview of Empagliflozin's mechanism of action, metabolism, excretion, drug interactions, efficacy, safety profile, and approved uses as monotherapy or add-on therapy for type 2 diabetes.
This document discusses dialysis in elderly patients. It notes that biological age is more important than calendar age when evaluating elderly patients for dialysis. Initiation of renal replacement therapy requires consideration of comorbidities, mental status, quality of life, life expectancy, vascular access, and socioeconomic factors. Dialysis in elderly patients is associated with higher rates of comorbidities like atherosclerosis and fewer vascular access options. Conservative care without dialysis is an alternative for some elderly patients with multiple comorbidities. Quality of life assessments are important when considering dialysis for elderly patients.
Guidelines for the prevention of stroke in patientsNeurologyKota
This document provides guidelines for preventing stroke in patients who have had a stroke or transient ischemic attack (TIA). It discusses risk factors like hypertension, diabetes, dyslipidemia, lifestyle factors, and recommends treatments and lifestyle changes to reduce risk. For hypertension, it recommends blood pressure management and provides evidence from clinical trials supporting treatment. It also recommends statin therapy and lifestyle changes to manage dyslipidemia and other risk factors.
Stroke prevention in patients with atrial fibrillationMgfamiliar Net
This document summarizes a webinar on stroke prevention in patients with atrial fibrillation. It reviews the evidence for using novel oral anticoagulants (NOACs), provides a clinical guide on how to use NOACs in practice, and discusses strategies to reduce ischemic and bleeding risks using real-world cases. The document also includes a quiz on the clinical use of NOACs and summarizes key advantages of NOACs over warfarin. Real-world cases demonstrate the impact of NOAC introduction on optimizing anticoagulation and reducing strokes in atrial fibrillation patients.
Rivaroxaban is an oral anticoagulant used to treat and prevent blood clots. It works by selectively inhibiting factor Xa. It is administered as tablets in doses of 2.5 mg, 10 mg, 15 mg, or 20 mg once or twice daily depending on the indication. Adverse reactions include hematoma, back pain, wound secretion and abdominal pain. Rivaroxaban is contraindicated in patients with hypersensitivity or active pathological bleeding. Dosage adjustments are required for patients with renal or hepatic impairment. Drug interactions can occur with strong CYP3A4 inhibitors or NSAIDs.
This document discusses sodium glucose cotransporter-2 inhibitors (SGLT2i) across the spectrum of renal diseases. It begins with an overview of renal glucose handling and the role of the SGLT2 channel. It then reviews the rationale for SGLT2 inhibition in diabetic and non-diabetic kidney diseases and basic SGLT2i pharmacology. Finally, it examines clinical outcomes data from trials demonstrating the cardiovascular, renal, and heart failure benefits of SGLT2is across levels of renal function and in diabetic and non-diabetic patients.
The DCCT trial showed that intensive diabetes management reduced the risk of eye, kidney, and nerve complications compared to standard management. Intensive therapy aimed for blood glucose levels between 70-120 mg/dl, while standard therapy aimed to avoid symptoms of high or low blood glucose. The risks of intensive therapy were increased hypoglycemia and weight gain. The follow up EDIC study found metabolic memory effects, with long term benefits of early intensive control.
Intensive glycemic control aimed at maintaining blood glucose between 80-110 mg/dl in adult ICU patients does not reduce mortality and significantly increases the risk of hypoglycemia compared to conventional control between 140-180 mg/dl. Multiple large randomized controlled trials found no benefit to intensive control and post-hoc analyses determined hypoglycemia independently increases mortality. Current guidelines recommend insulin therapy only for blood glucose over 180 mg/dl and targeting 140-180 mg/dl range to minimize hypoglycemia risk while avoiding hyperglycemia's harmful effects.
This document summarizes key information about the drug Empagliflozin. It belongs to the sodium glucose co-transporter 2 inhibitor class, which works by inhibiting glucose reabsorption in the kidney and increasing glucose excretion. The document outlines Empagliflozin's pharmacodynamics, pharmacokinetics, adverse reactions, dosage and administration, current status, and references. It provides an overview of Empagliflozin's mechanism of action, metabolism, excretion, drug interactions, efficacy, safety profile, and approved uses as monotherapy or add-on therapy for type 2 diabetes.
This document discusses dialysis in elderly patients. It notes that biological age is more important than calendar age when evaluating elderly patients for dialysis. Initiation of renal replacement therapy requires consideration of comorbidities, mental status, quality of life, life expectancy, vascular access, and socioeconomic factors. Dialysis in elderly patients is associated with higher rates of comorbidities like atherosclerosis and fewer vascular access options. Conservative care without dialysis is an alternative for some elderly patients with multiple comorbidities. Quality of life assessments are important when considering dialysis for elderly patients.
This a is a slide set (42 slides) covering clinically used drugs for lipid lowering. This is an updated version of the lecture series for the 2021-2022 academic year. Suitable for intermediate level learners
This document discusses factors to consider when prescribing hemodialysis, including machine settings, filter selection, and patient characteristics. It covers dialysis targets, complications to prevent, and how blood and dialysate flow rates impact filtration coefficient. The goal is to individualize treatment and achieve a balanced dialysis prescription that addresses clearance needs while preventing harm.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Effects of Sodium Glucose contransporter (SGLT2) inhibition on renal outcomes in patients with (diabetic) chronic kidney disease.
Presentation given during the East by Southwest, Annual Update in Nephrology, September 17th 2017, Santa Fe, NM
http://medicine.unm.edu/academic-divisions/nephrology/east-by-southwest.html
Update in management of atrial fibrillation,DR adel sallam ,Lixiana.pptxAdelSALLAM4
The document discusses updates to guidelines for the management of atrial fibrillation from the 2020 ESC Guidelines and 2020 CCS/CHRS Comprehensive AF Guidelines. It provides summaries of the epidemiology and risk factors for AF, the classification of different AF patterns, tools for assessing stroke and bleeding risk like CHA2DS2-VASc and HAS-BLED scores, and components of integrated AF management including diagnosis, treatment, and follow-up.
Renal replacement therapy prof. ahmed rabeeFarragBahbah
The document discusses renal replacement therapy (RRT) and indications for dialysis. It provides definitions of dialysis and notes it is used for acute kidney injury (AKI) and end-stage renal disease (CKD stage 5). For AKI, the main indications for dialysis are electrolyte abnormalities, fluid overload, and uremia complications. Hemodialysis, peritoneal dialysis and hemofiltration are the primary RRT modalities for AKI. For CKD, indications include refractory fluid overload, metabolic abnormalities, and symptoms like nausea/vomiting or malnutrition. The decision to start dialysis involves clinical status and quality of life considerations.
This document discusses diabetes management in patients receiving dialysis for end-stage renal disease. It covers alterations in glucose metabolism caused by kidney dysfunction, limitations of monitoring glycemic control in dialysis patients, glycemic targets and outcomes, and safety of diabetic medications in this population. Treatment approaches discussed include insulin regimens, non-insulin agents like sulfonylureas and DPP-4 inhibitors, and unique considerations for peritoneal dialysis patients. Guidelines recommend A1c monitoring along with home glucose testing, though optimal glycemic targets in dialysis are unclear due to limited evidence.
Continuous rrt and its role in critically ill patients [autosaved]Harsh shaH
The document discusses renal replacement therapy (RRT) for acute kidney injury (AKI) in critically ill patients. It describes that early initiation of RRT may improve outcomes compared to late initiation. Continuous RRT is preferred for hemodynamically unstable patients as it allows for slower fluid and solute removal. The optimal RRT approach depends on the individual patient's clinical status and needs.
Management of atrial fibrillation (summary)Adel Hasanin
Based on the guidelines presented in the document, the following procedures would not be considered or would fail for rhythm control in atrial fibrillation:
1. Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation
2. Percutaneous endoscopic catheter laser balloon ablation
The document recommends left atrial catheter ablation or left atrial surgical ablation if drug treatment fails to control symptoms. It does not mention the above specific ablation procedures.
Hypertensive emergencies require rapid blood pressure reduction to prevent target organ damage, while hypertensive urgencies only require gradual reduction over 24 hours without end organ involvement. The case study describes a patient presenting with acute pulmonary edema secondary to hypertensive emergency and acute kidney injury. He was intubated and given intravenous nitrates, frusemide and morphine to rapidly reduce blood pressure and relieve pulmonary congestion over several hours.
1) The UKPDS trial compared intensive blood glucose control using sulfonylureas or insulin to conventional treatment in over 3,800 patients with newly diagnosed type 2 diabetes over 10 years.
2) Intensive treatment lowered A1C more but did not reduce macrovascular complications like heart disease. It did reduce microvascular complications like eye and kidney disease.
3) Intensive treatment was associated with more hypoglycemia.
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
2019 ESC guidelines for pulmonary embolism Dina Mostafa
The document summarizes the key points of the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (PE). Some of the main updates in the new guidelines include: using age-adjusted D-dimer cut-offs rather than fixed values; revising the risk stratification algorithm to emphasize multidisciplinary care and early risk assessment; strengthening recommendations for rescue thrombolysis and interventional treatments for unstable patients; and recommending direct oral anticoagulants over warfarin as first-line treatments. The guidelines also provide a dedicated diagnostic algorithm for PE in pregnancy and recommend follow-up care after PE to monitor for long-term sequelae.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
Empagliflozin in acute myocardial infarction.pptxpurraSameer
1) The EMMY trial investigated whether early initiation of empagliflozin following myocardial infarction improved cardiac function and reduced heart failure biomarkers.
2) Patients receiving empagliflozin had a significantly greater reduction in NT-proBNP levels and greater improvement in left ventricular ejection fraction compared to placebo.
3) Empagliflozin treatment also resulted in smaller increases in left ventricular volumes and improved diastolic function versus placebo with no difference in safety events between the groups.
Stroke a rare complication in Post PCI patientPRAVEEN GUPTA
In this ppt i am going to describe about one patient who develop acute stroke after PCI in our hospital. Also i am going to discuss how to diagnose, manage and treat such patient, risk factor associated with stroke after PCI.
Haemodialysis or Haemodifiltration? - Prof. Mohsen El KosiMNDU net
This document discusses haemodialysis versus haemodiafiltration (HDF) for end-stage renal disease therapy. It provides historical context on the development of dialysis. It describes how HDF combines diffusion and convection to clear small molecules as well as middle and larger molecules like beta-2 microglobulins that standard haemodialysis cannot. Several studies comparing HDF and haemodialysis are summarized that have had mixed results, with some showing benefits of HDF like reduced symptoms and beta-2 microglobulin levels but not clear improvements in mortality. For HDF to provide benefits, a minimum convective volume of 20 litres per session is recommended. Barriers to wider adoption of HDF include cost and infrastructure requirements.
The UK Prospective Diabetes Study was a 20-year multicenter randomized controlled trial that investigated the effects of intensive glucose control and tight blood pressure control on diabetes complications. Over 5,000 patients with newly diagnosed type 2 diabetes were recruited between 1977-1991 and followed for a median of 10 years. The study found that intensive glucose control reduced the risk of diabetes complications, particularly microvascular complications, by 10-25%. The blood pressure control study found that tight blood pressure control reduced the risk of diabetes-related endpoints by 24% and strokes by 44% compared to less tight control.
A ppt about contrast nephropathy: basics, risk factors, comparison of preventive strategies.
critical review of POSEIDON trial and brief about PRESERVE trial.
1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
This a is a slide set (42 slides) covering clinically used drugs for lipid lowering. This is an updated version of the lecture series for the 2021-2022 academic year. Suitable for intermediate level learners
This document discusses factors to consider when prescribing hemodialysis, including machine settings, filter selection, and patient characteristics. It covers dialysis targets, complications to prevent, and how blood and dialysate flow rates impact filtration coefficient. The goal is to individualize treatment and achieve a balanced dialysis prescription that addresses clearance needs while preventing harm.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Effects of Sodium Glucose contransporter (SGLT2) inhibition on renal outcomes in patients with (diabetic) chronic kidney disease.
Presentation given during the East by Southwest, Annual Update in Nephrology, September 17th 2017, Santa Fe, NM
http://medicine.unm.edu/academic-divisions/nephrology/east-by-southwest.html
Update in management of atrial fibrillation,DR adel sallam ,Lixiana.pptxAdelSALLAM4
The document discusses updates to guidelines for the management of atrial fibrillation from the 2020 ESC Guidelines and 2020 CCS/CHRS Comprehensive AF Guidelines. It provides summaries of the epidemiology and risk factors for AF, the classification of different AF patterns, tools for assessing stroke and bleeding risk like CHA2DS2-VASc and HAS-BLED scores, and components of integrated AF management including diagnosis, treatment, and follow-up.
Renal replacement therapy prof. ahmed rabeeFarragBahbah
The document discusses renal replacement therapy (RRT) and indications for dialysis. It provides definitions of dialysis and notes it is used for acute kidney injury (AKI) and end-stage renal disease (CKD stage 5). For AKI, the main indications for dialysis are electrolyte abnormalities, fluid overload, and uremia complications. Hemodialysis, peritoneal dialysis and hemofiltration are the primary RRT modalities for AKI. For CKD, indications include refractory fluid overload, metabolic abnormalities, and symptoms like nausea/vomiting or malnutrition. The decision to start dialysis involves clinical status and quality of life considerations.
This document discusses diabetes management in patients receiving dialysis for end-stage renal disease. It covers alterations in glucose metabolism caused by kidney dysfunction, limitations of monitoring glycemic control in dialysis patients, glycemic targets and outcomes, and safety of diabetic medications in this population. Treatment approaches discussed include insulin regimens, non-insulin agents like sulfonylureas and DPP-4 inhibitors, and unique considerations for peritoneal dialysis patients. Guidelines recommend A1c monitoring along with home glucose testing, though optimal glycemic targets in dialysis are unclear due to limited evidence.
Continuous rrt and its role in critically ill patients [autosaved]Harsh shaH
The document discusses renal replacement therapy (RRT) for acute kidney injury (AKI) in critically ill patients. It describes that early initiation of RRT may improve outcomes compared to late initiation. Continuous RRT is preferred for hemodynamically unstable patients as it allows for slower fluid and solute removal. The optimal RRT approach depends on the individual patient's clinical status and needs.
Management of atrial fibrillation (summary)Adel Hasanin
Based on the guidelines presented in the document, the following procedures would not be considered or would fail for rhythm control in atrial fibrillation:
1. Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation
2. Percutaneous endoscopic catheter laser balloon ablation
The document recommends left atrial catheter ablation or left atrial surgical ablation if drug treatment fails to control symptoms. It does not mention the above specific ablation procedures.
Hypertensive emergencies require rapid blood pressure reduction to prevent target organ damage, while hypertensive urgencies only require gradual reduction over 24 hours without end organ involvement. The case study describes a patient presenting with acute pulmonary edema secondary to hypertensive emergency and acute kidney injury. He was intubated and given intravenous nitrates, frusemide and morphine to rapidly reduce blood pressure and relieve pulmonary congestion over several hours.
1) The UKPDS trial compared intensive blood glucose control using sulfonylureas or insulin to conventional treatment in over 3,800 patients with newly diagnosed type 2 diabetes over 10 years.
2) Intensive treatment lowered A1C more but did not reduce macrovascular complications like heart disease. It did reduce microvascular complications like eye and kidney disease.
3) Intensive treatment was associated with more hypoglycemia.
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
2019 ESC guidelines for pulmonary embolism Dina Mostafa
The document summarizes the key points of the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (PE). Some of the main updates in the new guidelines include: using age-adjusted D-dimer cut-offs rather than fixed values; revising the risk stratification algorithm to emphasize multidisciplinary care and early risk assessment; strengthening recommendations for rescue thrombolysis and interventional treatments for unstable patients; and recommending direct oral anticoagulants over warfarin as first-line treatments. The guidelines also provide a dedicated diagnostic algorithm for PE in pregnancy and recommend follow-up care after PE to monitor for long-term sequelae.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
Empagliflozin in acute myocardial infarction.pptxpurraSameer
1) The EMMY trial investigated whether early initiation of empagliflozin following myocardial infarction improved cardiac function and reduced heart failure biomarkers.
2) Patients receiving empagliflozin had a significantly greater reduction in NT-proBNP levels and greater improvement in left ventricular ejection fraction compared to placebo.
3) Empagliflozin treatment also resulted in smaller increases in left ventricular volumes and improved diastolic function versus placebo with no difference in safety events between the groups.
Stroke a rare complication in Post PCI patientPRAVEEN GUPTA
In this ppt i am going to describe about one patient who develop acute stroke after PCI in our hospital. Also i am going to discuss how to diagnose, manage and treat such patient, risk factor associated with stroke after PCI.
Haemodialysis or Haemodifiltration? - Prof. Mohsen El KosiMNDU net
This document discusses haemodialysis versus haemodiafiltration (HDF) for end-stage renal disease therapy. It provides historical context on the development of dialysis. It describes how HDF combines diffusion and convection to clear small molecules as well as middle and larger molecules like beta-2 microglobulins that standard haemodialysis cannot. Several studies comparing HDF and haemodialysis are summarized that have had mixed results, with some showing benefits of HDF like reduced symptoms and beta-2 microglobulin levels but not clear improvements in mortality. For HDF to provide benefits, a minimum convective volume of 20 litres per session is recommended. Barriers to wider adoption of HDF include cost and infrastructure requirements.
The UK Prospective Diabetes Study was a 20-year multicenter randomized controlled trial that investigated the effects of intensive glucose control and tight blood pressure control on diabetes complications. Over 5,000 patients with newly diagnosed type 2 diabetes were recruited between 1977-1991 and followed for a median of 10 years. The study found that intensive glucose control reduced the risk of diabetes complications, particularly microvascular complications, by 10-25%. The blood pressure control study found that tight blood pressure control reduced the risk of diabetes-related endpoints by 24% and strokes by 44% compared to less tight control.
A ppt about contrast nephropathy: basics, risk factors, comparison of preventive strategies.
critical review of POSEIDON trial and brief about PRESERVE trial.
1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
This document discusses renal evaluation and protection in diabetic nephropathy, with a focus on differences in the elderly population. It summarizes that diabetic nephropathy was once a terminal disease but physicians have gained a better understanding of it over time. It also discusses different classification systems for diabetic nephropathy and chronic kidney disease. When evaluating renal function in the elderly, formulas that consider age are recommended due to changes in muscle mass and kidney size with aging. Management of diabetic nephropathy differs in the elderly population compared to younger patients, as cardiovascular risks may be prioritized over slowing renal disease progression due to competing mortality risks.
This randomized controlled trial compared early versus late initiation of dialysis in patients with stage 5 chronic kidney disease. 828 patients were randomly assigned to either start dialysis when their estimated GFR was 10-14 ml/min (early start group) or 5-7 ml/min (late start group). The median time to starting dialysis was 1.80 months in the early start group and 7.40 months in the late start group. There was no significant difference in all-cause mortality between the two groups, with 152 deaths in the early start group and 155 in the late start group. The study found no benefit to earlier initiation of dialysis in terms of survival.
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment. Fluid accumulates between the three weekly sessions, putting stress on the heart. While ultrafiltration rates have decreased in recent years, cardiovascular hospitalization rates have risen. Standard hemodialysis treatment may not adequately address fluid management issues between, during, and after sessions, indicating poor fluid control.
cardiorenal syndrome and its characteristics and complications and causes.pptxArunDeva8
This study analyzed the risk factors and outcomes of acute cardiorenal syndrome (CRS-1) in 460 patients admitted with acute coronary syndrome or acute decompensated heart failure at a tertiary care center in South India. 34% of patients developed CRS-1, defined as acute kidney injury resulting from acute worsening of cardiac function. Risk factors for CRS-1 included diabetes, chronic kidney disease, lower ejection fraction, and higher levels of cardiac biomarkers. Patients with CRS-1 required more intensive care interventions and had higher in-hospital mortality of 20.2% compared to 7.8% in patients without CRS-1. Early detection and multidisciplinary management can help provide better outcomes for patients with
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
Chronic Kidney Disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. It affects over 26 million Americans and is a major public health issue. The leading causes are diabetes and hypertension. As CKD progresses, kidney function declines and complications increase like anemia and bone disease. Cardiovascular disease risk also rises substantially. Inflammation, lipid abnormalities, and genetic factors can all contribute to CKD progression if not properly managed.
Hypertension is a major public health issue and leading cause of cardiovascular disease globally. It is responsible for about half of heart disease and stroke deaths. The number of hypertensive individuals in India is expected to nearly double by 2025. Chronic kidney disease (CKD) is a major complication of hypertension, with hypertension being the primary cause of end stage renal disease. Strict blood pressure control and use of renin-angiotensin system inhibitors are important for slowing the progression of CKD and reducing proteinuria. Calcium channel blockers, particularly non-dihydropyridine types like cilnidipine, have beneficial effects on renal function through reduction of intraglomerular pressure and antioxidant properties independent of blood pressure
1. Management of older patients on dialysis requires a focus on overall aging aspects and quality of life rather than just dialysis.
2. Almost all frail elderly patients receive in-center hemodialysis due to physical and cognitive impairments, though assisted peritoneal dialysis enables home dialysis.
3. Understanding individual patient goals and life expectancy is important for elderly patients, as some may choose no dialysis or conservative care over treatment burdens when remaining life is short.
This document discusses chronic kidney disease (CKD), including its definition, classification, causes, epidemiology, progression, and risk factors. CKD is defined as kidney damage or decreased kidney function (GFR <60 mL/min/1.73m2) for at least 3 months. It is classified based on GFR levels (G1-G5) and albuminuria levels (A1-A3). Common causes include diabetes, hypertension, glomerulonephritis, and polycystic kidney disease. Risk factors for faster progression include older age, male sex, proteinuria, hypertension, and factors related to the renin-angiotensin-aldosterone system. Progression rates vary significantly
This document discusses chronic kidney disease (CKD), including its pathophysiology, risk factors, and treatment strategies to slow progression. It notes that CKD progression involves both hemodynamic and non-hemodynamic mechanisms, such as activation of the renin-angiotensin-aldosterone system leading to inflammation and fibrosis. Blocking the RAAS through ACE inhibitors, ARBs, and blood pressure control has been shown to slow CKD progression by reducing proteinuria, glomerular hypertension, and inflammation. The document reviews several landmark clinical trials that established the renoprotective effects of RAAS inhibition in diabetic and non-diabetic kidney diseases.
The document discusses hypertension and its effects on the kidney. It begins by defining normal blood pressure regulation and the role of the kidney in long-term blood pressure control. It then discusses the epidemiology of hypertension globally and in various countries. The document also covers the epidemiology of chronic kidney disease, how hypertension affects the kidney and can lead to hypertensive nephropathy, and how chronic kidney disease in turn affects blood pressure. It concludes by outlining blood pressure targets and treatment strategies for patients with hypertension and chronic kidney disease.
Peritoneal dialysis (PD) has several potential advantages over hemodialysis (HD), but each modality also has limitations that must be considered for each patient. PD is generally less expensive than HD due to lower infrastructure and labor costs. It allows more freedom and flexibility for patients while preserving residual kidney function for longer compared to HD. However, not all patients are medically suitable for PD due to certain comorbidities. The optimal dialysis modality must be selected individually based on each patient's medical needs and preferences.
Peritoneal dialysis (PD) has several potential advantages over hemodialysis (HD), though patient and clinical factors must be considered when determining the optimal renal replacement therapy (RRT). PD is associated with better preservation of residual renal function, higher quality of life due to greater flexibility, and lower risk of infection. However, HD requires more nursing staff per patient. The "right modality at the right time" depends on individual patient characteristics and preferences as well as resource availability. Overall, PD can be a cost-effective first-line RRT option when integrated with HD.
This summary outlines the key findings of the EMPA-KIDNEY trial which evaluated the effect of empagliflozin treatment on kidney disease progression and cardiovascular outcomes in patients with chronic kidney disease (CKD). The randomized, double-blind trial involved over 6,600 patients with CKD across 8 countries. Patients received either empagliflozin 10mg or placebo daily. The primary outcome of kidney disease progression or cardiovascular death occurred in 13.1% of the empagliflozin group versus 16.9% of the placebo group, representing a 28% lower risk with empagliflozin. Secondary outcomes also favored empagliflozin treatment, including lower rates of hospitalization. The benefits were
Contrast-induced nephropathy (CIN) is acute kidney injury caused by iodinated contrast media used in medical imaging. [1] It is a significant problem, the third most common cause of hospital-acquired renal dysfunction. [2] While CIN is usually reversible, it increases mortality and the risk of progressing to chronic kidney disease. [3] CIN can be prevented through measures such as intravenous hydration, using low-dose iso-osmolar contrast, and managing risk factors. [4] Once occurred, CIN is typically not difficult to treat as renal function usually recovers within 1-3 weeks, but it may require short-term dialysis in severe cases. [5
This document discusses chronic kidney disease (CKD) and its management. It provides definitions of CKD and outlines its stages according to the KDIGO classification system. Diabetes and hypertension are highlighted as leading causes of CKD globally. Early detection of CKD is important as it can be asymptomatic for long periods. Screening high-risk individuals through estimated GFR and urine albumin or protein tests is recommended. Left unmanaged, CKD can progress to end-stage renal disease requiring renal replacement therapies like dialysis, which are costly treatments.
This document summarizes current treatment guidelines for lupus nephritis. It defines lupus nephritis based on ACR criteria and recommends an early renal biopsy. For initial treatment of proliferative lupus nephritis (classes III/IV), guidelines differ on whether cyclophosphamide or mycophenolate mofetil is preferred. Maintenance therapy with mycophenolate mofetil or azathioprine with low-dose steroids is recommended, with mycophenolate mofetil showing better outcomes. Immunosuppression should be continued for at least one year after complete remission is achieved.
Similar to Integrated renal replacement therapy (20)
The document provides historical background on the development of peritoneal dialysis (PD) and outlines its use in acute kidney injury (AKI). It discusses:
1. The first experiments using the peritoneal cavity for uremia removal in the 1920s.
2. The development of intermittent PD in the 1960s and continuous ambulatory PD in the 1970s.
3. Evidence that high doses of continuous PD can provide appropriate metabolic control in AKI, with survival and renal recovery rates similar to other renal replacement therapies.
4. Indications for acute PD include hemodynamic instability and bleeding risks, while contraindications include recent abdominal surgery and severe peritonitis.
This document summarizes a presentation on therapeutic plasma exchange (PEX) given by Kamal Mohamed Okasha. It provides an overview of the PEX procedure and potential indications for PEX, including Goodpasture's Syndrome, thrombotic thrombocytopenic purpura, cryoglobulinemia, multiple myeloma, and ANCA disease. It discusses complications of PEX and guidelines for efficacy based on recent studies. In particular, it examines the use of PEX for Goodpasture's Syndrome, noting that PEX aims to remove circulating anti-GBM antibodies and that studies have found improved outcomes, including renal function and survival, for patients receiving PEX treatment.
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This document discusses acute kidney injury (AKI). It notes that AKI is often not recognized or coded for correctly. The incidence of AKI is increasing globally due to factors like comorbidities. Treatment for AKI is mainly supportive as there are no effective preventative or curative treatments. Several studies discussed found that diuretics and mannitol did not prevent AKI and may increase the risk of contrast-induced nephropathy. Hydration with sodium bicarbonate or saline was compared, with meta-analyses finding sodium bicarbonate may reduce the risk of AKI compared to saline. Dopamine and fenoldopam were also discussed but did not show clear benefits for preventing or treating AK
This document summarizes key information about lupus nephritis (LN) from a lecture given by Dr. Hussein Sheashaa. It begins with an outline of topics to be covered, including histopathology/biopsy, predictors of outcome, treatment approaches, and special situations. Regarding biopsy findings, it indicates that class IV LN is most common and describes revised classification guidelines. Treatment principles focus on early, aggressive therapy to achieve remission and prevent flares/progression. Standard induction therapies are discussed as well as new options like voclosporin. Maintenance strategies and treatment algorithms are presented. Predictors of poor outcome and management of special cases like pregnancy and refractory LN are also summarized.
This document summarizes key aspects of fluid management in peritoneal dialysis (PD) patients. It discusses optimizing PD prescriptions to balance adequate solute clearance while avoiding excess dialysis fluid exposure. Factors like residual renal function, membrane characteristics, fill volume and dwell time are considered. Monitoring adequacy includes measuring clearances and adjusting therapy if targets are not met. Guidelines recommend strategies to preserve renal function like ACEi/ARB use and avoiding dehydration.
Membranous nephropathy 22 october 2019, prof. hussein sheashaaFarragBahbah
This document summarizes a presentation on membranous nephropathy (MN). The presentation discusses: 1) The pathogenesis and pathology of MN, focusing on its autoimmune nature. 2) Immunosuppression treatments for MN including calcineurin inhibitors (CNIs), rituximab, and newer therapies. 3) Algorithms and guidelines for the management and treatment of MN. 4) Recent 2019 clinical studies on treatments like rituximab and CNIs. 5) Recurrent MN after kidney transplantation. 6) The use of circulating anti-PLA2R antibody levels to diagnose and monitor MN noninvasively.
This document discusses different modalities for treating acute kidney injury (AKI) in critically ill patients, including continuous renal replacement therapy (CRRT) and intermittent hemodialysis. It provides pros and cons of each modality and factors to consider in determining the optimal treatment for an individual patient. While CRRT allows for more gradual fluid removal and hemodynamic stability, clearance is better with intermittent therapies. The document concludes that hemodynamic stability is the main determinant of treatment choice and clearance is optimized through combination of diffusion and convection methods.
This document provides an outline and summary of a presentation on diabetic kidney disease (DKD). It discusses:
1. The epidemiology, presentation, and trends of DKD.
2. The pathology and biomarkers of DKD.
3. The management of DKD, including the use of RAAS blockers, anti-hyperglycemic drugs like SGLT2 inhibitors and GLP1 RAs, and renal replacement therapies.
4. It concludes with a discussion of taking a holistic approach to DKD and lessons that can be learned from basic research on autophagy.
The document discusses several cases of glomerular disease:
1) A 27-year-old male with nephrotic syndrome and a kidney biopsy showing IgG and C3 deposits along the glomerular basement membrane consistent with membranous nephropathy.
2) A 78-year-old female admitted with nephrotic syndrome after a history of NSAID use, with a biopsy showing focal segmental glomerulosclerosis.
3) A 26-year-old male with nephrotic syndrome and renal impairment, whose biopsy demonstrated membranoproliferative glomerulonephritis with C3 deposition and subendothelial electron dense deposits. Follow up showed elevated
A 30-year-old man presented with lower limb swelling, shortness of breath, and decreased urine output for 2 weeks. He had a history of drug abuse including heroin, tramadol, and marijuana. Initial labs showed severe kidney dysfunction with a creatinine of 7.5 mg/dl. A renal biopsy was performed which showed acute tubular injury, focal interstitial nephritis with eosinophil infiltrate, and mesangial proliferative glomerulonephritis. He was started on hemodialysis and steroids. After treatment, his kidney function improved and he was discharged with a creatinine of 1.5 mg/dl.
A 19-year-old male gym player presented with decreased urine output, fatigue, loss of appetite, joint pain, nausea, and vomiting for one week. Lab results showed impaired renal function. He has a history of artheralgia treated with long-acting penicillin. Investigations showed positive ANA and anti-ds DNA. A renal biopsy was done which revealed lupus nephritis class 4, indicating an active inflammation. The treatment plan includes high dose steroids, immunosuppressants, and supplements.
This document discusses tubulointerstitial nephritis (TIN), a pattern of renal injury characterized by inflammation and edema of the renal tubules and interstitium. TIN is most commonly caused by drugs (71% of cases) and infections (15% of cases). On biopsy, TIN shows lymphocytic infiltration of the tubules and interstitium with tubular atrophy and normal glomeruli and vessels. Treatment involves withdrawing the offending agent and supportive care. Corticosteroids may aid recovery but their effectiveness is debated. Prognosis depends on factors like duration of the insult and degree of fibrosis - complete recovery is more likely if treatment begins early.
Fasting ramadan nephrology prospective prof. osama el shahateFarragBahbah
Dr. Osama El-Shahat is the head of the nephrology department at New Mansoura General Hospital and vice president of the Dakahlia Nephrology Group. The document discusses kidney disease (CKD), transplantation, dialysis, and recommendations. It provides examples of how some animals fast during certain periods by not eating and reducing activity. It also discusses fasting guidelines for patients with illnesses, noting that those with more severe illnesses should generally be exempted from fasting. The document analyzes a study on the effects of Ramadan fasting on renal function in CKD patients and notes that more large studies are needed. It also reviews a case of a hypertensive patient wanting to fast for Ramadan
Ramadan fasting & kidney disease may 2019FarragBahbah
Ramadan fasting is a unique metabolic model that consists of alternating periods of fasting and feasting rather than continuous fasting. During the fast, the body breaks down fat stores and releases fatty acids into the bloodstream to be used for energy. This process can help eliminate toxins from the fatty acids. Fasting has also been shown to help reduce inflammation and support the immune system. However, fasting also carries risks and may not be appropriate for certain groups like pregnant women, those with medical conditions, or people on medication. Proper hydration and electrolyte replacement is important when fasting to avoid health issues.
- Short-term catheters should only be used for acute dialysis or limited hospital use. Non-cuffed femoral catheters are only for bed-bound patients.
- Long-term catheters should be used with a plan for permanent access and prefer those capable of high flow rates. Choice depends on local experience and goals.
- Long-term catheters should avoid the same side as a maturing arteriovenous access, if possible.
This document summarizes the medical history and treatment of a 55-year-old male patient with end-stage renal disease on hemodialysis for 17 years and secondary hyperparathyroidism. Medical treatment with cinacalcet and calcitriol was unsuccessful in lowering his high calcium, phosphorus, and PTH levels. Consultations with ENT and cardiology found no issues. The doctor decided that parathyroidectomy was the best option to treat his tertiary hyperparathyroidism that was not responding to medical treatment.
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
DECLARATION OF HELSINKI - History and principlesanaghabharat01
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
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We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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3. • For all CKD complications, prognosis will vary depending on:
• Cause of CKD;
• GFR category;
• Albuminuria category;
• Other risk factors and comorbid conditions.
• The risk associations of GFR and albuminuria categories appear to be largely
independent of one another. Therefore, neither the category of GFR nor the
category of albuminuria alone can fully capture the prognosis for a patient with
CKD.
• All of the parameters above have an impact on life expectancy and quality of life
and contribute substantially to predicting the prognosis of CKD.
• Key to color grid:
Colors indicate groups of patients at higher risk of major outcomes:
• Green represents low risk. If the patient does not have other markers of kidney
disease, then CKD is not diagnosed or confirmed.
• Compared with the Green box (eGFR>60 ml/min/1.73 m2 and ACR<30 mg/g [<3
mg/mmol]):
• Yellow = is one step away from normal down or across. It represents moderately increased
risk.
• Orange = is two steps away from normal: down two, across two, or down one/across one. It
represents high risk.
• Red = is three steps away from normal. It represents very high risk.
4.
5. Integrated Care Settings (ICS)
provide a holistic approach to the
transition from chronic kidney
disease into renal replacement
therapy (RRT), offering at least both
types of dialysis.
6. Initiation of dialysis
Many researchers thought that early dialysis
initiation would improve patient QOL and patient
survival by reducing the complication of dystrophy.
Furthermore, it was also believed that a decreased
glomerular filtration rate GFR at dialysis initiation
was associated with an increased probability of
hospitalization and death.
They held the idea that early dialysis initiation was
indispensable for preventing and reversing the
deteriorated nutritional status associated with
progressive uremia.
7.
8. All of the studies and guidelines that were supporting early
dialysis have all been promoted as conventional wisdom (CW).
The CW can be summarized as follows:
• (1) low levels of dialytic and endogenous renal
clearance are associated with improved morbidity
and mortality;
• (2) Nutrition can be improved with the early
initiation of dialysis;
• (3) Dialysis should be initiated earlier in diabetics
than in nondiabetics; and
• (4) Dialysis initiated at eGFRs below 6 mL/min per
1.73 m2 is potentially dangerous.
9. • Recently, certain registry and observational studies
that included a total of > 900000 analyzable patients
all demonstrated that late dialysis initiation was
associated with improved survival.
• The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)
• In 2002, Traynor et al….. In 2012, Yamagata et al...... In 2014, Crews et al
The IDEAL study
• The randomized controlled trial of early vs late
initiation of dialysis (IDEAL) study[ showed no
difference in mortality between the early and late
groups.
10. The IDEAL study
• The early group was expected to start dialysis when the CC (calculated
with the CG equation) was 10-14 mL/min per 1.73 m2, and the late group
was expected to start dialysis at 5-7 mL/min per 1.73 m2.
• It was allowed to start dialysis based on clinical indications,
disregardfulness CC in either group.
• The average CC values were 12.0 and 9.8 mL/min per 1.73 m2 at the time
of dialysis initiation in the early and late groups, respectively.
• Compared with the early group, the late group showed a 6-mo delay in
initiation. However, 76% of the patients who were allocated to the late
group actually commenced dialysis with a higher CC, and the mean
difference in the estimated GFR between the late and early groups was
only 2.2 mL/min.
• The gap between the 2 groups was too small to generate a difference in
the mortality rates.
• However, for some patients, who started RRT after their eGFR values
dropped below 5-7 mL/min per 1.73 m2, no harm was detected.
• In other words, initiating dialysis late might be safe for some patients
with fluid overload or other accompanying complications if they are
carefully monitored.
11. Recommendations that support late dialysis
• Many guidelines, including the ERBP 2002, the
Australia 2005
• and the United Kingdom 2009
• , recommend that RRT should be initiated before
the GFR reaches 6 mL/min per 1.73 m2.
• The ERBP 2002 recommends that dialysis
preparation should be initiated at a GFR of 8
mL/min per 1.73 m2 and that dialysis must be
initiated at a GFR of 6 mL/min per 1.73 m2.
• The CSN 2014 clinical practice guidelines
suggest that chronic dialysis should be
initiated when the eGFR drops to 6
mL/min per 1.73 m2, even if there are no
clinical indications.
12.
13. • In a Chinese study in Taiwan, the median eGFR level at
dialysis initiation was 4.7 mL/min per 1.73 m2 from July
2001 to December 2004 in > 23000 incident patients.
• Based on the eGFR level at dialysis initiation, patients
were divided into quintiles, and the best survival was
observed at < 3.29 mL/min per 1.73 m2. Impact of the clinical conditions at
dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan.Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC,
Taiwan Society of Nephrology.
• Nephrol Dial Transplant. 2010 Aug; 25(8):2616-24.
• In another report, the best survival was achieved in
patients with eGFRs of between 0 and 5 mL/min per
1.73 m2 among American subjects. This study included
81176 uremic subjects, aged 20-64 with no substantial
comorbidities other than hypertension, from the
USRDS dataset. Rosansky SJ, Eggers P, Jackson K, Glassock R, Clark WF. Early start of hemodialysis may be harmful. Arch
Intern Med. 2011;171:396–403.
14. Renal replacement therapy (RRT) modalities
Renal replacement therapy (RRT) modality
distribution in a given country is determined by a
constellation of patient, physician, and system-
related factors that interact in complex ways to
ultimately determine both patient outcomes and
treatment costs.
It should first be acknowledged that there is no
single perfect form of RRT, and that each of the
existing options has its own inherent strengths
and limitations.
15. MODALITY OPTIONS FOR RRT
Renal transplantation
Transplantation remains the preferred mode of
renal-replacement therapy with respect to both
outcomes and cost effectiveness. As its initial
cost is high, its long term cost savings make it a
dominant economic strategy in any financial
environment, including developing countries.
16. In general, preemptive living donor
transplantation is the preferred
strategy when feasible, as it appears to
be associated with improved patient
survival, and minimizes the impact on
health-related quality of life.
17. Hemodialysis
Conventional 3-times per week, in-center hemodialysis
(HD) is the most prevalent and costly form of RRT in use.
Home HD currently comprises less than 1% of all RRT
in the United States, yet surveyed nephrologists believe
that it should comprise more than 10% of an optimal
modality mix.
While home HD is associated with a greater up-front
cost, it appears to be cost effective in the long term when
compared with in-center HD, and is associated
with superior outcomes.
18. Alternate HD schedules
Frequent HD schedules such as
Short daily HD (1.5–2.5 hr/session, 5 or more days/week),
Daily nocturnal HD (6–10 hr/session, 5 or more
days/week),
and long intermittent HD (8 hr, 3 days or nights/week)
appear to offer a number of benefits over the
conventional HD regimen.
The improved hemodynamic stability, and improved
small and large solute clearance afforded by these
therapies appear to confer a number of important
physiologic benefits that may ultimately prove to improve
patient survival.
19. Peritoneal dialysis (PD)
Peritoneal dialysis remains highly cost effective, costing as
little as 53% as much as in-center HD in the United
States.
Despite this, the United States and Canada
have seen an overall decline in PD
prevalence, which remains difficult to
understand on the basis of outcomes and
cost analyses.
The rapid growth of large dialysis organizations
in the United States, and their tendency to promote
HD have likely contributed to the demise of PD in the
United States.
20. Peritoneal dialysis may fare better in the early
years because of the tendency to use HD over PD at
the initiation of RRT for sicker patients as well as
better preservation of residual renal function in PD
during the first 1–3 years.
In later years of PD, with loss of residual renal
function and membrane failure, complications such as
volume overload, hypertension, reduced clearance,
and accelerated atherosclerosis (because of the long
term atherogenic effect of most kinds of current PD
solutions) may supervene, resulting in better
outcomes with HD.
21. More recent and well-designed
observational studies based on
USRDS data have suggested that
patients beginning RRT with known
atherosclerotic heart disease or
congestive heart failure have a
greater relative risk of death on PD
than with HD at 2 years
22. Despite this, it has become relatively
clear from the existing data that the
apparent benefits for one modality over
the other are modest compared with the
influence of other more important
prognostic factors such as age,
diabetes, and heart disease.
23. The importance of residual renal
function in dialysis patients.
Preserving residual renal function has always been
the primary clinical goal for every nephrologist
managing patients with chronic kidney disease.
There is no reason why this important goal should
not extend to patients with stage 5 chronic kidney
disease receiving dialysis.
Indeed, there is now clear evidence that
preserving residual renal function remains
important after the commencement of dialysis.
24. Residual renal function contributes
significantly to the overall health and well-
being of dialysis patients.
It not only provides small solute clearance
but also plays an important role in
maintaining fluid balance, phosphorus
control.
Removal of middle molecular uremic
toxins,
It shows strong inverse relationships with
valvular calcification and cardiac
hypertrophy in dialysis patients.
25. • Decline of residual renal function
also contributes significantly to
anemia, inflammation, and
malnutrition in patients on dialysis.
• More importantly, the loss of
residual renal function, especially in
patients on peritoneal dialysis, is a
powerful predictor of mortality.
26. • In addition, there is increasing
evidence that residual renal and
peritoneal dialysis clearance
cannot be assumed to be
equivalent qualitatively, thus
indicating the need to preserve
residual renal function in patients
on dialysis.
27. Progressive loss of RKF in incident dialysis patients
is associated with increased death risk over time.
Nevertheless, mortality is the highest in the first
several months of dialysis therapy when most
patients starting kidney replacement therapy have
their highest RKF.
The loss of RKF is faster in patients on HD than
those receiving peritoneal dialysis (PD).
28. HD may cause episodic ischemic damage to the kidneys,
leading to repetitive bouts of ischemic events similar to acute
kidney injury (AKI).
The causal link between AKI and subsequent CKD and that the
use of the term “AKI” may not be appropriate for the
mechanism of the faster loss of RKF in HD patients, the
cumulative effect of repetitive ischemic events may accelerate
the decline in RKF.
Consistent with this hypothesis, the recent Frequent
Hemodialysis Network (FHN) study showed that frequent
nocturnal HD may accelerate loss of RKF.
29. • Intense dialysis therapy
may also remove the
stimulus for the
hyperfunctioning of the
remaining nephrons,
30. Conservative kidney management
(CKM)
• Personalisation of choice in ESKF care has been
an explicit policy goal. Increasing emphasis has
been given to preparation for ESKF and choice of
treatments including conservative kidney
management (CKM). The majority of patients
with stage 4 chronic kidney disease (CKD4) or
CKD5 approaching ESKF are now seen in
multidisciplinary renal clinics, where risk factors
for progression and major cardiovascular events
are managed, advanced CKD metabolic
abnormalities and symptoms are treated and
preparation for RRT is organised.
31. The term CKM to describe the management of
ESKF without RRT, but with active symptom
management, communication and advanced
care planning (ACP), interventions to delay
progression and minimise complications,
psychological support, social and family support,
and spiritual care.
32. • It is not simply a ‘no dialysis’ option.
• Maximum care to slow disease progression,management
of other comorbidities,
• assessment and active management of symptoms (e.g. by
correcting anaemia and acidosis,
• maintaining fluid balance and treating troublesome
symptoms with drugs) including dietary restrictions,
• optimising communication and ACP,
• and improving care at the end of life,
• are all recommended.
• Services have increasingly been developed to focus on
optimising conservative care.
33. Incremental peritoneal dialysis: a 10
year single-centre experience
Incremental dialysis consists in
prescribing a dialysis dose aimed
towards maintaining total solute
clearance (renal + dialysis) near the
targets set by guidelines. Incremental
peritoneal dialysis (incrPD) is defined
as one or two dwell-times per day on
CAPD, whereas standard peritoneal
dialysis (stPD) consists in three-four
dwell-times per day.
34.
35. PATIENTS AND METHODS
• Single-centre cohort study. Enrollement
period: January 2002-December 2007; end of
follow up (FU): December 2012.
36.
37. INCLUSION CRITERIA
Incident patients with FU ≥6 months, initial
residual renal function (RRF) 3-10 ml/min/1.73
sqm BSA, renal indication for PD.
38. RESULTS
• Median incrPD duration was 17 months (I-III Q: 10; 30).
• There were no statistically significant differences between 29
patients on incrPD and 76 on stPD regarding: clinical, demographic
and anthropometric characteristics at the beginning of treatment,
• adequacy indices,
• peritonitis-free survival (peritonitis incidence: 1/135 months-
patients in incrPD vs. 1/52 months-patients in stPD) and patient
survival.
• During the first 6 months, RRF remained stable in incrPD (6.20 ± 2.02
vs. 6.08 ± 1.47 ml/min/1.73 sqm BSA; p = 0.792)
• Whereas it decreased in stPD (4.48 ± 2.12 vs. 5.61 ± 1.49; p < 0.001).
Patient survival was affected negatively by ischemic cardiopathy
(HR: 4.269; p < 0.001), peripheral and cerebral vascular disease
(H2.842; p = 0.006) and cirrhosis (2.982; p = 0.032) and positively by
urine output (0.392; p = 0.034). Hospitalization rates were
significantly lower in incrPD (p = 0.021). Eight of 29 incrPD patients
were transplanted before reaching full dose treatment.
39.
40.
41. CONCLUSIONS
• IncrPD is a safe modality to start
PD; compared to stPD, it shows
similar survival rates, significantly
less hospitalization, a trend towards
lower peritonitis incidence and
slower reduction of renal function.
42. Incremental HD dialysis: Can it make a
difference for residual renal function?
• Currently, in some countries, including India and China,
over half of HD patients receive ≤2 treatments per
week. Some patients are dialyzed even less frequently,
e.g. once weekly to even once a month.
• This practice pattern may largely reflect limited
resources and financial constraints. Nevertheless it
may be associated with improved outcomes in some
patients.
• In a seven-year observational study in Taiwan, patients
dialyzed twice (n= 23) versus thrice (n=51) weekly had
a slower decline of RKF, as indicated by higher urine
output and better creatinine clearance.
• Patients dialyzed twice weekly also had lower levels
of serum beta-2-microglobulin, fewer intra-dialytic
hypotensive episodes, and fewer hospitalizations.
43. • There are other important reasons to
perform twice-weekly HD upon
initiating dialysis therapy.
• First, having two sessions a week
means less frequent cannulations of a
new ateriovenous fistula or graft, which
may prolong its longevity.
• In addition, incremental HD may offer
a compromise and reconciliation
between the two camps of early vs.
late dialysis initiation in lieu of the
traditional approach of initiating thrice-
weekly HD.
44. • Criteria for candidates that may benefit from incremental
hemodialysis (IHD)
• Good residual renal function with urine output > 0.5 L/d (or KRU>3
ml/min)
• Limited fluid retention between two conservative HD treatments
with fluid gain < 2.5 kg (or < 5% of ideal dry weight) without HD for 3-
4 days
• Limited or readily manageable cardiovascular or pulmonary
symptoms without clinically significant fluid overload
• Suitable body size relative to renal residual kidney function
• Hyperphosphatemia (P> 5.5 mEq/L) is infrequent or readily
manageable
• Good nutrition status
• Lack of profound anemia
• Infrequent hospitalizations and easily manageable comorbid
conditions
• Satisfactory health-related quality of life
• Use of the criteria on 2x/week HD therapy patients should be re-
evaluated once a month.
45. Implementation Strategies
• In order to initiate and maintain 2x/wk HD,
the patient should meet the first criterion
(urine output >0.5 Lit/day) plus most (5 out
of 9) of the other criteria.
• Examine these criteria every month in all
2x/wk HD patients and compare outcome
between 2x/wk and 3x/wk HD to assure
outcome non-inferiority for continuation of
2x/wk HD
• Consider transition from 2x/wk to 3x/wk HD
regimen if patient’s urine output drops (<0.5
L/day) or if patient’s nutritional status or
general health condition shows a
deteriorating trend over time
46. Take home messages
(1) Early referral to CKD programs should be promoted,
as it is associated with improved outcomes and
preservation of renal function.
(2) Chronic kidney disease care should include aggressive
medical management to delay the progression
of chronic renal failure as well as reduce cardiovascular disease
burden, and control the complications of chronic renal failure.
(3) Preemptive living donor transplantation should be
promoted as the first-line treatment for ESRD.
modality, when and if required.
(4) RRF is very precious and all efforts should be done to keep them as
long as possible