Chronic Kidney Disease CKD

Definition and Etiologies (A/wah 2003.139:137)

• -- 3 months of reduced GFR (- 60 ml min 1.73 mJ) and or kidney damage (abnormal pathology, blood urine markers, or imaging)

• Prevalence 11% in U.S.; Cr poor estimate of GFR; use prediction equation, eg.

MDRD equation: www.kidney.org professionals KDOQI gfr_calculator.cfm nb. equation may underestimate GFR in Pts w normal renal function

• Etiologies include diabetes HTN, PKD (lancet 2007:3691287). glomerulonephritis.

congenital disease, drug-induced, myeloma, progression of ARF

• Rates of all-cause mortality and CV events increase with each stage of CKD. and are significantly higher than the rate of progression to kidney failure (NEjm 2004:351 1296)

Stages of CKD

Stage

GFR

Goals

1 (nl or T GFR)

>90

Dx Rx of underlying condition & comorbidities, slow progression; cardiovascular risk reduction.

2 (mild)

60-89

Estimate progression

3 (moderate)

30-59

Evaluate and treat complications

4 (severe)

15-29

Prepare for renal replacement therapy (RRT)

5 (kidney failure)

<15 or dialysis

Dialysis if uremic

Signs and Symptoms of Uremia

General Neurologic

Nausea, anorexia, malaise, fetor uremicus. metallic taste, pruritis, uremic frost (white crystals in & on skin), susceptibility to drug O D Encephalopathy (a MS. 1 memory & attention), seizures, neuropathy

Cardiovascular

Pericarditis, accelerated atherosclerosis, hypertension, hyperlipidemia, volume overload. CHF. cardiomyopathy

Hematologic

Anemia, bleeding (due to platelet dysfunction)

Metabolic

t K. T PO4. acidosis. 1 Ca. 2° hyperparathyroidism, osteodystrophy

Treatment (Lancet 200S:365:331)

• General: early nephrology referral and access planning (avoid subclavian lines; preserve an arm for access by avoiding blood draws. BP measurements. IVs)

• Dietary restrictions: Na (if hypertensive). K (if oliguric or hyperkalemic). ? moderate protein restriction, strict glucose control in diabetics

start with ACEI. effective in diabetic & non-diabetic CKD (NÇ/M 1993:329:1456« 1996:334:939) ACEI • ARB may be superior to either alone (COOPERATE. Lancet 2003:361:117) ACEI may be effective and safe in nondiabetic CKD (Cr 3-5, nejm 2006:354 131)

• Metabolic acidosis: sodium bicarbonate or sodium citrate if HCOj - 22

• Anemia: goal Hgb 11-12 mg dl (1 death. HTN. and thrombosis w/ higher levels;

NEjM 2006:355:2071 & 2085. Lancet 2007:369:381)

epoetin (start 80-120 U kg SC. divided 3x wk) or darbepoetin (0.45 meg kg q wk)

iron supplementation when indicated (often given IV in HD Pts)

uremic bleeding: desmopressin (dDAVP) 0.3 p.g kg IV or 3 p.g kg intranasally

• 2° Hyperparathyroidism: T PO«, i Ca. i calcitriol all stimulate PTH release

CKD Stage

3

4

5

Target PTH (pg/ml)

3S-70

70-110

150-300

phosphorus binders if T PO« and J Ca — calcium acetate (PhosLo) or calcium carbonate if refractory T PO« or in setting of T Ca — sevelamer (Renagel). lanthanum (Fosrenol) if severe T PO« — aluminum hydroxide (Amphojel). short-term use only calcitriol or paricalcitol if Ca-PO« product <55 (? T survival in HD Pts. n£/m 2003:349.446) cinacalcet (parathyroid calcium sensing receptor agonist) if PTH remains elevated despite phosphorus binders • vit D analogue (nejm 2004:3501516) parathyroidectomy * Consider transplant evaluation

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