Chronic Kidney Disease

Chronic Kidney Disease: 

Chronic Kidney Disease

Staging and Definition of CKD: 

Staging and Definition of CKD K/DOQI, NKF K/DOQI, NKF

CKD Management: 

CKD Management BP control to sbp < 130mmHg and dbp < 80mmHg. RAAS inhibitor if proteinuric Thiazide (Loop diuretic if GFR<40ml/min) Reduce proteinuria to no more than 1g/day. RAAS inhibition (ACE I, ARB) is the cornerstone of antiproteinuric therapy. Non-dihydropyridine CCBs are alternative. Aldosterone antagonist can be used as an adjunct.

CKD Management: 

CKD Management Lipid control to LDL < 70 (CAD equivalent), HDL > 50, Trig < 150. Tight glucose control if diabetic (HgA1C < 7.0). Smoking cessation (if smoker) Anemia management: Initiate ESA and/or Iron therapy when hgb < 9-10; goal hgb 11-12. CHOIR, CREATE, and TREAT studies indicate increased mortality with higher vs. lower hgb levels.

Slide 5: 

CKD-Metabolic Bone Disease/ Renal Osteodystrophy management: Hyperphosphatemia: calcium-based (Calcium acetate) vs. non-calcium-based (Lanthanum carbonate, Sevelamer hydrochloride, Sevelamer Carbonate) binders. Risk of vascular calcification may be increased with use of calcium-based binders. Can add vit D analogue (Calcitriol, Doxercalciferol, Paricalcitol) and/or calcimimetic (Cinecalcet) if phoshorus control not enough to control PTH

Slide 6: 

Refer to vascular surgeon for fistula/graft creation Refer to transplant surgeon for transplant evaluation when GFR < 30ml/min.

ESRD: 

ESRD

Dialysis: 

Dialysis Indications for emergent dialysis: Hyperkalemia recalcitrant to medical therapy Metabolic acidosis recalcitrant to medical therapy Volume overload/HTN recalcitrant to medical therapy Uremic pericarditis Uremic encephalopathy Intoxications (alcohols, lithium, salicylates, theophylline)

Slide 9: 

Indications to initiate dialysis in CKD patient: Based on uremic features (failure to thrive, weight loss, fatigue, weak, nausea, vomiting, pruritis) Not based on BUN/Cr measures

Slide 10: 

Diagnosis of peritonitis in peritoneal dialysis patients requires two of the following criteria: Fluid wbc > 100 or >50% polymorphs Positive gram stain and culture Abdominal complaints (pain, nausea, vomiting, peritoneal signs).

Transplantation: 

Transplantation Acute Rejection Hyperacute (in OR) – associated with ABO incompatibility (extremely rare) Accelerated (24-48 hours) – associated with low-level preformed donor antibodies (rare) Treat with high dose steroids and lymphocyte-depleting agent (thymoglobulin; rituximab) Cellular (after 48 hours) – T-cell mediated. Treat with high dose steroids; may need lymphocyte-depleting agent if steroids resistant or if there is component of antibody/vascular-mediated rejection.

Slide 12: 

Recurrent disease in a new transplant can also lead to acute renal failure. Type 2 MPGN, FSGS, IgA nephropathy Chronic Allograft Nephropathy Likely secondary to a combination of factors: Disease recurrence De Novo disease (anti-GBM in Alport patients, diabetes) Calcineurin inhibitors BK virus

Post-Transplant Infections: 

Post-Transplant Infections