CKD-pre dialysis management

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CKD-pre dialysis management:

CKD-pre dialysis management Shruthi K

Chronic kidney disease :

Chronic kidney disease Global health problem Rising incidence – doubled in last 15 years In India – 0nly 10% of patients with ESRD have access to RRT

CKD-definition :

CKD-definition GFR ≤ 60ml/min/1.73m that is present for ≥ 3months with or without evidence of kidney damage OR Evidence of kidney damage with or without decreased GFR that is present for ≥ 3months as evidenced by Microalbuminuria Proteinuria Glomerular haematuria Pathological abnormalities (e.g. abnormal biopsy) Anatomical abnormalities (e.g. scarring seen on imaging or polycystic kidneys)

Pre dialysis management – Why? :

Pre dialysis management – Why? Optimal pre-dialysis care improve Morbidity Mortality Dialysis and transplantation outcome

CKD Predicts CVD:

CKD Predicts CVD Age-Standardized Rate of Cardiovascular Events (per 100 person-yr) Estimated GFR (mL/min/1.73 m2)

Early Treatment Makes a Difference:

Early Treatment Makes a Difference Brenner, et al., 2001

Goal :

Goal To establish diagnosis Rule out reversible causes Slow down progression Evaluate and treat complications Treat co-morbidities Reduce cardiovascular risk Prepare for replacement therapy Select & start renal replacement therapy at appropriate time

Management :

Management Treatment of reversible causes Preventing or slowing the progression of disease Treatment of the complications Identification and adequate preparation of the patient in whom renal replacement therapy will be required

Treatment of reversible causes :

Treatment of reversible causes Decreased renal perfusion Hypovolemia (such as vomiting, diarrhea, diuretic use, bleeding) Hypotension (due to myocardial dysfunction or pericardial disease) Infection /sepsis Drugs which lower the GFR Urinary tract obstruction

Slowing the rate of progression:

Slowing the rate of progression Proteinuria < 1 gm/day or at least 60% of baseline values Optimal level of protein intake Not been determined 0.8 to 1.0 g/kg/day ACEI/ARB Smoking cessation

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Blood pressure <130/80mmHg <125/75mmHg if proteinuria >1g/day Salt restriction Antihypertensives ACE,diuretics,CCB Exercise

Treatment of complications:

Treatment of complications Volume overload Salt restriction Loop diuretics

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Hyperkalemia Develops in the patient who is oliguric or who has an additional problem such as a high potassium diet, increased tissue breakdown, or hypoaldosteronism Low K+ diet – 40 to 70meq / day Avoid NSAIDs

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Metabolic acidosis Due to Decreased ability to regenerate bicarbonate Reduced ammonia production Decreased hydrogen ion secretion Decreased filtration of titrable acids – sulphate, phosphate, urate, hippurates Decreased proximal tubular re-absorption of bicarbonate

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Treatment of academia is desirable Bicarbonate supplementation may slow the progression of CKD Bone buffering of the some of the excess hydrogen ion is associated with the release of calcium and phosphate from bone, contributing to worsening of renal osteodystrophy Uremia acidosis can increase skeletal muscle breakdown and diminish albumin synthesis leading to loss of lean body mass and muscles weakness- contributing to malnutrition

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Therapy is targeted to maintain serum bicarbonate concentration above 23 mEq/Lit Drug of choice : sodium bicarbonate < 0.5-1.0 mEq/kg/day

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Hyperphosphatemia Diet restriction : 800mg/day GFR<25 to 30 ml/min: oral phosphate binders Stage 3 & 4 : between 2.7 and 4.6 mg/dL Stage 5 : between 3.5 and 5.5 mg/dL

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Renal osteodystrophy High phosphate load and hypocalcemia stimulate PTH secretion Leads to sec hyper parathyroidism which increases bone resorption

Treatment :

Treatment Control serum phosphate CKD stage-specific target levels of intact PTH CKD stage 3: treat elevated PTH to target 35-70pg/ml CKD stage 4 to target 70-110 pg/ml CKD stage 5 to target 150-300 pg/ml Next step is assessment of 25-(OH)D levels and replacement with vitamin D (ergocalciferol) if levels are lower than 30 ng/mL.

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If the intact PTH level is elevated and the serum 25-(OH)D level is higher than 30 ng/mL, treatment with an active form of vitamin D is indicated Available options Calcitriol Alfacalcidol Doxecalciferol

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Cinacalcet Calcimimetic Used if elevated phosphorus/Ca limit use of vit D

Hypertension :

Hypertension Cause and complication of CKD Target <130/80 or <125 /75 mmHg if proteinuria is >1 gm /day or diabetes is + Non pharmacological Lifestyle modification Salt restriction Exercise,weight reduction Diet Smoking cessation etc….

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Pharmacological May require 3 or more drugs Diabetes & proteinuria : treat with ACEI /ARB as 1 st line therapy Monitor Creatinine & K+ on day 3 ,7 &weekly Loop and thiazide diuretics as an adjunct therapy CVD: beta blockers CCBs Alpha blockers : prazosin,doxazosin followed by direct vascular smooth muscle relaxant minoxidil is considered

Anemia :

Anemia Caused by insufficient erythropoietin production ,short life span of RBCs , iron deficiency Target Hb: 10 to 12gm% Correct iron deficiency EPO : 80 to 120units/kg/wk Alternative : darbepoietin alfa Longer acting agent Dose: 0.45µg/kg s/c once a week

Preparation for RRT:

Preparation for RRT Counselling HD,peritoneal dialysis / renal transplant If not for transplant : vascular access should be created in preferably native AV fistula in CKD stage 4 Venous preservation should start from stage 2 or 3 Vaccinate against hep B, pneumococcal and H influenza infection Drug dosage according to eGFR , avoid contrast