Nephrology Book

Organ Failure

  • Prevention of Kidney Disease Progression

http://www.fpnotebook.com/

Prevention of Kidney Disease ProgressionAka: Chronic Kidney Disease Prevention

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  1. See Also
    1. Chronic Kidney Disease
    2. Intravenous Contrast Related Acute Renal Failure
    3. Drug Dosing in Chronic Kidney Disease
  2. Management: Nephrology consultation indications
    1. Glomerular Filtration Rate <30 ml/min or
    2. Assistance with evaluation or management strategy
  3. Management: Fluids, electrolytes and nutrition
    1. Careful fluid balance (avoid Fluid Overload as well as dehydration)
    2. Protein restriction (controversial)
      1. Low Protein diet
        1. Serum Creatinine 2-4 (GFR 25-55): 0.8 mg/kg/day
        2. Serum Creatinine >4 (GFR <25): 0.6 mg/kg/day
      2. Institute when Serum Creatinine >= 1.7
      3. Appears to significantly benefit only Diabetics
      4. Contraindications to protein restriction
        1. Hemodialysis
        2. Elderly
        3. Malnutrition
        4. Nephrotic Syndrome (due to high protein losses)
    3. Hyperkalemia
      1. Limit Dietary Potassium intake to 70 meq/day
    4. Metabolic Acidosis
    5. Unintentional Weight Loss
      1. Minimum intake: 35 Kcal/kg/day
    6. Hyperphosphatemia (renal osteodystrophy)
      1. Causes Osteitis fibrosa cystica (poor bone strength)
      2. Results from Hyperparathyroidism
      3. Management
        1. Restrict dietary phosphate (limit to 1200 mg/day)
          1. Avoid soda
          2. Avoid nuts, peas or beans
          3. Avoid dairy products
        2. Medications
          1. Calcium Supplementation 1-2 grams daily
          2. Phosphate-binding: Calcium Carbonate
          3. Vitamin D Supplementation (critical!)
  4. Management: Comorbid conditions
    1. Maximize glycemic control in Diabetes Mellitus
    2. Observe closely for Coronary Artery Disease
      1. High Incidence of comorbidity
      2. Most ESRD patients die of CAD before dialysis
    3. Control Hyperlipidemia (Statin drugs are preferred)
      1. Goal LDL Cholesterol <100 mg/dl
      2. Goal Triglycerides <200 mg/dl
    4. Avoid additional kidney injury
      1. Early recognition and treatment of UTI
      2. Avoid volume depletion
      3. Avoid Nephrotoxic Drugs
      4. Tobacco Cessation
      5. Limit radiologic Contrast Material to low density
  5. Management: Evaluate and manage common complications
    1. Anemia (Hemoglobin <11 grams per dl)
      1. Iron supplement indicated for Ferritin <100 ng/ml
      2. Erythropoetin or Aranesp indications
        1. Anemia dependent Angina
        2. Hemoglobin <10 grams/dl or Hematocrit <30-32
  6. Management: Hypertension and Proteinuria
    1. Most important preventive measure
    2. Control Hypertension and Proteinuria with ACE Inhibitor
      1. ACE Inhibitor should be first antihypertensive used
        1. Efficacious in Diabetic Nephropathy
        2. Efficacious in non-diabetic renal disease
        3. Jafar (2001) Ann Intern Med 135:73
      2. Indication
        1. Proteinuria on Urinalysis (1+ Protein on Urinalysis or >1 gram per day)
        2. Microalbuminuria in Diabetes Mellitus
        3. Hypertension (Blood Pressure >130/80 mmHg)
      3. Observe for Hyperkalemia
        1. Avoid with potassium sparing Diuretic
        2. Avoid with Potassium Supplementation
      4. Management with adverse effects
        1. Orthostasis: Maximize clear fluid intake
    3. Adjunctive antihypertensive agents
      1. Step 1: ACE Inhibitor or Angiotensin Receptor Blocker
        1. See above
      2. Step 2: Non-Dihydropyridine Calcium Channel Blocker
        1. Diltiazem or
        2. Verapamil
      3. Step 3: Hydrochlorothiazide
        1. Not helpful if Creatinine Clearance <30 ml/min
      4. Step 4: Beta Blocker
        1. Use with caution due to possible adverse outcomes
  7. References
    1. (2002) Am J Kidney Dis 39:S1
    2. Snively (2004) Am Fam Physician 70:1921
    3. Stigant (2003) CMAJ 168:1553

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