II. Management: Nephrology Consultation indications
- Single GFR in past 12 months < 30 mL/min
- Single GFR < 60 mL/min AND Blood Pressure > 130/80 (consistently) despite antihypertensive medications
- Single GFR < 60 mL/min AND Hemoglobin < 10 g/dL
- Single GFR < 60 mL/min AND Hyperparathyroidism (PTH > 72 pg/mL) despite correcting for any Vitamin D Deficiency
- Proteinuria > 1 gram/24 hours
- Unexplained Hematuria
- Unexplained decline in GFR > 15 mL/min between two readings
III. Management: Fluids, Electrolytes and nutrition
- See Chronic Kidney Disease
- Careful fluid balance (avoid Fluid Overload as well as Dehydration)
-
Protein restriction (controversial)
- Low Protein diet
- Serum Creatinine 2-4 (GFR 25-55): 0.8 g/kg/day
- Serum Creatinine >4 (GFR <25): 0.6 g/kg/day
- Institute when Serum Creatinine >= 1.7
- Appears to significantly benefit only patients with Diabetes Mellitus
- Contraindications to Protein restriction
- Hemodialysis
- Elderly
- Malnutrition
- Nephrotic Syndrome (due to high Protein losses)
- Low Protein diet
-
Hyperkalemia
- Limit Dietary Potassium intake to 70 meq/day
-
Metabolic Acidosis
- Treat if serum bicarbonate <20
-
Unintentional Weight Loss
- Minimum intake: 35 Kcal/kg/day
-
Hyperphosphatemia
- See Renal Osteodystrophy
- Causes Osteitis fibrosa cystica (poor bone strength)
- Results from Hyperparathyroidism
- Management
- Restrict dietary phosphate (limit to 1200 mg/day)
- Avoid soda
- Avoid nuts, peas or beans
- Avoid dairy products
- Medications
- See Calcium and Phophorus Metabolism in Chronic Kidney Disease
- Calcium Supplementation (maximum 1.2 to 2.0 grams daily)
- Phosphate-binding
- Calcium Carbonate or acetate
- Sevelamer hydrochloride or carbonate
- Vitamin D Supplementation (critical!)
- Correct acidosis
- Restrict dietary phosphate (limit to 1200 mg/day)
IV. Management: Comorbid conditions
-
Diabetes Mellitus
- See Diabetic Nephropathy
- Maximize glycemic control in Diabetes Mellitus
- Hemoglobin A1C <7% best reduces Diabetic Nephropathy risk
- Precaution: ACCORD Study found higher overall mortality with intensive glycemic control in Type II Diabetes
-
Coronary Artery Disease
- High Incidence of comorbidity
- Most ESRD patients die of Coronary Artery Disease before Dialysis
- CAD primary prevention in Chronic Kidney Disease for those WITHOUT Coronary Artery Disease
- Antiplatelet Therapy (e.g. Aspirin) reduces the risk of MI (NNT 125) but increases the risk of major bleed (NNH 100)
- Natale (2022) Cochrane Database Syst Rev (2): CD008834 [PubMed]
-
Hyperlipidemia
- Statin drugs are preferred
- Goal LDL Cholesterol <100 mg/dl
- Goal Triglycerides <200 mg/dl
- Lipid lowering therapy beyond age 80 does not appear to alter all-cause mortality
- Avoid additional Kidney injury
- Early recognition and treatment of UTI
- Tobacco Cessation
- Avoid Rhabdomyolysis Causes
- Maintain hemodynamic stability in Acute Renal Failure
- Avoid volume depletion
- Maintain mean arterial pressure >65 mmHg
- Vasopressors may be required
- Avoid renal dose Dopamine due toworse outcomes
- Manage Nephrotoxicity Risks
- Avoid Nephrotoxic Drugs
- Measure drug levels of nephrotoxic medications
- Limit radiologic Contrast Material to low density
- See Intravenous Contrast Related Acute Renal Failure
- See Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)
- See Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
- Prefer lowest volume of lowest osmolar Contrast Material
- Optimize hydration status (e.g. Isotonic Saline) prior to Contrast Material and consider N-Acetylcysteine
-
Chemotherapy with risk of Tumor Lysis Syndrome (prevent Uric Acid nephropathy)
- Pre-hydrate prior to Chemotherapy
- Consider Allopurinol prior to Chemotherapy
- Hepatic failure (Cirrhosis)
- Early recognition and treatment of bleeding, Ascites and Spontaneous Bacterial Peritonitis
- Replace albumin as needed
V. Management: Evaluate and manage common complications
-
Anemia (Hemoglobin <11 grams per dl)
- Iron supplement indicated for Ferritin <10 ng/ml
- Erythropoetin or Aranesp indications
- Anemia dependent Angina
- Hemoglobin decline requires transfusion
- Hemoglobin <10 grams/dl or Hematocrit <30-32
- Use goal >9 grams/dl in comorbid cancer
- Avoid increasing Hemoglobin >11 g/dl (higher morbidity and mortality)
- References
- (2007) Am J Kidney Dis 50(3): 471-530 [PubMed]
- FDA EPO agent recommendations
-
Osteoporosis
- Control Calcium and Phosphorus
- Control Parathyroid Hormone
- Use Bisphosphonates only with caution
- Consider nephrology Consultation
- Do not use for GFR <30-40 ml/min
- Only use for strong indications
- Fractures or bone loss
- High bone turnover by bone biopsy
- Controlled PTH, Calcium and Phosphorus
VI. Management: Hypertension and Proteinuria
- Most important preventive measure
- Goals of therapy
- Decrease Proteinuria by 50%
- Decrease Blood Pressure below 130/80
- Goal BP in Chronic Kidney Disease is controversial
- Arguedas (2009) Cochrane Database Syst Rev CD004349
- (2004) Am J Kidney Dis 43(5 suppl 1): S1-S290 [PubMed]
-
General Measures
- Limit Dietary Sodium intake (<2300 mg/day)
- Lowers Blood Pressure and decreases albuminuria
- McMahon (2021) Cochrane Database Syst Rev (6):CD010070 [PubMed]
- Limit Dietary Sodium intake (<2300 mg/day)
- Control Hypertension and Proteinuria with ACE Inhibitor
- ACE Inhibitor should be first antihypertensive used
- Efficacious in Diabetic Nephropathy
- Efficacious in non-diabetic renal disease
- Jafar (2001) Ann Intern Med 135:73-87 [PubMed]
- Indication
- Hypertension (Blood Pressure >130/80 mmHg)
- Proteinuria
- Diabetes Mellitus
- Non-Diabetic
- Proteinuria on Urinalysis (1+ Protein on Urinalysis or >1 gram per day)
- Random Protein to Creatinine ratio >200 mg Protein/g Creatinine
- Observe for Hyperkalemia
- Avoid with Potassium sparing Diuretic
- Avoid with Potassium Supplementation
- Management with adverse effects
- Orthostasis: Maximize clear fluid intake
- ACE Inhibitor should be first antihypertensive used
- Adjunctive antihypertensive agents
- Step 1: ACE Inhibitor or Angiotensin Receptor Blocker
- See above
- Step 2: Non-Dihydropyridine Calcium Channel Blocker
- Step 3: Hydrochlorothiazide (or other Thiazide Diuretic)
- Use Furosemide (or other Loop Diuretic) instead if Creatinine Clearance <30 ml/min
- Step 4: Beta Blocker
- Use with caution due to possible adverse outcomes (including third degree AV Block)
- Step 1: ACE Inhibitor or Angiotensin Receptor Blocker