recent advances in management of crf
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Recent Advances in Recent Advances in Management of CRFManagement of CRF
Yousef Boobess, M.D.Head, Nephrology Division
Tawam Hospital
What is chronic renal failure ? What is chronic renal failure ? DefinitionsDefinitions
Azotemia: Elevated blood urea and creatinine
Chronic renal failure: The irreversible, substantial, and usually long-
standing (>3 months) loss of renal function.
Uremia: Azotemia with symptoms or signs of renal failure
End-stage renal disease (ESRD): The degree of CRF that without renal replacement
treatment would result in death.
Urinary abnormalities
(GFR 90 ml/min)
Mildly impaired (GFR 60 - 89 ml/min)
Moderate CRF(GFR 30 - 59 ml/min)
Severe CRF (GFR 15 - 29 ml/min)
ESRD(GFR < 15 ml/min)
STAGES OF STAGES OF Chronic Kidney Chronic Kidney Disease (CKD)Disease (CKD)
EpidemiologyEpidemiology
The number of ESRD patients is increasing rapidly, with very costly treatment
Early recognition of renal disease and appropriate interventions may decreaseHuman sufferingFinancial costs associated with ESRD
Dialysis Sessions in Dialysis Sessions in TawamTawam
0100020003000400050006000700080009000
10000
Sess
ion
No
Incidence Rates of ESRD Incidence Rates of ESRD TherapyTherapy
U.S. Renal Data System, (1997)U.S. Renal Data System, (1997)
1982 1984 1986 1988 1990 1992 1994 1995
Years
Rat
e p
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illi
on P
opu
lati
on
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250
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Causes of ESRD in USACauses of ESRD in USA40.3
27.1
10.5
2.4 4.2 3.4 1.7 3 4 3.5
0
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10
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45D
M
HT
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S . GP
IN
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Oth
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kno
wn
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nre
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rted
Primary Diagnosis
ES
RD
Pop
ulat
ion
(%)
1999 USRDS Report
Team Approach: Team Approach: Primary Helth Care (PHC) Physician and Primary Helth Care (PHC) Physician and
Nephrologist in CKDNephrologist in CKD
PHC PhysicianEarly recognition of renal disease PHC Physicians treat
patients with DM, HTN
Timely referral to a Nephrologist Collaboration with a Nephrologist to provide long term care Patient education
NephrologistDiagnose and assess patients
Assist in developing strategic guidance
Recommend and implement patient care
Provide role-specific patient education
Principles of Management of Principles of Management of CKD PatientsCKD Patients
Early recognition of CKD Estimate the severity of CKD What is the cause of CKD?
Detection and correction of any reversible cause. Avoidance of additional renal injury Institution of interventions to delay progressionTreatment of complications Planning for renal replacement therapy
Principles of Management of Principles of Management of CKD PatientsCKD Patients
Early recognition of CKD Estimate the severity of CKD What is the cause of CKD?
Detection and correction of any reversible cause. Avoidance of additional renal injury Institution of interventions to delay progressionTreatment of complications Planning for renal replacement therapy
Recognizing Renal Failure,Recognizing Renal Failure,
Clinical FeaturesClinical FeaturesRecognizing Renal Failure,Recognizing Renal Failure,
Clinical FeaturesClinical FeaturesMild to Moderate renal failure: Usually no symptoms
Severe renal failure: non specific Pale, fatigueability & shortness of breath Hypertension, headaches Polyuria/nocturia Body itch Poor appetite, nausea, vomiting Hyperventilation Swelling of the face and legs
Recognizing Renal Failure,Recognizing Renal Failure,
Clinical FeaturesClinical FeaturesRecognizing Renal Failure,Recognizing Renal Failure,
Clinical FeaturesClinical FeaturesMild to Moderate renal failure: Usually no symptoms
Severe renal failure: non specific Pale, fatigueability & shortness of breath Hypertension, headaches Polyuria/nocturia Body itch Poor appetite, nausea, vomiting Hyperventilation Swelling of the face and legs
HyperventilationHyperventilation
13 y-o-f, came to ER with hyperventilation ER physician examined her psychosis valium, reassured the family & DCNo improvement taken to another hospital Blood Chemistry & ABGs ESRD with very severe metabolic acidosis (Bicarbonate ~ 2.7 mmol/l)
Recognizing Renal Failure,Recognizing Renal Failure,
InvestigationsInvestigationsRecognizing Renal Failure,Recognizing Renal Failure,
InvestigationsInvestigationsUrinalysis: Urine dipstick & microscopic exam => Ptu, Htu, pyuria, glycosuria
Blood chemistry: s.Creatinine, urea (or BUN) Electrolytes (Na+, K+, CO2, Ca++, Ph--)
GFR: Estimated or measured
Ultrasound Morphologic evaluation
s.Creatinine Concentration s.Creatinine Concentration s.Creatinine Concentration s.Creatinine Concentration
Normal values: <115 umol/L in males (1.3 mg/dL) <90 umol/L in females (1 mg/dL)
Changes in its level are more important: an increase from 55 to 110 umol/L represents a
50% decline in renal function
Limitations
High s.Creatinine with High s.Creatinine with Normal GFRNormal GFR
Spurious elevation: Cephalosporin DKA Alcohol intoxication
Blocking tubular secretion: Cimetidine or trimethoprim
Increased creatinine production: Exogenous: ingestion of large quantities of cooked
meat Endogenous: Muscular disorders, or increases in
muscular mass
Normal s.Creatinine with CRF Normal s.Creatinine with CRF
Poor production of creatinine:Severely malnourished patients ElderlySmall childrenLadies of small size
Glomerular Filtration Rate Glomerular Filtration Rate “GFR” “GFR”
Normal values: In males 120 20 mL/minute In females 115 20 mL/minute.
Creatinine Clearance (24-h urine collection)
Creatinine Clearance in Severe CKD: Overestimate GFR due to the tubular secretion To correct this overestimation:
Take the average of urea and creatinine clearances Or give oral cimetidine 1200 mg, 3h before collection
Estimation of Creatinine Estimation of Creatinine ClearanceClearance
Creat. Cl =1.23 x weight x(140-age)/(s.creat)Creat. Cl =1.23 x weight x(140-age)/(s.creat)
In Male:
In Female
Cockcroft, Nephron, 1976; 16: 31-41
1.03
Determine the cause of CKDDetermine the cause of CKD
A specific diagnosis is needed:To consider specific TRT:
obstructive uropathy, analgesic NP, drug-related IN, RPGN, SLE, vasculitis, accelerated HTN, tuberculosis, myeloma, amyloid, ..
To be aware of potential complications:SLE, DM..
To advise the family:PKD or other familial renal disease.
Principles of Management of Principles of Management of CKD PatientsCKD Patients
1. Early recognition of CKDEstimate the severity of CKDWhat is the cause of CKD?
2. Detection and correction of any reversible cause. Avoidance of additional renal injury
3. Institution of interventions to delay progression
4. Treatment of complications 5. Planning for renal replacement therapy
Correcting any Reversible Correcting any Reversible CauseCause
Correction a Reversible CauseCorrection a Reversible Cause“Sarcoidosis”“Sarcoidosis”
0
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Time (days)
Cre
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/ l )
Corticotherapy
Dialysis Sessions
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Time (days)
Cre
atin
ine
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/ l )
Corticotherapy
Dialysis Sessions
Volume DepletionVolume Depletion
Causes: Diarrhea, vomiting, iatrogenic (surgery,
overzealous use of diuretics) Renal loss Worsening renal arterial stenosis, cholesterol
emboliVolume repletion Restores renal function promptly Some degree of transient or permanent damage
may occur
Principles of Management of Principles of Management of CKD PatientsCKD Patients
Principles of Management of Principles of Management of CKD PatientsCKD Patients
1. Early recognition of CKDEstimate the severity of CKDWhat is the cause of CKD?
2. Detection and correction of any reversible cause. Avoidance of additional renal injury
3. Institution of interventions to delay progression
4. Treatment of complications 5. Planning for renal replacement therapy
Slowing the Rate of Slowing the Rate of ProgressionProgression
The earlier we alter factors that damage the kidneys, the better
Successful InterventionSuccessful Intervention
0
0.001
0.002
0.003
0.004
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0.006
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0 5 10 15 20
1/s
.cre
tin
ine
Therapeutic Intervention
Months, follow-up
Rashed M., Tawam #125991
InterventionInterventionRenal DietRenal Diet
InterventionInterventionRenal DietRenal Diet
Protein Restriction
High calories
Law potassium
Law salt
Law phosphate
Intervention:Intervention:Controlling BP in CKD Controlling BP in CKD
Target BP: CKD: <130/85 mm Hg If proteinuria: <125/75 mm Hg
Benefits Slows the progression of CKD, especially if
proteinuriaReduces the cardiovascular complications
Zabetakis PM, Nissenson AR. Am J Kid Dis. 2000;36(suppl):S31-S38.
BP Control and GFR DeclineBP Control and GFR Decline
•Parving HH et al. Br Med J 1989 Moschio G et al. NEJM 1996• Viberti GC et al. JAMA 1993
Prevalence of LV Disorders at Prevalence of LV Disorders at Start of Dialysis Start of Dialysis
Parfrey PS, et al.. Nephrol Dial Transplant. 1996;11:1277-1285
LV dilation28%
Cincentric LVH41%
Normal16%
Systolic dysfunct.16%
Echocardiograms of 413 incident hemodialysis patients
Consequences of CKD: Consequences of CKD: (LVH) (LVH)
LVH is an independent predictor of cardiac death in dialysis patients.
Hypertension, anemia and diabetics are modifiable predictors of LVH
Increase in LVH risk: For each: Ccr of 25 mL/min => 3% increased risk of LVH. Systolic BP by 5 mm Hg => 3% increased risk. Hemoglobin by 1 g/dl => 6% increased risk of
LVH
Levin A, et al. Am J Kid Dis. 1996;27:347-354.
< 130/8511%
< 140/9027%
> 140/9062%
BP is Poorly Controlled in BP is Poorly Controlled in CKDCKD
Coresh J, et al. Arch Intern Med. 2001;161:1207-1216.
Blood Pressure ControlBlood Pressure Control
Several classes of drugs are available
Some can slow the decline of GFR:First-line treatment:
ACE inhibitors & angiotensin receptor blockers There's still a great reluctance by PHC physicians to
use them for fear that they will damage the kidneys rather than preserve function.
Diuretics in combination with ACE inhibitors.
JNC VI. Arch Intern Med. 1997;157:2413-2446.
Reno-protective Effect of Reno-protective Effect of ACEisACEis
ACEis (independent of their antihypertensive action):
Decrease proteinuria Delay the progression of renal disease
Mechanisms: Dilatation of EA =>reducing intra-glomerular
pressure Restoration of glomerular perm-selectivity in
proteinuric NPs ? Effect on the GH like of AII
Adverse Effects of ACEisAdverse Effects of ACEis
Acute worsening of renal function if bilateral renal artery stenosis or if decreased
effective circulating volume advices:
monitor renal function after initiation of ACEi in high risk patients: renal scan with captopril test adjust the dose according to the renal function
Hyperkalemia same considerations apply
Glycemic Control in DiabeticsGlycemic Control in Diabetics
Tight control of blood glucose: HbA1C <7%Delay the onset of microalbuminuriaDecrease or stabilize protein excretion in
patients who already had microalbuminuria
ACE inhibitors, and ARBs: Delay the progression of kidney
dysfunction.
Zabetakis PM, Nissenson AR. Am J Kid Dis. 2000;36(suppl):S31-S38.The Diabetes Control and Complications Trial, long-term Sweden study, Japanese study
RENAAL Primary Components
ESRD
Months
% w
ith
ev
ent
0 12 24 36 480
10
20
30
p=0.002Risk Reduction: 28%
P
L
ESRD or Death
P (+ CT)L (+ CT)
Months
% w
ith
ev
ent
0 12 24 36 480
10
20
30
40
50
751 714 625 375 69762 715 610 347 42
P
L
p=0.010Risk Reduction: 20%
Doubling of Serum Creatinine
Months
% w
ith
ev
ent
p=0.006Risk Reduction: 25%
751 692 583 329 52762 689 554 295 36P (+ CT)
L (+ CT)
0 12 24 36 480
10
20
30
P
L
P (+ CT)L (+ CT) 751 714 625 375 69
762 715 610 347 42
Brenner BM et al New Engl J Med 2001;345(12):861-869.
HyperlipidemiaHyperlipidemiaHyperlipidemiaHyperlipidemia
In CRF: Mainly hypertriglyceridemia
=> Increases glomerulosclerosis by: Increasing mesangial proliferation and
matrix productionAltering glomerular hemodynamics Increasing local inflammation
Smoking CessationSmoking Cessation
All patients with renal disease should be encouraged to quit smokingDM is 3 to 4 times more common in
smokers than in nonsmokersSmoking increases the relative risk for
progression of CRF in nondiabetics
Former smokers have an intermediate risk
Principles of Management of Principles of Management of CKD PatientsCKD Patients
1. Early recognition of CKDEstimate the severity of CKD What is the cause of CKD?
2. Detection and correction of any reversible causes. Avoidance of additional renal injury
3. Institution of interventions to delay progression
4. Treatment of complications 5. Planning for renal replacement therapy
Fluid and electrolyte disorders Fluid and electrolyte disorders
Sodium and WaterSodium and WaterMost often: Impaired Na excretion => Edema, HTN, CHF TRT:
Moderate Na+ restriction Loop diuretics
In some patients: Salt wasting => volume depletion => worsening of
CRF TRT:
Na+ replacement
Fluid and Electrolyte DisordersFluid and Electrolyte Disorders
Potassium BalancePotassium BalanceFluid and Electrolyte DisordersFluid and Electrolyte Disorders
Potassium BalancePotassium BalanceHyperkalemia Develops in advanced CRF Can occur earlier in patients with:
Tubulointerstitial disease Diabetic NP and hyporeninemic hypoaldosteronism Drugs: as ACEis, A2 antagonist, b- blockers, NSAIDs,
K+ sparing diuretics, trimethoprim, salt substitutes.. TRT:
Dietary K+ restriction, loop diuretics, K+ exchange resins..
Fluid and Electrolyte DisordersFluid and Electrolyte Disorders
Acid-Base DisordersAcid-Base DisordersFluid and Electrolyte DisordersFluid and Electrolyte Disorders
Acid-Base DisordersAcid-Base Disorders
Metabolic acidosis: Occurs relatively early
Treatment: Decrease protein intake Alkali supplementation if bicarbonate < 17mEq/L
Na bicarbonate or Na citrate, 1 mEq/kg/day This will prevent:
Excessive bone loss Muscle breakdown Tubulointerstitial inflammation
Hypocalcemia & Hypocalcemia & HyperphosphatemiaHyperphosphatemia
Hypocalcemia & Hypocalcemia & HyperphosphatemiaHyperphosphatemia
Hypocalcemia Deficiency in Vit.D, Hyperphosphatemia
Hyperphosphatemia Early in renal failure: Ph-- clearance => Ph-- =>
PTH => Ph-- clearance Frank hyperphosphatemia occur if GFR < 30 mL/min
Management: Dietary phosphate restriction Phosphate binders: Ca carbonate, Renalgel,.. Vit D: Rocaltrol, One Alpha,..
AnemiaAnemiaAnemiaAnemia
Present when GFR < 30-35 mL/minCauses: Reduced EPO production Others: iron deficiency, rapid destruction of RBC,..
Anemia is an independent risk factor for death in CHF Studies of Left Ventricular Dysfunction (SOLVD)
7000 patients 1% lower Hct was associated with 1% higher risk of
mortality
Al Ahmad. et al. J Am Coll Cardiol. 2001;38:955-962.
Independent Risk of a Fall in Independent Risk of a Fall in Mean Hb of 1 g/dL in Dialysis Mean Hb of 1 g/dL in Dialysis
Patients Patients Odds ratio P
LV Dilation 1.42 0.02
De novo cardiac failure
1.28 0.02
Recurrent cardiac failure
1.20 0.05
IHD NA
Death 1.14 0.02
Foley PS, et al. Am J Kidney Dis. 1996;28:53-61.
Cardio - Renal - Anemia Cardio - Renal - Anemia Syndrome Syndrome
CKDCKD
CHFCHF AnemiaAnemia
Vicious Circle of DestructionVicious Circle of Destruction
Cardio - Renal - Anemia Cardio - Renal - Anemia SyndromeSyndrome
CHF is a common and crucial contributor to the progression of CKD. (new concept)
Treatment of anemia in patients with CHF may improve both the cardiac and the renal function
=> To save the heart and the kidney, treat the anemia
Treatment of AnemiaTreatment of Anemia
Target Hgb 11 to 12 g/dL
Epoetin: Dose: 50 U/kg/inj, iv or sc 1-3 times/week
IV Iron Sucrose: Target:
Serum ferritin: 100 - 500 ng/mL Transferrin saturation: 20 – 50%.
Dose: 100 mg/session X 10, then reevaluate
Principles of Management of Principles of Management of CRF PatientsCRF Patients
1. Early recognition of CRF Estimate the severity of CKD What is the cause of CRF?
2. Detection and correction of any reversible cause. Avoidance of additional renal injury
3. Institution of interventions to delay progression
4. Treatment of complications 5. Planning for renal replacement therapy
Planning for Renal Replacement Planning for Renal Replacement Therapy Therapy
Planning for Renal Replacement Planning for Renal Replacement Therapy Therapy
Options of RRT should be discussed: Difference modalities of dialysis
HD, PD
Transplantation Possibility of preemptive Tx
Outcomes are optimal when RRT is initiated in a planned manner HD => need for A-V fistula (4-6 months) Tx: work-up
TRADITIONAL DIALYSIS TRADITIONAL DIALYSIS STARTSTART
Timely Dialysis StartTimely Dialysis Start
EARLY DIALYSIS STARTEARLY DIALYSIS START
Early dialysis start (CrCl > 10 ml/min) vs late dialysis start (CrCl < 4 ml/min):=> higher 12 yr survival (85% vs 51%)
[Bonomini et al Kidney Int 17:S57 1985]
=> improved quality of life at 6 months post initiation of RRT
[Korevaar et al AJKD Jan 2002]
Conclusion, 1Conclusion, 1
Early recognition of renal disease
Early referral to Nephrologist
Detect and correct any reversible cause
Avoid any additional renal injury
Use ACE inhibitors whenever it is indicated
Lipid-lowering drugs
Conclusion, 2Conclusion, 2Conclusion, 2Conclusion, 2
Avoid: Nephrotoxic drugs:
NSAIDs, aminoglycosides, radiocontrast
In moderate to severe CRF: Diuretic therapy: often necessary Dietary potassium restriction Potassium exchange resins if hyperkalemia Alkali supplementation: if CO2 < 16-17 mEq/L Phosphate binders, Vit D EPO, Iron