Sunday, October 24, 2010

Specific Management of CKD

By Dr MOhd Ramly Seman, Nephrologist HTAA

Purpose of the management
1) To delay the progression or to regress the CKD
2) To manage the associated complications of CKD
3) To prepare patient for RRT

A) To Delay The Progression or To Regress the CKD

In research it proves that, slowing the progress of renal disease will retard the progression of renal failure.
For example, renal disease usually progress slowly about about 3ml/mins/year. By this, the person will had renal failure at the age of 55. But slowing the progression for example to 1ml/min/year, will delay the age of occurence at more than 75 years old.

What are the factors that leads to the progression??
1) Angiotensin II plays central role in the renal damage
- Artherosclerosis & vasoconstriction which can lead to STROKE
- Vascular hypertrophy & endothelial dysfunction can lead to HYPERTENSION
- Left Ventricular hypertrophy, Fibrosis, Remodelling & Apoptosis can lead to HEART FAILURE / MI
- Reduce GFR, Increase Proteinuria, increase aldosterone release & glomerular sclerosis can lead

All this if not treated can cause death to the patient

2)Aldosterone ( in the presence of No & CVS disease - HTN, renal disease, DM, heart failure,etc) can cause vascular damage (vasculopathy) & microischemia
There will be vascular inflammation (activation of cytokines,prostaglandins, etc)
--> cause necrosis & inflammatory cells infiltration --> fibrosis which leads to abnormal tissue remodelling & organ dysfunction
Lastly, the patient end up having Renal failure, Heart failure, MI or stroke

3) Hypertension.
Based on research, the lower the BP, the more renal function will be preserved

4) Diabetes Mellitus.
Good glycemic control will reduce the incidence of complications
retinopathy by 20%
nephropathy by 30%
Macrovascula disease by 16%

5) Proteinuria
A study on renal survival in adult FSGS based on proteinuria
for non nephrotic patient, the survival was very much longer compared to Nephrotic patient
Nephrotic pt only 50% survival in 8 years
Much more worse in pt with GFR >14gm/24H, the whole renal survival is only for 5-6 years

6) Family History in relation to microalbuminuria
In the research: interaction between FMHx of CVA in 1st degree relatives & glycemic control with the prevalence of microalbuminuria
Family hx + HbA1c >8% - dev microalnuminuria in 48%
either have FMHx or HbA1c >8% - only about 2% dev microalbuminuria
Non of both - 0%

7) Obesity
Mechanisms of kidney damage in obesity
1) mechanical: can cause hyperfiltration
2) Metabolic: can cause Insulin resistance, inflammation, hypertension & dyslipidemia
All this cause renal damage

8) Smoking
can cause vasoconstriction, thrombosis & direct toxin effect
& cause the vascular endothelium to increase in urine protein excretion & induce declines in renal function

9) Anemia
CKD patient with Hb <11.2>13
The more severe the anemia, the greater the risk

10) Usage of chinese herbs

So what should be done??

-Glycemic control
Pt with type 2 DM with 3/more injections of insulin per day resulted in lower rate in new or progresive nephropathy over a period of 6years compared to conventional therapy of 1/2 injections of insulin per day

- Control BP
130/80 in pt with proteinuria <1g/day>1g/day

- Use ACE / ARB
Based on research could reduce in getting nephropathy even in pt who is nondiabetic or normotensive compared to given placebo or other types of hypertensive medication such as CCB

So, choice of antihypertensive in:-
1) Diabetic Kidney Disease (DKD) - ACEI / ARB
2) Non-DKD + Urine PCR >200mg - ACEI/ARB
3) Non-DKD + Urine PCR <200mg style="font-style: italic;">Avoid NSAIDs. Use aspirin or tramadol
acute usually reversible decline in GFR
idiosyncratic forms of membranous nephropathy
interstitial nephritis
progressive nephrotoxicity - chronic usage

- dietary protein restriction: 0.6 - 0.8g/kg/day

B) Manage the associated complication of CKD

- Anemia
Early treatment has good impact in increasing the Hb over months compared to late treatment.
The best is given IV iron - Raises & effectively increase Hb compared to oral form
which one is better?? Either given IV iron alone / combine with erythropoitin??
ans: IV iron alone is beneficial enough for treatment. But if patient could afford erythropoietin, you can suggest the usage

- Cardiovascular disease
CVD is already well established at the onset of ESRD
Cause of death in dialysis patient: about 50 - 60% is due to cardiovascular

- Renal Bone disease (renal osteodystrophy)
CRF will cause phosphate retention ( phosphate excrete by kidneys) & will decreased the active Vit D. All this leads to hypocalcemia & later develop hyperparathyroidism
As CKD progressing from stage I - stage 4, there will be reduced in Vit D & increasing of PTH
Increasing of phosphate & calcium (secondary to PTH) - deposits at vessels, soft tissue, joints & viscera

Pt with GFR <60>65 starts given vitamin D therapy or started in pt with stage 3

Elevated phosphate increase mortality

- Metabolic acidosis
adverse effect on bone, nutrition & metabolic
Maintain Bicarbonate - 22mmol

- Depression, anxiety & denial stage
watch out for this in patient. all this could lead to non compliance & later progression of CKD

C) How To Prepare Patient for RRT

- Ultrasound Kidney - mainly TRO reversible cause esp obstruction
- Screen for Viral status - HbSAg, HBSAb, HIV, HCVAb
Done as dialyse patient will be divide according to status & we do not want negative patient to be infected with these.
Done 6 monthly. Extra caution with HCVAb - lots of false positive - so if result not consistent. repeat the test
- Cardiac Status - ECG, KIV ECHO, ask for symptoms of angina
- Eye referral to diabetic patient.
Could cause blindness if start dialysis in severe one
- Preserve the vein
- ?? Connective tissue screening
SHould be done in selected patient. NOt all patient
- Social history, family history, occupation or previous occupation
Important, as the treatment is costly
regarding ex-army. They will be given more money if sponsored by army compared to SOCSO
SOme patient did not know that they are elligible for SOCSO

- Predialysis Education
- Slow progression of CKD
-treat comorbidities of CKD
- educate patient to make informed decisions
- ensure timely selection of treatment modalities
- reduce hospitalization
- improve psychosocial, physical & rehabilitative outcomes
- save healthcare dollars

Who is collaborative team
Nurses, physicians, social workers, dieticians, pharmacist, other healthcare professional & staffs, patient & family

Important fact
Early referral is very important
Late referral will cause 40% of 1 year mortality, longer the hospitalization needed & increase cost

=== Nephrology Update ===

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