Prevent
Prevention of Kidney Disease Progression
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Prevention of Kidney Disease Progression
, Chronic Kidney Disease Prevention
See Also
Chronic Kidney Disease
Acute Kidney Injury
Intravenous Contrast Related Acute Renal Failure
Drug Dosing in Chronic Kidney Disease
Nephrotoxic Drug
s
Renal Osteodystrophy
Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
Gadolinium-Associated Nephrogenic Systemic Fibrosis
(
Nephrogenic Fibrosing Dermopathy
)
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
Management
Fluids,
Electrolyte
s 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)
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
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
Gerstein (2008) N Engl J Med 358(24): 2545-59 [PubMed]
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
Triglyceride
s <200 mg/dl
Lipid
lowering therapy beyond age 80 does not appear to alter all-cause mortality
Petersen (2010) Age Ageing 39(6): 674-80 [PubMed]
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
Vasopressor
s may be required
Avoid renal dose
Dopamine
due toworse outcomes
Manage
Nephrotoxicity Risk
s
Avoid
Nephrotoxic Drug
s
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
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
http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm
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
Fracture
s or bone loss
High bone turnover by bone biopsy
Controlled PTH,
Calcium
and
Phosphorus
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]
Gene
ral Measures
Limit
Dietary Sodium
intake (<2300 mg/day)
Lowers
Blood Pressure
and decreases albuminuria
McMahon (2021) Cochrane Database Syst Rev (6):CD010070 [PubMed]
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
Microalbuminuria
in
Diabetes Mellitus
(
Diabetic Nephropathy
)
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
Adjunctive antihypertensive agents
Step 1:
ACE Inhibitor
or
Angiotensin Receptor Blocker
See above
Step 2:
Non-Dihydropyridine Calcium Channel Blocker
Diltiazem
or
Verapamil
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
)
References
(2002) Am J
Kidney
Dis 39:S1
Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
Snively (2004) Am Fam Physician 70:1921-30 [PubMed]
Stigant (2003) CMAJ 168:1553-60 [PubMed]
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