Chronic renal failure medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Treatment is aimed at specific causes of [[chronic renal failure]]. It includes optimized glucose levels in patients with [[diabetes]], management of [[blood pressure]], [[immunomodulators]] for [[glomerulonephritis]], emerging specific therapies to retard cytogenesis in [[polycystic kidney disease]] and replacement of critical hormones and chemicals produced and utilized by normally healthy [[kidneys]]. Any acceleration in the disease process should prompt a search for superimposed acute or subacute disease process that is potentially reversible. These include extravascular fluid volume depletion, [[urinary tract infection]], [[obstructive uropathy]], exposure to [[nephrotoxicity|nephrotoxic agents]] such as [[ | Treatment is aimed at specific causes of [[chronic renal failure]]. It includes optimized glucose levels in patients with [[diabetes]], management of [[blood pressure]], [[immunomodulators]] for [[glomerulonephritis]], emerging specific therapies to retard cytogenesis in [[polycystic kidney disease]] and replacement of critical hormones and chemicals produced and utilized by normally healthy [[kidneys]]. Any acceleration in the disease process should prompt a search for superimposed acute or subacute disease process that is potentially reversible. These include extravascular fluid volume depletion, [[urinary tract infection]], [[obstructive uropathy]], exposure to [[nephrotoxicity|nephrotoxic agents]] such as [[NSAIDS]] or [[radiocontrast]]s, re-activation and flare of the primary disease like [[SLE]] or [[vasculitis]]. | ||
==Medical therapy== | ==Medical therapy== | ||
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*In addition to reducing the cardiovascular disease risk, use of [[antihypertensive]] therapy in patients with [[CRF]] also aims at slowing the progression of [[nephron]] injury by reducing intra-glomerular hypertension. | *In addition to reducing the cardiovascular disease risk, use of [[antihypertensive]] therapy in patients with [[CRF]] also aims at slowing the progression of [[nephron]] injury by reducing intra-glomerular hypertension. | ||
*Elevated [[blood pressure]] increases [[albuminuria]] by increasing its flux through the renal capillaries. | *Elevated [[blood pressure]] increases [[albuminuria]] by increasing its flux through the renal capillaries. | ||
*Generally, [[angiotensin converting enzyme inhibitor]]s ([[ACEI]]s) or [[angiotensin II receptor blockers]] ( | *Generally, [[angiotensin converting enzyme inhibitor]]s ([[ACEI]]s) or [[angiotensin II receptor blockers]] ([[ARB]]s) are used, as they have been found to slow the progression of [[CRF]] by reducing intra-glomerular pressure.<ref>Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet. 1998 Oct 17;352(9136):1252-6. PMID 9788454.</ref><ref>Ruggenenti P, Perna A, Gherardi G, Garini G, Zoccali C, Salvadori M, Scolari F, Schena FP, Remuzzi G. Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuria. Lancet. 1999 Jul 31;354(9176):359-64. PMID 10437863.</ref> Thus, the more effective a drug is in reducing protein filtration into renal tubules, the greater is the impact on improving [[GFR]]. | ||
*[[Angiotensin converting enzyme inhibitors]] act by inhibiting [[angiotensin]] mediated vasoconstriction of efferent arterioles, thereby reducing filtration pressures and [[proteinuria]]. | *[[Angiotensin converting enzyme inhibitors]] act by inhibiting [[angiotensin]] mediated vasoconstriction of efferent arterioles, thereby reducing filtration pressures and [[proteinuria]]. | ||
*Combination of [[ACE inhibitor]]s and [[ARB]]'s is associated with greater reduction in [[proteinuria]] than either drug used alone. | *Combination of [[ACE inhibitor]]s and [[ARB]]'s is associated with greater reduction in [[proteinuria]] than either drug used alone. | ||
*Side effects include [[cough]] and [[angioedema]] with [[ACE inhibitor]]s, whereas [[anaphylaxis]] and [[hyperkalemia]] is common to use of both [[ACE inhibitors]] and [[ARB]]'s. Progressive increase in [[serum creatinine]] levels suggests concomitant [[renovascular disorder]]s. | *Side effects include [[cough]] and [[angioedema]] with [[ACE inhibitor]]s, whereas [[anaphylaxis]] and [[hyperkalemia]] is common to use of both [[ACE inhibitors]] and [[ARB]]'s. Progressive increase in [[serum creatinine]] levels suggests concomitant [[renovascular disorder]]s. | ||
*Development of the above mentioned side effects may warrant use of other [[antihypertensive]] agents like calcium channel blockers like [[diltiazem]] and [[verapamil]]. | *Development of the above mentioned side effects may warrant use of other [[antihypertensive]] agents like calcium channel blockers like [[diltiazem]] and [[verapamil]]. | ||
*If [[proteinuria]] is strongly associated with the disease progression, like in [[diabetic nephropathy]] or glomerular disease, [[ACE inhibitor]]s should be the first line drugs, whereas in diseases like [[polycystic | *If [[proteinuria]] is strongly associated with the disease progression, like in [[diabetic nephropathy]] or glomerular disease, [[ACE inhibitor]]s should be the first line drugs, whereas in diseases like [[polycystic kidney]] and [[tubulointerstitial disease]]s in which there is minimal or absent [[proteinuria]], other [[antihypertensive]] agents may be used. | ||
===Control of blood glucose=== | ===Control of blood glucose=== | ||
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===Drug dose adjustments=== | ===Drug dose adjustments=== | ||
*Drugs that undergo hepatic elimination do not need drug adjustments. | *Drugs that undergo hepatic elimination do not need drug adjustments. | ||
*Moreover, only the maintenance dose of the drug need to be adjusted as the loading dose does not depend on its renal clearance. *Nonetheless, some drugs should be avoided like [[NSAID's]], [[oral hypoglycemics]], [[radiocontrast]] agents and [[gadolinium]]. | *Moreover, only the maintenance dose of the drug need to be adjusted as the loading dose does not depend on its [[renal clearance]]. | ||
*Nonetheless, some drugs should be avoided like [[NSAID's]], [[oral hypoglycemics]], [[radiocontrast]] agents and [[gadolinium]]. | |||
===Replacement therapy=== | ===Replacement therapy=== | ||
* | ====Indications for dialysis in [[CRF]]==== | ||
* | *[[Uremic pericarditis]] | ||
*[[Uremic encephalopathy]] | |||
*Intractable [[muscle cramps]] | |||
*[[Anorexia]] and [[nausea]] not attributable to reversible causes such as [[peptic ulcer disease]] | |||
*[[Protein energy malnutrition]] | |||
*[[Hyperkalemia]] | |||
*Extracellular fluid volume overload | |||
Recent studies have shown no benefits of initiating early dialysis with improved patient survival. <ref name="pmid20581422">{{cite journal |author=Cooper BA, Branley P, Bulfone L, ''et al.'' |title=A randomized, controlled trial of early versus late initiation of dialysis |journal=[[The New England Journal of Medicine]] |volume=363 |issue=7 |pages=609–19 |year=2010 |month=August |pmid=20581422 |doi=10.1056/NEJMoa1000552 |url=}}</ref>However, advanced preparation for [[dialysis]] can help avoid complications like poorly functioning fistula for [[hemodialysis]] or malfunctioning [[peritoneal dialysis]] catheter, [[sepsis]], [[bleeding]] and [[thrombosis]]. | |||
===Kidney Transplant=== | |||
*Offers the best potential for complete rehabilitation | |||
===Patient education=== | |||
====Multidisciplinary approach==== | |||
*Explain likelihood and timing of initiation of renal replacement therapy and other options available | |||
*Discuss home based [[dialysis]] therapy | |||
**Less expensive | |||
**Improved quality of life | |||
*Counsel family members about home dialysis helper | |||
*Explore options to look for potential biologically related kidney donor | |||
==References== | ==References== | ||
Revision as of 04:02, 2 August 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]
Overview
Treatment is aimed at specific causes of chronic renal failure. It includes optimized glucose levels in patients with diabetes, management of blood pressure, immunomodulators for glomerulonephritis, emerging specific therapies to retard cytogenesis in polycystic kidney disease and replacement of critical hormones and chemicals produced and utilized by normally healthy kidneys. Any acceleration in the disease process should prompt a search for superimposed acute or subacute disease process that is potentially reversible. These include extravascular fluid volume depletion, urinary tract infection, obstructive uropathy, exposure to nephrotoxic agents such as NSAIDS or radiocontrasts, re-activation and flare of the primary disease like SLE or vasculitis.
Medical therapy
Blood pressure management
- The goal of therapy is to slow down or halt the otherwise relentless progression of CRF.
- In addition to reducing the cardiovascular disease risk, use of antihypertensive therapy in patients with CRF also aims at slowing the progression of nephron injury by reducing intra-glomerular hypertension.
- Elevated blood pressure increases albuminuria by increasing its flux through the renal capillaries.
- Generally, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are used, as they have been found to slow the progression of CRF by reducing intra-glomerular pressure.[1][2] Thus, the more effective a drug is in reducing protein filtration into renal tubules, the greater is the impact on improving GFR.
- Angiotensin converting enzyme inhibitors act by inhibiting angiotensin mediated vasoconstriction of efferent arterioles, thereby reducing filtration pressures and proteinuria.
- Combination of ACE inhibitors and ARB's is associated with greater reduction in proteinuria than either drug used alone.
- Side effects include cough and angioedema with ACE inhibitors, whereas anaphylaxis and hyperkalemia is common to use of both ACE inhibitors and ARB's. Progressive increase in serum creatinine levels suggests concomitant renovascular disorders.
- Development of the above mentioned side effects may warrant use of other antihypertensive agents like calcium channel blockers like diltiazem and verapamil.
- If proteinuria is strongly associated with the disease progression, like in diabetic nephropathy or glomerular disease, ACE inhibitors should be the first line drugs, whereas in diseases like polycystic kidney and tubulointerstitial diseases in which there is minimal or absent proteinuria, other antihypertensive agents may be used.
Control of blood glucose
- Tight glycemic control reduces the risk of progression of diabetic nephropathy. Ideally, the blood glucose levels should be between 90-130 mg/dL(5.0-7.2 mmol/L) and hemoglobin A1c below 7%.
- If the GFR progressively decreases inspite of tight glycemic control, the use and dose of oral hypoglycemics have to be reevaluated.
- In presence of renal compromise, chlorpropamide has an exaggerated hypoglycemic effect, metfromin can cause lactic acidosis and thiazolidinediones may aggravate volume overload states.
- Renal degradation of administered insulin decreases with reduction in GFR and hence the need to reduce the dose for appropriate glucose control.
Protein restriction
- Protein restricted diets have been believed to not only temporarily reduce symptoms associated with uremia, but also slow the rate of decline in renal function at an earlier stage by reducing protein mediated hyperfiltration. [3]
- A low protein intake can be recommended for patients who enter a state of malnutrition from decreased intake.
- Therefore, monitoring nutritional status must accompany dietary intervention.
Drug dose adjustments
- Drugs that undergo hepatic elimination do not need drug adjustments.
- Moreover, only the maintenance dose of the drug need to be adjusted as the loading dose does not depend on its renal clearance.
- Nonetheless, some drugs should be avoided like NSAID's, oral hypoglycemics, radiocontrast agents and gadolinium.
Replacement therapy
Indications for dialysis in CRF
- Uremic pericarditis
- Uremic encephalopathy
- Intractable muscle cramps
- Anorexia and nausea not attributable to reversible causes such as peptic ulcer disease
- Protein energy malnutrition
- Hyperkalemia
- Extracellular fluid volume overload
Recent studies have shown no benefits of initiating early dialysis with improved patient survival. [4]However, advanced preparation for dialysis can help avoid complications like poorly functioning fistula for hemodialysis or malfunctioning peritoneal dialysis catheter, sepsis, bleeding and thrombosis.
Kidney Transplant
- Offers the best potential for complete rehabilitation
Patient education
Multidisciplinary approach
- Explain likelihood and timing of initiation of renal replacement therapy and other options available
- Discuss home based dialysis therapy
- Less expensive
- Improved quality of life
- Counsel family members about home dialysis helper
- Explore options to look for potential biologically related kidney donor
References
- ↑ Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet. 1998 Oct 17;352(9136):1252-6. PMID 9788454.
- ↑ Ruggenenti P, Perna A, Gherardi G, Garini G, Zoccali C, Salvadori M, Scolari F, Schena FP, Remuzzi G. Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuria. Lancet. 1999 Jul 31;354(9176):359-64. PMID 10437863.
- ↑ Aparicio M, Bellizzi V, Chauveau P; et al. (2012). "Protein-restricted diets plus keto/amino acids--a valid therapeutic approach for chronic kidney disease patients". Journal of Renal Nutrition : the Official Journal of the Council on Renal Nutrition of the National Kidney Foundation. 22 (2 Suppl): S1–21. doi:10.1053/j.jrn.2011.09.005. PMID 22365371. Unknown parameter
|month=ignored (help) - ↑ Cooper BA, Branley P, Bulfone L; et al. (2010). "A randomized, controlled trial of early versus late initiation of dialysis". The New England Journal of Medicine. 363 (7): 609–19. doi:10.1056/NEJMoa1000552. PMID 20581422. Unknown parameter
|month=ignored (help)