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*Protective therapy most effective if initiated '''early''', before [[Creatinine]] > 1.5-2.0 mg/dL  
*Protective therapy most effective if initiated '''early''', before [[Creatinine]] > 1.5-2.0 mg/dL  
**Treat [[Hypertension]]
**Treat [[Hypertension]]
*** Systemic [[hypertension]]--elevated intraglomerular pressure +/or glom hypertrophy
*** Systemic [[hypertension]]--elevated intraglomerular pressure +/or glom hypertrophy.
*** [[Blood Pressure]] (BP) control shown in multiple trials to slow progression of renal disease
*** [[Blood Pressure]] (BP) control shown in multiple trials to slow progression of renal disease.
*** Goal [[Blood pressure]] < 130/80-85; < 125/75 in patients with [[proteinuria]] > 1-2 g/d
*** Goal [[Blood pressure]] < 130/80-85; < 125/75 in patients with [[proteinuria]] > 1-2 g/d.
*** [[ACE inhibitors]] (ACEI) and [[Angiotensin II receptor antagonist|Angiotensin II receptor blockers]] (ARB) preferred 1st line agents due to reno-protective effects
*** [[ACE inhibitors]] (ACEI) and [[Angiotensin II receptor antagonist|Angiotensin II receptor blockers]] (ARB) preferred 1st line agents due to reno-protective effects.<ref name="pmid3651580">{{cite journal |vauthors=Lerche D, Kozlov MM, Markin VS |title=Electrostatic free energy and spontaneous curvature of spherical charged layered membrane |journal=Biorheology |volume=24 |issue=1 |pages=23–34 |date=1987 |pmid=3651580 |doi= |url=}}</ref>
*** Additional agents as needed, including [[diuretics]] if volume overload
*** Additional agents as needed, including [[diuretics]] if volume overload.
** Restrict Dietary Protein
** Restrict Dietary Protein
*** Controversial – may decrease intraglomerular pressure
*** Controversial – may decrease intraglomerular pressure.
*** Conflicting studies – some show benefit, others do not
*** Conflicting studies – some show benefit, others do not.
*** No significant adverse effects shown in large trial
*** No significant adverse effects shown in large trial.
*** Recommendations  
*** Recommendations  
**** No restriction (> 0.8 g/kg/d) if [[GFR]] 25-55 mL/min
**** No restriction (> 0.8 g/kg/d) if [[GFR]] 25-55 mL/min.
**** Limit protein to 0.8 g/kg/d if progression or [[Uremia|uremic]] symptoms
**** Limit protein to 0.8 g/kg/d if progression or [[Uremia|uremic]] symptoms.
**** Limit to 0.6 g/kg/d if severe [[renal insufficiency]] ([[GFR]] 13-25 mL/min)
**** Limit to 0.6 g/kg/d if severe [[renal insufficiency]] ([[GFR]] 13-25 mL/min).
*** Close follow-up by dietician given risk of [[malnutrition]] in this population
*** Close follow-up by dietician given risk of [[malnutrition]] in this population.
** Control [[Blood sugar]]:
** Control [[Blood sugar]]:
*** Tight control ([[HbA1c]] < 7.0, [[Fasting blood sugar 70-120) reduces progression in [[Diabetes Mellitus Type 1|DM I]]
*** Tight control ([[HbA1c]] < 7.0, [[Fasting blood sugar 70-120) reduces progression in [[Diabetes Mellitus Type 1|DM I]].
*** Unclear if as beneficial in [[Diabetes Mellitus Type 2|DM II]], but potentially helpful
*** Unclear if as beneficial in [[Diabetes Mellitus Type 2|DM II]], but potentially helpful.


===Treat complications===
===Treat complications===
* Volume Overload
* Volume Overload
** Impaired excretion of sodium and water due to decreased [[GFR]] +/- [[Aldosterone|AII/aldo]] activation
** Impaired excretion of sodium and water due to decreased [[GFR]] +/- [[Aldosterone|AII/aldo]] activation.
** Restrict dietary sodium to 1-2 g/d if [[hypertension]] or [[edema]]
** Restrict dietary sodium to 1-2 g/d if [[hypertension]] or [[edema]].
** [[Diuretic]]s
** [[Diuretic]]s
*** [[Thiazide]]s ineffective if [[GFR]] < 25 mL/min (~[[Creatinine]] > 2-3)
*** [[Thiazide]]s ineffective if [[GFR]] < 25 mL/min (~[[Creatinine]] > 2-3).
*** Switch to [[Loop diuretic]] as [[Creatinine]] rises; may need bid dosing
*** Switch to [[Loop diuretic]] as [[Creatinine]] rises; may need bid dosing.
*** Addition of [[thiazide]] to [[Loop diuretic]] can--additional [[Diuresis]]
*** Addition of [[thiazide]] to [[Loop diuretic]] can--additional [[Diuresis]].
*** Watch for excessive volume depletion
*** Watch for excessive volume depletion
* [[Hyperkalemia]]
* [[Hyperkalemia]]
** Potassium usually maintained until [[GFR]] < 15-20 mL/min
** Potassium usually maintained until [[GFR]] < 15-20 mL/min.
**Increased risk of [[hyperkalemia]] with [[Oliguria]], high [[K|potassium]] diet, ([[ACEI|ACE inhibitors]] therapy)
**Increased risk of [[hyperkalemia]] with [[Oliguria]], high [[K|potassium]] diet, ([[ACEI|ACE inhibitors]] therapy).
** Increased risk with many meds:  [[ACEI]], [[NSAID]]s, [[Potassium-sparing diuretic]]s, [[digoxin]], [[TMP]]
** Increased risk with many meds:  [[ACEI]], [[NSAID]]s, [[Potassium-sparing diuretic]]s, [[digoxin]], [[TMP]].
** Increased risk in diabetics with [[Renal tubular acidosis|type IV RTA]]
** Increased risk in diabetics with [[Renal tubular acidosis|type IV RTA]]
* Management
* Management
** Low potassium diet (< 60 mEq/d) once GFR < 15 mL/min
** Low potassium diet (< 60 mEq/d) once GFR < 15 mL/min.
** Avoidance of salt substitutes (may contain potassium salts)
** Avoidance of salt substitutes (may contain potassium salts).
** +/- [[loop diuretic]]
** +/- [[loop diuretic]]
** Low dose [[Kayexelate]] (5 g with meals) if needed  
** Low dose [[Kayexelate]] (5 g with meals) if needed.
* Calcium/phosphate Abnormalities
* Calcium/phosphate Abnormalities
** Reduced renal synthesis [[Calcitriol]]/[[Vitamin D]]--low serum Calcium-- [[Secondary hyperparathyroidism]]
** Reduced renal synthesis [[Calcitriol]]/[[Vitamin D]]--low serum Calcium-- [[Secondary hyperparathyroidism]].
** (Occurs when [[GFR]] < 40 mL/min)
** (Occurs when [[GFR]] < 40 mL/min)
** Reduced [[GFR]]--phosphate retention  
** Reduced [[GFR]]--phosphate retention  
** Elevated [[parathyroid hormone]] ([[PTH]])--mobilization of Calcium from bone; increased excretion phosphate
** Elevated [[parathyroid hormone]] ([[PTH]])--mobilization of Calcium from bone; increased excretion phosphate.
** Allows maintenance of normal Calcium/phosphate while [[GFR]] > 30 mL/min
** Allows maintenance of normal Calcium/phosphate while [[GFR]] > 30 mL/min.
** Causes [[renal osteodystrophy]]
** Causes [[renal osteodystrophy]]
** Once [[GFR]] < 25-30 mL/min, [[hyperphosphatemia]] occurs
** Once [[GFR]] < 25-30 mL/min, [[hyperphosphatemia]] occurs
** Therapy goals = normalize Calcium/Phosphate and maintain [[parathyroid hormone]] (PTH)< 200 (2-3x uln)
** Therapy goals = normalize Calcium/Phosphate and maintain [[parathyroid hormone]] (PTH)< 200 (2-3x uln).
*** Calcium/Phosphate management should be initiated when [[Creatinine]] ~ 2  
*** Calcium/Phosphate management should be initiated when [[Creatinine]] ~ 2.
*** Calcium x phosphate product should be < 60 to prevent met calcification
*** Calcium x phosphate product should be < 60 to prevent met calcification.
*** Low phosphate diet:  < 800 mg/d (challenging)
*** Low phosphate diet:  < 800 mg/d (challenging)
*** Calcium-based oral phosphate binders:  Calcium acetate or Calcium carbonate with meals
*** Calcium-based oral phosphate binders:  Calcium acetate or Calcium carbonate with meals.
*** Avoid Aluminium-based phosphate binders except for acute therapy of high Calcium x Phosphate products
*** Avoid Aluminium-based phosphate binders except for acute therapy of high Calcium x Phosphate products.
**** (Aluminium toxicity = [[osteomalacia]], [[anemia]], [[encephalopathy]])
**** (Aluminium toxicity = [[osteomalacia]], [[anemia]], [[encephalopathy]])
*** Avoid Calcium citrate (increases gastrointestinal absorption of aluminum)
*** Avoid Calcium citrate (increases gastrointestinal absorption of aluminum)
**** RenaGel = new non-Calcium/Aluminium-containing phosphate binder (cationic polymer)  
**** RenaGel = new non-Calcium/Aluminium-containing phosphate binder (cationic polymer).
***** (For patients who cannot tolerate Calcium carbonate or need additional agent)
***** (For patients who cannot tolerate Calcium carbonate or need additional agent)
**** [[Calcitriol]] 0.125-0.25 mg/d improves Calcium & [[Parathyroid hormone]] levels, decreases bone disease
**** [[Calcitriol]] 0.125-0.25 mg/d improves Calcium & [[Parathyroid hormone]] levels, decreases bone disease.
***** (Monitor Calcium--reduce dose if [[Hypercalcemia|hypercalcemic]])
***** (Monitor Calcium--reduce dose if [[Hypercalcemia|hypercalcemic]])
*[[Metabolic Acidosis]]
*[[Metabolic Acidosis]]
**Occurs when [[GFR]] < 25 mL/min due to inability to excrete H+ ions
**Occurs when [[GFR]] < 25 mL/min due to inability to excrete H+ ions.
**Underlying cause = impaired renal ammonia production and bicarbonate reabsorption
**Underlying cause = impaired renal ammonia production and bicarbonate reabsorption.
**Risk = bone buffering of [[acidosis]]--worsened [[Osteodystrophy]] via Calcium/phosphate loss
**Risk = bone buffering of [[acidosis]]--worsened [[Osteodystrophy]] via Calcium/phosphate loss.
**Increased skeletal muscle breakdown--loss of lean body mass
**Increased skeletal muscle breakdown--loss of lean body mass.
**Therapy goal = bicarbonate > 22 mEq/L via alkali therapy (NaHCO3 0.5-1 mEq/kg/d)
**Therapy goal = bicarbonate > 22 mEq/L via alkali therapy (NaHCO3 0.5-1 mEq/kg/d)
*[[Anemia]]
*[[Anemia]]
**[[Normocytic normochromic anemia]] due to reduced [[Erythropoietin]] production
**[[Normocytic normochromic anemia]] due to reduced [[Erythropoietin]] production.
**May be exacerbated by reduced [[RBC]] survival, coexistent iron/folate deficiency, etc.
**May be exacerbated by reduced [[RBC]] survival, coexistent iron/folate deficiency, etc.
**Generally occurs when [[Creatinine]] > 2-3 mg/dL
**Generally occurs when [[Creatinine]] > 2-3 mg/dL.
**If untreated, [[hematocrit]] (Hct) usually stabilizes at ~ 25
**If untreated, [[hematocrit]] (Hct) usually stabilizes at ~ 25.
**Therapy recommendations = [[Erythropoietin]] if symptomatic [[anemia]] or [[Hemoglobin]] < 10 g/dL (in pre-dialysis patients)
**Therapy recommendations = [[Erythropoietin]] if symptomatic [[anemia]] or [[Hemoglobin]] < 10 g/dL (in pre-dialysis patients).
**Goal [[Hematocrit]] 33-36
**Goal [[Hematocrit]] 33-36
**Must replete iron stores first (oral ferrous sulfate)
**Must replete iron stores first (oral ferrous sulfate)
**Initial dose ~ 150 U/kg sc weekly to increase [[Hematocrit]]
**Initial dose ~ 150 U/kg sc weekly to increase [[Hematocrit]].
**Maintenance dose ~ 75 U/kg weekly once [[Hematocrit]] goal reached
**Maintenance dose ~ 75 U/kg weekly once [[Hematocrit]] goal reached.
**Improves symtoms and may reduce left ventricle (LV) mass (via improvemt of hyperdynamic state)
**Improves symtoms and may reduce left ventricle (LV) mass (via improvemt of hyperdynamic state).
**Side effects = increased [[blood pressure]] (BP); may need to augment [[Antihypertensive]] regimen
**Side effects = increased [[blood pressure]] (BP); may need to augment [[Antihypertensive]] regimen.
===Plan for Renal Replacement Therapy (RRT)===
===Plan for Renal Replacement Therapy (RRT)===
*Indications for [[Dialysis]]
*Indications for [[Dialysis]]
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**[[Peritoneal dialysis]]
**[[Peritoneal dialysis]]
**[[Renal transplant]]
**[[Renal transplant]]
*Access for [[hemodialysis]] should be established when [[GFR]] < 25 mL/min (estimated [[Chronic renal failure]] within 1 year)
*Access for [[hemodialysis]] should be established when [[GFR]] < 25 mL/min (estimated [[Chronic renal failure]] within 1 year).
*Diabetics tend to require [[dialysis]] sooner than non-diabetics because more symptomatic at given [[GFR]]
*Diabetics tend to require [[dialysis]] sooner than non-diabetics because more symptomatic at given [[GFR]].
*Indications for referral to nephrologist
*Indications for referral to nephrologist
**Unclear etiology of new or chronic [[renal insufficiency]]  
**Unclear etiology of new or chronic [[renal insufficiency]]  

Revision as of 19:07, 6 August 2018

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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]

Secondary Prevention

Reduce Progression

  • Protective therapy most effective if initiated early, before Creatinine > 1.5-2.0 mg/dL
    • Treat Hypertension
    • Restrict Dietary Protein
      • Controversial – may decrease intraglomerular pressure.
      • Conflicting studies – some show benefit, others do not.
      • No significant adverse effects shown in large trial.
      • Recommendations
        • No restriction (> 0.8 g/kg/d) if GFR 25-55 mL/min.
        • Limit protein to 0.8 g/kg/d if progression or uremic symptoms.
        • Limit to 0.6 g/kg/d if severe renal insufficiency (GFR 13-25 mL/min).
      • Close follow-up by dietician given risk of malnutrition in this population.
    • Control Blood sugar:
      • Tight control (HbA1c < 7.0, [[Fasting blood sugar 70-120) reduces progression in DM I.
      • Unclear if as beneficial in DM II, but potentially helpful.

Treat complications

  • Volume Overload
  • Hyperkalemia
  • Management
    • Low potassium diet (< 60 mEq/d) once GFR < 15 mL/min.
    • Avoidance of salt substitutes (may contain potassium salts).
    • +/- loop diuretic
    • Low dose Kayexelate (5 g with meals) if needed.
  • Calcium/phosphate Abnormalities
    • Reduced renal synthesis Calcitriol/Vitamin D--low serum Calcium-- Secondary hyperparathyroidism.
    • (Occurs when GFR < 40 mL/min)
    • Reduced GFR--phosphate retention
    • Elevated parathyroid hormone (PTH)--mobilization of Calcium from bone; increased excretion phosphate.
    • Allows maintenance of normal Calcium/phosphate while GFR > 30 mL/min.
    • Causes renal osteodystrophy
    • Once GFR < 25-30 mL/min, hyperphosphatemia occurs
    • Therapy goals = normalize Calcium/Phosphate and maintain parathyroid hormone (PTH)< 200 (2-3x uln).
      • Calcium/Phosphate management should be initiated when Creatinine ~ 2.
      • Calcium x phosphate product should be < 60 to prevent met calcification.
      • Low phosphate diet: < 800 mg/d (challenging)
      • Calcium-based oral phosphate binders: Calcium acetate or Calcium carbonate with meals.
      • Avoid Aluminium-based phosphate binders except for acute therapy of high Calcium x Phosphate products.
      • Avoid Calcium citrate (increases gastrointestinal absorption of aluminum)
        • RenaGel = new non-Calcium/Aluminium-containing phosphate binder (cationic polymer).
          • (For patients who cannot tolerate Calcium carbonate or need additional agent)
        • Calcitriol 0.125-0.25 mg/d improves Calcium & Parathyroid hormone levels, decreases bone disease.
  • Metabolic Acidosis
    • Occurs when GFR < 25 mL/min due to inability to excrete H+ ions.
    • Underlying cause = impaired renal ammonia production and bicarbonate reabsorption.
    • Risk = bone buffering of acidosis--worsened Osteodystrophy via Calcium/phosphate loss.
    • Increased skeletal muscle breakdown--loss of lean body mass.
    • Therapy goal = bicarbonate > 22 mEq/L via alkali therapy (NaHCO3 0.5-1 mEq/kg/d)
  • Anemia

Plan for Renal Replacement Therapy (RRT)

Recent studies have shown no benefits of initiating early dialysis with improved patient survival. [2]However, advanced preparation for dialysis can help avoid complications like poorly functioning fistula for hemodialysis or malfunctioning peritoneal dialysis catheter, sepsis, bleeding and thrombosis.


References

  1. ↑ Lerche D, Kozlov MM, Markin VS (1987). "Electrostatic free energy and spontaneous curvature of spherical charged layered membrane". Biorheology. 24 (1): 23–34. PMID 3651580.
  2. ↑ 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)


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