CKD-PRE DIALYSIS MANAGEMENT

Shruthi K

Chronic kidney disease

Global health problem Rising incidence – doubled in last 15 years In India – 0nly 10% of patients with ESRD have

access to RRT

CKD-definition

GFR ≤ 60ml/min/1.73m that is present for ≥ 3months with or without evidence of kidney damage

OR Evidence of kidney damage with or without decreased

GFR that is present for ≥ 3months as evidenced by Microalbuminuria Proteinuria Glomerular haematuria Pathological abnormalities (e.g. abnormal biopsy) Anatomical abnormalities (e.g. scarring seen on imaging or

polycystic kidneys)

Pre dialysis management – Why?

Optimal pre-dialysis care improve

Morbidity Mortality Dialysis and transplantation outcome

CKD Predicts CVD

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Estimated GFR (mL/min/1.73 m2)

Early Treatment Makes a Difference

Brenner, et al., 2001

Goal

To establish diagnosis Rule out reversible causes Slow down progression Evaluate and treat complications Treat co-morbidities Reduce cardiovascular risk Prepare for replacement therapy Select & start renal replacement therapy at

appropriate time

Management

Treatment of reversible causes Preventing or slowing the progression of disease Treatment of the complications Identification and adequate preparation of the

patient in whom renal replacement therapy will be required

Treatment of reversible causes

Decreased renal perfusion Hypovolemia (such as vomiting, diarrhea, diuretic use,

bleeding) Hypotension (due to myocardial dysfunction or

pericardial disease) Infection /sepsis Drugs which lower the GFR

Urinary tract obstruction

Slowing the rate of progression

Proteinuria < 1 gm/day or at least 60% of baseline values Optimal level of protein intake

Not been determined 0.8 to 1.0 g/kg/day

ACEI/ARB Smoking cessation

Blood pressure <130/80mmHg <125/75mmHg if proteinuria >1g/day Salt restriction Antihypertensives

ACE,diuretics,CCB

Exercise

Treatment of complications

Volume overload 

Salt restriction

Loop diuretics

Hyperkalemia Develops in the patient who is oliguric or who has an

additional problem such as a high potassium diet, increased tissue breakdown, or hypoaldosteronism

Low K+ diet – 40 to 70meq / day

Avoid NSAIDs

Metabolic acidosis  Due to

Decreased ability to regenerate bicarbonate Reduced ammonia production Decreased hydrogen ion secretion Decreased filtration of titrable acids – sulphate,

phosphate, urate, hippurates Decreased proximal tubular re-absorption of

bicarbonate

Treatment of academia is desirable Bicarbonate supplementation may slow the progression

of CKD Bone buffering of the some of the excess hydrogen ion

is associated with the release of calcium and phosphate from bone, contributing to worsening of renal osteodystrophy

Uremia acidosis can increase skeletal muscle breakdown and diminish albumin synthesis leading to loss of lean body mass and muscles weakness- contributing to malnutrition

Therapy is targeted to maintain serum bicarbonate concentration above 23 mEq/Lit

Drug of choice : sodium bicarbonate < 0.5-1.0 mEq/kg/day

Hyperphosphatemia Diet restriction : 800mg/day GFR<25 to 30 ml/min: oral phosphate binders Stage 3 & 4 : between 2.7 and 4.6 mg/dL Stage 5 : between 3.5 and 5.5 mg/dL

Renal osteodystrophy High phosphate load and hypocalcemia stimulate

PTH secretion Leads to sec hyper parathyroidism which increases

bone resorption

Treatment

Control serum phosphate CKD stage-specific target levels of intact PTH

CKD stage 3: treat elevated PTH to target 35-70pg/ml

CKD stage 4 to target 70-110 pg/ml CKD stage 5 to target 150-300 pg/ml

Next step is assessment of 25-(OH)D levels and replacement with vitamin D (ergocalciferol) if levels are lower than 30 ng/mL.

If the intact PTH level is elevated and the serum 25-(OH)D level is higher than 30 ng/mL, treatment with an active form of vitamin D is indicated

Available options Calcitriol Alfacalcidol Doxecalciferol

Cinacalcet Calcimimetic Used if elevated phosphorus/Ca limit use of vit D

Hypertension 

Cause and complication of CKD Target <130/80 or <125 /75 mmHg if proteinuria is >1

gm /day or diabetes is + Non pharmacological

Lifestyle modification Salt restriction Exercise,weight reduction Diet Smoking cessation etc….

Pharmacological May require 3 or more drugs Diabetes & proteinuria : treat with ACEI /ARB as 1st line

therapy Monitor Creatinine & K+ on day 3 ,7 &weekly Loop and thiazide diuretics as an adjunct therapy CVD: beta blockers CCBs Alpha blockers : prazosin,doxazosin followed by direct

vascular smooth muscle relaxant minoxidil is considered

Anemia

Caused by insufficient erythropoietin production ,short life span of RBCs , iron deficiency

Target Hb: 10 to 12gm% Correct iron deficiency EPO : 80 to 120units/kg/wk Alternative : darbepoietin alfa Longer acting agent Dose: 0.45µg/kg s/c once a week

Preparation for RRT

Counselling HD,peritoneal dialysis / renal transplant If not for transplant : vascular access should be

created in preferably native AV fistula in CKD stage 4

Venous preservation should start from stage 2 or 3 Vaccinate against hep B, pneumococcal and H

influenza infection Drug dosage according to eGFR, avoid contrast