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CHRONIC RENAL FAILURE The Clinical Approach Dr. Manoj Chaudhary Consultant Nephrologist Kidney Hospital, Jalandhar

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  • CHRONIC RENAL FAILURE The Clinical Approach Dr. Manoj Chaudhary Consultant Nephrologist Kidney Hospital, Jalandhar
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  • Why to know about CRF/CKD India Worlds sharpest due to Type II DM, Hypertension (CAUSE-VASCULAR DYSFUNCTION) Death from communicable disease - 20 million-starting to decline, CVS disease to 26 million in 2020, DM-150 million in 2000 will to 370 million in 2030 (75% in developing world) Estimation of CRF/CKD - 1 lakh/yr Minority seen by Nephrologists
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  • CRD - Pathophysiologic process with multiple etiologies, resulting in inexorable attrition of nephron number and function frequently leading to End stage renal disease. ESRD - Clinical state or condition that has irreversible loss of endogenous renal function of sufficient degree to render the patient dependent on Dialysis or Transplantation in order to avoid Uraemia. Uraemia - Clinical and laboratory syndrome, reflecting all organ system dysfunction as result of untreated or treated Acute or CRF.
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  • STAGES OF CHRONIC RENAL DISEASE STAGEGFR,ML/MIN/1.73M 2 1KIDNEY DAMAGE WITH NORMAL OR INCREASED GFR 90 2KIDNEY DAMAGE WITH MILDLY DECREASED GFR 60-89 3MODERATELY DECREASED GFR30-59 4SEVERLY DECREASED GFR15-29 5RENAL FAILURE
  • IRON STUDIES S.Fe, TIBC, S.Ferritin If TSAT800mg/ml (>800g/L)
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  • ERYTHROPOIETIN Starting dose 50-150 units/kg/wk IV or S.C (once, twice or thrice/ wk) TARGET Hb-11-12gm/dl Optimal rate of correction-1-2gm/dl over 4 wks.
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  • EPO BENEFITS Increased Exercise tolerance Normalization of elevated Cardiac Output Increased BP in 30% of patients Decreased Symptom of Angina Decreased LVH Decreased Cardiac size on chest X-Ray PA Improved quality of life Decreased Uraemic bleeding Improved platelet function Enhanced immune function Decreased Uraemic pruritis
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  • ADVERSE EFFECT OF EPO Hypertension Seizures/ Encephalopathy Clotting of dialysis lines Hyperkalemia Myalgia/ Influenza like syndrome
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  • DARBOPOIETIN ALPHA Analogue of EPO -Greater biological activity -Prolonged half life Starting dose -0.45mg/kg iv or s.c. weekly or single dose 0.75mg/kg single iv or s.c. every 2 wks. Optimal rate of correction -Hb by 1-2 gm/dl over 4 wk period
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  • ORAL IRON POOR ABSORPTION INTOLERANCE DIALYSIS Adequate dialysis.(CAPD better HD for 3 yrs., then same.)
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  • BLOOD TRANSFUSION Suppresses residual EPO production Iron overload deleterious effect on heart, liver, pancreas Infection HepB, HepC, HIV, CMV Exposure to wide range of HLA Cytotoxic Ab Risk of +ve crossmatch and Ac. rejection
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  • ANDROGEN THERAPY Effective in mild cases only S/E-Virilization, Muscle & Liver damage, Cholestasis
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  • BONE DISEASE AND DISORDERS OF CALCIUM AND PHOSPHATE METABOLISM High turnover bone disease Low turnover bone disease Osteomalacia Adynamic bone disease LABS: Ca 2+, Phosporous, Alk. Phosphatase, S.PTH
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  • PRACTICAL RECOMMENDATION Early CRF CaCO 3 2gms/day Dietary Phosphate
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  • FAR advanced stages Daily phosphate - 600-750 mg/day CaCo3 - 3gm /day Watch for Metabolic acidosis - NaHCO 3 Plasma calcidiol Add Calcitriol 0.25 pg daily If hypercalcemia - restrict or half the dose calcidiol hyperphosphatemia - target PTH around 2-3 times the upper limit
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  • Sevalamer Non reabsorbable, Non calcium containing polymer, No Hypercalcemia Attenuates calcium deposition in coronary arteries and aorta. Adynamic bone disease Overzealous suppression of secondary Hyperparathyroidism (keep PTH
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  • CARDIOVASCULAR ABNORMALITIES Leading cause of mortality and morbidity IHD Classical risk factors Hypervolumia Dyslipidemia Sympathetic overactivity S Hyperhomocysteinemia Tt - HMG COA if + Gem fibozil Risk of Myositis
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  • CRD RELATED Anaemia Hyperphosphatemia Hyperparathyroidism Microinflammation-IL6, CRP NO
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  • CHF Abnormal cardiac function secondary to IHD or LVH, Salt and Water retention Unique feature - Even in absence of volume overload there is normal or increased Intracardiac or PCWP Butterfly wing distribution due to increased permeability of capillary alveolar membrane leading to low pressure pulmonary edema. - Treatment by vigorous dialysis
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  • HYPERTENSION Most common complication Develop early in course associated with adverse outcome LVH & Cardiovascular morbidity Anaemia & LVF If Hypertension absent Salt wasting renal disease, Medullary cystic disease, Chronic T1 disease, Volume depletion or Reduced cardiac index.
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  • Treatment: Slow progression of disease Prevent complication - CVS disease and stroke Target BP 130/ 80 85 (Protenuria < 1gm/ 24hrs) If protenuria > 1gm/ 24hrs Target BP 125/ 75 Volume Control -Salt restriction -Diuretics Ace inhibitor can be used Avoid direct Vasodilators Minoxidil Hydralaizne
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  • If increased Cardiac hypertrophy - Use only in Refractory hypertension - Target BP-->130/80-85 (Protenuria1gm/24hrs-Target BP 125/75 Volume control--> Salt restriction --> Diuretics ACE or ARB ? Or both ? Avoid direct vasodilators Minoxidil Hydralazine Leads to Cardiac hypertrophy Use only in refractory hypertension
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  • NUTRITION PEM- Common problem Indian scenario-malnutrition widely prevalent CAUSES: Anorexia Altered taste sensation Intercurrent stress Unpalatable prescribed diets Catabolic response to superimposed illness Endocrine disorders of uraemia (resistance to IgF, hyperglucagonemia, hyperparathyroidism)
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  • Energy - 35 k cal/kg/day On vegetarian diet -Av. Protein intake 0.64 + 0.15 gms/kg/day Diabetic pt.- 30-35 kcal/kg of IBW/day, 60% carbohydrates, 30% - fats 15% from mono unsaturated fats. For MHD- Calories - same Protein -1.2 gm/kg. (50% HBV)
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  • INDICATIONS OF RENAL REPLACEMENT THERAPY Anorexia & nausea Fluid & Electrolytes abnormalities that are refractory to conservative means Volume overload refractory to diuretics Hyperkalemia unresponsive to protein restricted Progressive metabolic acidosis that cannot be managed by alkali Pericarditis Progressive neuropathy attributable to ureamia Encephalopathy Muscle irritability
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  • CLINICAL CLUES INDICATING DEVELOPMENT OF URAEMIC COMPLICATIONS Morning nausea Vomiting Intractable pruritis H/O Hiccuping Muscle twitching & cramps Presence of asterixis Pts whose follow up and compliance with conservative management is difficult- considered for earlier management Considerable interindividual variability in severity of uraemic symptoms and renal function It is ill advised to assign a certain usual level of BUN, S.creatinine, GFR to need to start Dialysis
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  • Recent controlled studies failed to show a survival advantage for early initiation of RRT prior to onset of clinical indications.
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  • Modality of RRT Haemodialysis Chronic Ambulatory Peritoneal Dialysis Renal Transplantation
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  • HD- most common modality of ESRD (USA- 80%) PD -Younger pt-because of better manual dexterity and greater visual acuity Difficult vascular access Larger pt-Truncal obesity (>80kg) suited for HD
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