Transcript LOGICAL DRUG THERAPY IN CHRONIC KIDNEY DISEASE Dr S

LOGICAL DRUG THERAPY IN
CHRONIC KIDNEY DISEASE
Dr S.Raeisi
Nephrologist, MD
GENERAL MANAGEMENT OF CHRONIC
KIDNEY DISEASE
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Treatment of reversible causes of renal
dysfunction
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Preventing or slowing the progression of renal
disease
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Treatment of the complications of renal
dysfunction
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Identification and adequate preparation of the
patient in whom renal replacement therapy
will be required
Can be
treated
preventing
SECONDARY
FACTORS
Minimizing
further
renal injury
GENERAL MANAGEMENT OF CHRONIC
KIDNEY DISEASE
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Strict glycemic control in diabetics with CKD
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Strict control lf hypertension
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Correction of anemia
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Control of serum phosphorus, vitamin D, and parathyroid hormone
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Lipid-lowering therapy
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Hyperkalemia, Metabolic acidosis, Uremic bleeding
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Volume overload
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Beta-blockers and aspirin: Cardioprotective effects
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Supplements
K/DOQI classification for the 5 stages of
CKD
DRUG DOSE ADJUSTMENTS IN CRF
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Estimate GFR
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MDRD formula: GFR (mL/min/1.73 m2)=
186.3 × (PCr)−1.154 × (age)−0.203 × 0.742 (if female)
× 1.21 (if black),
where PCr = plasma creatinine concentration in mg/dL
(to convert from μmol/L to mg/dL, divide by 88.4).
case
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A 68 yr old man with DM and Scr=2 mg/dl
and BW=60 kg came for check up what is her
eGFR?
= (140-68) × 60 / 72 × 2
= 72 × 60 / 72 × 2
= 60 / 2 = 30 ml/min
Lipid-lowering therapy
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Elevated levels of low-density lipoprotein cholesterol (LDL-C) and other
lipid marker molecules are a traditional risk factor for cardiovascular
disease
Also, data in animals suggest that high lipid levels and cholesterol
loading may augment glomerular injury. Thus, treatment of CKD
patients with statins to reduce lipids may both prevent progression and
lower cardiovascular risk.
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LDL-C goal of <100 mg/dL is recommended.
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Drug therapy is recommended when LDL-C levels are >130 mg/dL
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and is optional when LDL-C levels are between 100 and 130 mg/dL
Dose adjustment for renal
insufficiency
Statins as a class have been associated with rhabdomyolysis,
and dose reduction in severe renal impairment is
recommended for some statins (e.g., rosuvastatin) or when
statins are used in combination with fibrates
Volume overload
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Thiazide diuretics are the diuretic of choice
for mild CKD, when SCr is <1.8 mg/dL
. When SCr is >1.8 mg/dL, a loop diuretic
(twice-a-day dosing regimen) is
recommended, due to presumed reduced
efficacy of thiazides.
Hyperkalemia
• In selected patients, low dose Kayexalate
(5 grams with each meal) can be used to
lower the serum potassium concentration
without the side effects associated with
larger doses.
• 20-40g QID for sever hyperkalemia.
Acidosis
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Given that chronic metabolic acidosis
results in increased resorption of bone, the
use of sodium bicarbonate is
recommended to maintain the serum
bicarbonate level at 22 mmol/L.
The usual amount of sodium bicarbonate
to give is 0.5 - 1.0 mmol/L/kg per day
Uremic bleeding
•
An increased tendency to bleeding is
present in both acute and chronic kidney
disease.
•
The administration of:
1. Desmopressin (dDAVP),
2. Cryoprecipitate,
3. Estrogen,
Beta-blockers and aspirin:
Cardioprotective effects
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The cardioprotective effects of beta-blockers are not diminished
in CKD patients. Aspirin and beta-blocker cardioprotection after
myocardial infarction is similar in CKD patients and in patients
with normal renal function.
Because most CKD patients, especially in stage 3 and higher,
tend to have cardiac disease, a case can be made for routinely
treating such patients with both aspirin and beta-blockers,
although this is not widely practiced at all centers. Aspirin has
been associated with GI bleeding in end-stage renal disease
(ESRD) patients. Whether an increased risk is present in stage 1
to 4 CKD patients is not well known.
When to initiate dialysis
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The uremic syndrome consists of symptoms and signs that
result from toxic effects of elevated levels of nitrogenous and
other wastes in the blood.
Symptoms. Uremic patients commonly become
nauseated and often vomit soon after awakening.
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They may lose their appetite such that the mere thought of
eating makes them feel ill.
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They often feel fatigued, weak, and/or cold.
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Their mental status is altered; at first, only subtle
changes in personality may appear, but eventually, the patients
become confused and, ultimately, comatose.
When to initiate dialysis
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Signs. The classic uremic physical findings of a sallow coloration
of the skin due to accumulation of urochrome pigment (the
pigment that gives urine its yellow color) and of an ammonialike or urine-like odor to the breath are rarely seen unless the
degree of uremia is severe.
A pericardial friction rub or evidence of pericardial effusion with
or without tamponade reflects uremic pericarditis, a condition
that urgently requires dialysis treatment.
Foot- or wrist-drop may be evidence of uremic motor
neuropathy, a condition that also responds to dialysis. Tremor,
asterixis, multifocal myoclonus, or seizures are signs of uremic
encephalopathy.
Prolongation of the bleeding time occurs and can be a problem
in the patient requiring surgery.
Indications for dialysis in the chronic setting
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Usually dialysis is initiated in adult
patients when the eGFR decreases to
about 10 mL per minute per 1.73 m2.
However, evaluation of the need for
dialysis should begin at a higher eGFR
level, probably somewhere around
15-20 mL per minute per 1.73 m2.
Complications that may prompt initiation
of kidney replacement therapy
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Intractable extracellular volume overload and/or hypertension
Hyperkalemia refractory to dietary restriction and pharmacologic
treatment
Metabolic acidosis refractory to bicarbonate treatment
Hyperphosphatemia refractory to dietary counseling and to
treatment with phosphorus binders
Anemia refractory to erythropoietin and iron treatment
Otherwise unexplained decline in functioning or well-being
Recent weight loss or deterioration of nutritional status,
especially if accompanied by nausea, vomiting, or other
evidence of gastroduodenitis
Urgent Indications
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Neurologic dysfunction (e.g., neuropathy, encephalopathy,
psychiatric disturbance)
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Pulmonary edema
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Sever hyperkalemia or sever acidosis resistant to therapy
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Pleuritis or pericarditis without other explanation
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Bleeding diathesis manifested by prolonged bleeding time
Questions
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1.
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3.
4.
A 68 yr old woman with DM and HTN came to your office
with a lab paper, her cr=2.0 mg/dl
Hb=12, K=5, Na=137, LDL=139
she is 50 kg and her drugs are:
metformin 1000 mg/d, furosemide 40mg/d,
losartan 50 mg/d, cefixime 400mg/d?
How much is her eGFR?
Which drug must be discontinued?
Which drug must be dose adjusted?
Is there any drug that must be added to her list?
Questions
Questions
Questions