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Renal Failure
Mary Rose G. Tantoco
How do we assess renal function?
What markers can we use to assess renal function
Inulin (Gold standard)
Iothalmate
Iohexol
Urea
Cystatin C**
CREATININE***
What is creatinine
Function of muscle breakdown i.e. it is a function of muscle mass
Can be affected by factors that can affect muscle mass
Age
Gender
Race
Used in calculating estimated Glomerular filtration rate
Cockcroft-Gault equation
MDRD**
CKD-EPI**
How reliable is using creatinine and
eGFR?
How do we ensure accuracy?
Cystatin C: expensive, not universally available
24 hour urine: calculate measure clearance
Can we use these markers in Acute Kidney Injury?
Acute Kidney Injury
Abrupt decline in the functioning of the kidneys
Assess severity: different criteria e.g. RIFLE etc.
Different causes: Pre/Renal/Post
Pre-renal: disrupt effective circulating volume to the kidney e.g.
hypotension, profound anemia, dehydration, heart failure.
Renal: ATN, AIN, GN
Post: obstruction from stones, BPH, strictures etc.
Acute Kidney Injury
ATN: Ischemic or Nephrotoxic
AIN: Drug-induced, infectious
GN: IgA, HSP, Good Pasture’s, ANCA vasculitis, Cryoglobulinemiarelated GN, post-infectious, FSGS, MGN, MPGN
How to treat AKI?
Remove offending agents and other potential nephrotoxins: ACE
Inhibitors/ARB/NSAIDs/Phosphasoda enemas/certain antibiotics, antiviral and anti-fungals agents/certain chemotherapeutic agents/CT IV
contrast etc.
Optimize effective circulating volume.
Treat electrolyte abnormalities medically or through dialysis.
When to consider biopsy?
Call nephrology consult.
Chronic Kidney Disease (KDOKI website)
Causes for CKD
Diabetes Mellitus
Hypertension
Other chronic disease
Drug therapy
Toxin exposure
Recurrent infections/ATN
GN
Management of CKD
Dependent on stage
ALL stages:
Management of co-morbid chronic diseases/underlying pathology***
Minimization of nephrotoxic exposure ( including CT IV contrast +/- MRI
contrast)
Managing proteinuria (DM)
Stage 3 and up
Electrolytes: dietary modification
Anemia
Bone/Mineral health
Stage 4 and up
Start preparation for renal replacement therapy
Why is proteinuria important?
Prognostic factor: associated with progression of renal
disease
RENAAL trial (In patient with diabetic nephropathy,
Losartan decreased risk of development to ESRD compared
to placebo)
Might point to other underlying pathology
FSGS, malignancy etc.
Treatment: ACE Inhibitors/ARB’s**
Renal diet: Why low Potassium?
Potassium has a narrow therapeutic window
High levels linked to bradycardia and heart block
High K + EKG changes = indications for renal replacement
therapy particularly in the setting of impaired renal
functions without response to medical therapy.
Medical therapy: Kayexalate/Sodium Bicarbonate/Insulin
and D50/IV Calcium***
Foods High in Potassium
Renal Diet: why low Phosphorus
Generalized itching
Can cause abnormal mineralization with dire
consequences e.g. Calciphylaxis
Foods High in Phosphorus**
Other considerations:
Other considerations
Anemia of Chronic Disease
Iron stores
Need for Epogen
CKD related mineral bone disease
Vitamin stores
Parathyroid activity
Getting ready for dialysis
Education, education, education!!!
Is the patient a candidate?
Big lifestyle change
What about transplant?
Dialysis access: AVF/AVG/ PC/ PD***
Hemodialysis
Hemodialysis
Access management: avoid needle sticks in same arm with
AVF/AVG, weight lifting limit, no restrictive/binding
clothing, monitoring for function/infections/aneurysm
Fistula first
2 types: In-center and Home hemodialysis.
Peritoneal Dialysis
Access management: drainage/placement/infection
2 types: Automated or Manual
You can live a relatively normal life on
dialysis
It is not a “death sentence”
People can travel on both HD and PD
Kidney Transplant
A Few words on Kidney Transplant
Not an immediate solution to renal failure
Extensive work-up required to ensure that patients will be
safe for procedure and that they don’t have any factors
that might be impediments to having a kidney transplant
(heart disease, lung disease, malignancy, noncompliance***)
Living Donor vs Deceased Donor Kidney Transplant: for the
latter once listed wait time can be on average 3 to 5 yrs
New allograft allocation criteria since December 2014
Also need to consider the chronic financial repercussions