Transcript Introduction to Nephrology - University of North Texas

Introduction to Nephrology
Sandeep K. Shori, D.O.
Dialysis Associates
Fort Worth, TX
The ultimate goal of a nephrologist is to maintain
renal function and manage associated metabolic
changes and prolong time till dialysis.
Only a nephrologist can perform hemodialysis
Nephrologists manage Acute Renal Failure and
provide lifesaving Continuous Renal
Replacement Threapy (CRRT) in the ICU.
Nephrologists are specialists in electrolyte, fluid
balance, acid/base, anemia assoc renal disease,
metabolic bone disease, and Hypertension
management.
When should you call for a nephrologist?
When does a patient need a Nephrologist?
What therapy can be given?
What is the most common cause of kidney
disease?
Why is kidney disease increasing so rapidly?
How many Americans are on dialysis now?
What is a interventional nephrologist?
What you need to know about kidney disease
including Diagnosis, intervention, and
prognosis?
What is GFR and what is its importance in renal
management and dialysis?
KDOQI expands the Dialysis Outcomes Quality
Initiative or DOQI, a project begun by the
National Kidney Foundation in 1997 and
recognized throughout the world for improving
the care of dialysis patients
A sustained decrease in blood flow or prolonged
obstruction is often associated with kidney
damage. Chronically decreased GFR is more
often associated with kidney damage. > 3
months for the definition of chronic kidney
disease.
Decreased GFR may be acute or chronic. An
acute decrease in GFR does not necessarily
indicate the presence of kidney damage.
Decreased GFR is one of the markers of kidney
damage. This marker is used to evaluate for
kidney disease and its associated etiology.
Individuals without evidence of kidney damage,
yet chronically decreased GFR, are at increased
risk for adverse outcomes (for example, toxicity
from drugs excreted by the kidney, and acute
kidney failure in a wide variety of
circumstances).
Chronically low GFR is age dependent. GFR
<90 mL/min/1.73 m2 would be abnormal in a
young adult.
On the other hand, a GFR of 60–89 mL/min/1.73
m2 could be normal from approximately 8 weeks
to 1 year of age and in older individuals.
GFR 30 to 59 mL/min/1.73 m2 could also be
normal in individuals at the extremes of age, in
vegetarians, after unilateral nephrectomy or in
an older individual. It is likely that a GFR <30
mL/min/1.73 m2 is abnormal at all ages other
than neonates
Clinicians initiate replacement therapy based on
-Level of kidney function, presence of signs and
symptoms of uremia, the availability of therapy.
Variabile relationship exists between level of
kidney function to signs/symptoms of uremia.
The level of GFR at the beginning of dialysis has
been estimated in more than 90,000 patients in
the United States between 1995 and 1997,
using data collected on the Medical Evidence
Report (HCFA Form 2728) and the MDRD Study
prediction equation
EVALUATION AND TREATMENT
The evaluation and treatment of patients with kidney
disease requires understanding of separate but
related concepts of diagnosis, comorbid conditions,
severity of disease, complications of disease, and
risks for loss of kidney function and cardiovascular
disease.
Patients with kidney disease should be evaluated to
determine:
– Diagnosis (type of kidney disease);
– Comorbid conditions;
– Severity, assessed by level of kidney function;
– Complications, related to level of kidney function;
– Risk for loss of kidney function;
– Risk for cardiovascular disease.
Treatment of kidney disease should include:
– Specific therapy, based on diagnosis;
– Evaluation and management of comorbid
conditions;
– Slowing the loss of kidney function;
– Prevention + treatment cardiovascular
disease;
– Prevention and treatment of complications
of decreased kidney function;
– Preparation for kidney failure and kidney
replacement therapy;
– Replacement of kidney function by dialysis
and transplantation, if signs and
symptoms of uremia are present.
Review of medications should be performed
at all visits for the following:
– Dosage adjustment based on level of
kidney function
– Detection of potentially adverse effects on
kidney function or complications of
chronic kidney disease
– Detection of drug interactions
– Therapeutic drug monitoring, if possible.
Self-management behaviors should be
incorporated into the treatment plan at all
stages of kidney disease.
Refer to a nephrologist for consultation and
co-management when GFR <30 mL/min/1.73
m2
The definitive diagnosis type of kidney disease is
based on biopsy or imaging studies.
Often avoided unless a definitive diagnosis
would change either the treatment or prognosis.
Diabetic kidney disease is the largest single
cause of kidney failure. Both type 1 and type 2
diabetes cause chronic kidney disease. Because
of the higher prevalence of type 2 diabetes, it is
the more common cause of diabetic kidney
disease.
Diabetic kidney disease usually follows a
characteristic clinical course after the onset of
diabetes, first manifested by microalbuminuria,
then clinical proteinuria, hypertension, and
declining GFR.
Diseases which cause chronic kidney disease.
Evaluation and management of these diseases is
important for patients’ well being and may improve the
course of chronic kidney disease. This is particularly
important for patients with diabetes and high blood
pressure, the leading causes of chronic kidney disease
and cardiovascular disease in the United States.
Cardiovascular disease. Cardiovascular disease is
singled out from among the possible comorbid conditions
to emphasize its complex relationship with chronic kidney
disease, and its importance as a preventable cause of
morbidity and mortality in patients with chronic kidney
disease.
In all cases, management of comorbid conditions must be
integrated into the overall care of patients with chronic
kidney disease.