Transcript Optimal Versus Minimal Care

Minimal versus Optimal Care
Chronic Renal Failure
Omar EL khashab
Professor of Renal Medicine
Cairo University
Minimal Versus Optimal Care
1- Prevention
2- Detection
3- Management
4- Regular Dialysis
5- Transplantation
Minimal Versus Optimal Care
Prevention
Magnitude of the Problem:
150 new case/million population.
25000 cases on regular hemodialysis.
5000 transplant cases.
COST: 350 millions direct costs for Dx cases.
250 millions indirect costs for DX cases.
50 million direct transplantation costs.
Huge costs for conservatively treated cases
Minimal Versus Optimal Care
Prevention(Community level)
Hypertension:
• Raising awareness of the disease and benefits of
control.
• Decreasing salt content of processed foods.
• Concept of HTN clinics.
• Proper control of HTN , not necessarily using
expensive drugs(control is more important than
agent). Tight versus usual control is less important.
Minimal Versus Optimal Care
Prevention (Community level)
Diabetes:
• Raising awareness of the disease and benefit of
control
• Concept of Diabetes clinics.
• Stressing the role of diet control in management.
• Adjusting HbA1c at 7 every 6 months check.
• Benefits of new expensive medications is not crucial
Minimal Versus Optimal Care
Prevention(community level)
Other Factors:
• NSAIDs restriction of use.
Orthopedician orientation.
• Acrotoxin control.
• Obstructive Uropathy.
Minimal Versus Optimal Care
Detection and Diagnosis
Biochemistry:
• Creatinine, urea, urine analysis are needed.
• Others are needed only when clinical suspicion
is high ( 24 hours urinary proteins, Blood
sugar,C3&C4, Auto Abs, PEP etc.)
• Na, K, only in special circumstances.
• Frequency of investigations should in months not
weeks.
Minimal Versus Optimal Care
Detection and Diagnosis
Radiological
• Abdominal ultrasound is essential.
• Plain UT, IVP in suspected obstruction.
• Isotopic studies not needed (all information can
be deduced from US).
• Duplex renal vessels only when RAstenosis is
suspected.
Minimal Versus Optimal Care
Management
Dietary control.
BP Control.
Ca,Phosphorous control
Anemia correction
CVS complication prevention
Minimal Versus Optimal Care
Management
Dietary Control
• Ideally a dietician is included in the team.
• Physician can take their role:
Low protein diet
Avoid high K foods
Excess water (guided with simple scale)
Decrease salt
Minimal versus Optimal Care
Management
BP control
• 130/80 , 120/75 are optimal targets. At least
140/90 or below is needed.
• 24 hours regulation needed. long acting
preparations, or 12 hours administration is
practical, preferably of different classes.
• 24 hours monitoring is optimal but not
essential.
Minimal versus Optimal Care
Management
BP control
• ACEi or ARBs (in diabetic nephropathy II)
are optimal. But the main benefit comes
from the control of BP with any agent.
• Slowing progression by ACEi comes mainly
from BP control rather than specific agents,
and their benefit concerns mainly early
cases with gross proteinuria.
• In advanced diabetic cases ACEi proved to
be cardioprotective.
Minimal Versus Optimal Care
Management
Calcium and Phosphorous control
• Prevent bone problems
• Prevent CVS problems
Key is to normalize serum Phosphorus.
Dietary control is mandatory.
Bone biopsy not essential.
Minimal Versus Optimal Care
Management
Calcium and Phosphorus control
• Calcium carbonate is the standard
• If still hyperphosphatemic shift to Ca acetate.
• If hypercalcemia supervenes , use Sevalemer
optimally. But Aluminum containing antacids can be
used instead ( use short periods, safe in early cases).
• Ca, PO4 every 2 months and PTH 6 monthly is
sufficient.
• Bisphosphonates and Calcitonin of no value.
Minimal Versus Optimal Care
Management
Control of Anemia
• Target HB >12 gm (optimal) , can be
reduced to 10 gm.
• Exclude blood loss.
• EPO use in special indication. Concomitant
use of anabolic steroids, SC administration
and proper diet can minimize the dose
needed.Packed cell transfusion can be used
if no EPO available.
Minimal Versus Optimal Care
Management
Reduction of CVS complications
• Unusual risk factors are operating.
• Control of BP , Diabetes CA,PO4 is essential.
• Statins are of very limited value.
• Antioxidants of no value
• ACEi in high risk cases are emerging.
Minimal Versus Optimal Care
Unusual Cardiovascular risk factors in CRF:
• Anemia (major CVS risk factor, QOL )
• High PO4, Ca&PO4 > 55, elevated PTH.
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Low Cholesterol, high LDL.
Chronic inflammation syndrome.
Low serum Albumin, high fibrinogen.
Oxidative stress.
ASDA.
• Low AGEs.
Homocysteine. • Folic acid deficiency.
Minimal Versus Optimal Care
Regular Hemodialysis
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Make sure patient is ESRD( no reversible factors).
Some cases need only twice /week at least early.
Bicarbonate dialysis restricted to special indications.
Routine monthly investigations restricted to HB,
CA&PO4, K, Creatinine, SGPT.
HCV, albumin, cholesterol Checked 3 monthly.
HIV 6 monthly.
Hemodiafiltration, Diasafe dialysis, use of special
hemodialysers are of little value.
RE_USE of dialysers can be safely applied.
Minimal Versus Optimal Care
Transplantation
Better quality of life,should be encouraged.
• Use of new agents( Tacrolimus, Sirolimus,
Monoclonal Abs) only when indicated.
• MMF only when indicated or in the first year.
• Routine investigations restricted to the minimum