Renal FailureMary 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, Cryoglobulinemia-related 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, anti-viral 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, non-compliance***)

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