Conservative Management of Chronic Renal Failure

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Dr Chaitanya Vemuri

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Kidney damage for >= 3months ,

as defined by structural / functional abnormalities of 

kidney

with or without decreased GFR,

and manifest by either :

Pathologic abnormalities

Markers of kidney damage, including abnormalities in

composition of blood / urine or abnormalities on imaging GFR < 60 ml/min/1.73m2 for >=3 months,

with / without kidney damage

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By Radiology –  USG / CT / MRI etc… 

By Histology – Renal Biopsy

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Microalbuminuria

Proteinuria

Hematuria esp associated with proteinuria

Casts ( with cellular elements )

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Cockcroft-Gaul t formula 

Ccr (ml/min) = (140-age) x weight *0.85 if female

72 x Scr  

MDRD Study equation 

GFR (ml/min/1.73 m2) = 186 x (Scr )-1.154 x (age)-.203 x

(0.742 if female) x (1.210 if African American)

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STAGE DESCRIPTION GFR ( ml/min/1.73m2 )

1 Kidney damage with

normal / increased GFR 

>=90

2 Kidney damage with

mildly decreased GFR 

60 – 89

3 Moderately decreased GFR 30 – 59

4 Severely decreased GFR 15 – 29

5 Kidney failure < 15 / dialysis

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STAGE ACTION PLAN

1 DIAGNOSIS AND TREATMENT

SLOW PROGRESSION

2 ESTIMATE PROGRESSION

3 EVALUATE AND TREAT

COMPLICATIONS

4 PREPARE FOR RENAL

REPLACEMENT THERAPY

5 RENAL REPLACEMENT

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Diagnosis

Measures to slow progression

Estimate Progression

Evaluation and Treatment of Complications

Preparation for Renal Replacement Therapy

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History

Physical Examination

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CLINICAL FACTORS SOCIODEMOGRAPHIC FACTORS

DIABETES MELLITUS OLDER AGE

HYPERTENSION EXPOSURE TO CERTAIN CHEMICALS

/ ENVIRONMENTAL CONDITIONS

AUTOIMMUNE DISEASES LOW INCOME / EDUCATION

SYSTEMIC INFECTIONS

URINARY TRACT INFECTIONS

URINARY STONES

LOWER URINARY TRACT

OBSTRUCTION

 NEOPLASIA

FAMILY HISTORY OF CKDRECOVERY FROM AKI

REDUCTION IN KIDNEY MASS

DRUGS

LOW BIRTH WEIGHT

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Tests & Diagnostics Significance / Goal

Blood Pressure < 130 / 80 mm Hg ; Use ACEI /ARB

Serum Creatinine To estimate GFR;

Historical values assist in determining

acuity and progression of disease

Urinalysis with microscopy Presence of RBCs / RBC casts and or 

Proteinuria – further work up

Serum Electrolytes ( Na+, K+ ) Useful as crude surrogate of renal disease

Help to guide antihypertensives

Help to identify patients in need of 

medical nutrition education

Calcium, Phosphorus, PTH, ALP,

25-OH VITAMIN D

Assists in treatment of metabolic bone

disease

Complete Blood Count

Peripheral Blood Smear 

Evaluate for anemia

TSAT , S.Ferritin Useful in evaluation of iron stores

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Tests & Diagnostics Significance / Goals

Renal Ultrasound with or without Arterial

Doppler 

Characterize Kidney number and size

Echogenicity of kidneys

Rule out presence of obstruction

Rule out renovascular disease

Cholesterol panel Especially useful for patients with

nephrotic range proteinuria

Random urine protein

Random urine creatinine

Ratio approximate values obtained by

24 hour collection

Hepatitis Serology Negative Hep B testing mandates

vaccination

Serum Protein Electrophoresis

Urine Protein Electrophoresis

In adults with renal disease to rule out

Myeloma

Antinuclear antibody Warranted for adults with proteinuria /

evidence for SLE

HIV Warranted in selected population

Renal Biopsy Indicated in pts with hematuria and /

 proteinuria and lack of evidence of 

systemic disease

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Protein Restriction

Reducing Intraglomerular Hypertension

Reducing Proteinuria

Control of Blood Glucose

Control of Blood Pressure

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Reduces symptoms associated with uremia

Slows the rate of decline in renal function at earlier stages of renal diseases

K/DOQI clinical practice guidelines recommenddaily protein intake between 0.60 – 0.75 g / Kg per day

50 % of protein intake should be of high biological value

As patient approaches CKD Stage V,spontaneous protein intake decreases & patient enter a state of Protein – Energy Malnutrition . Recommended protein intake is0.9 g / Kg per day

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Increased intraglomerular filtration pressure & glomerular hypertrophy - a response to loss of nephron number 

It promotes ongoing decline of kidney function even if the inciting process has been treated.

ACEI & ARBs

Inhibit angiotensin induced vasoconstriction of efferent arteriole

Reduces intraglomerular filtration pressure and proteinuria

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If monotherapy is not effective , combined therapy with

 both ACEI & ARB can be tried

2nd line drugs : Calcium Channel Blockers

Diltiazem , Verapamil

Especially - Diabetic Nephropathy & Glomerular diseases

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Leading cause of Chronic Kidney Disease

Control of Blood Glucose : excellent glycemic control

reduces the risk of kidney disease & its progression in both Type 1 & 2 Diabetes Mellitus

Recommendations : FBS : 90 – 130 mg/dl

HbA1C < 7%

Control of Blood Pressure & Proteinuria : ACEI & ARBs 

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Hypertension : sodium and water retention

renin angiotensin system activation

Control of BP : to slow progression of CKD

to prevent extrarenal complications

( cardiovascular disease / stroke )

Goal : BP < 130 / 80 mm Hg

BP < 125 / 75 mm Hg ( DM / Proteinuria > 1g/day )

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Salt Restriction

Diuretics

Loop Diuretics : Furosemide 40 mg BD

Bumetanide 1mg BD

Thiazides : less efficacious gfr < 30 – 40 ml/min

Both ameliorate hyperkalemia seen with ACEI / ARB

 ACEI / ARB

Check S.Creat & S.K+ within 1 -2 weeksUpto 30 % increase in creatinine is acceptable

Beta blockers / CCB / Alpha blockers / Vasodilators

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Anemia

Bone Disorders

Dyslipidemia

Cardiovascular disease

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Defined as Hemoglobin < 13.5 g/dl in males

< 12 g/dl in females

 Normocytic normochromic anemia  –  

as early as in Stage III CKD or universally by Stage IV CKD

Primary cause : insufficient production of Erythropoetin

Additional factors : iron deficiency

folate / vit B12 deficiencychronic inflammation

hyperparathyroidism / bm fibrosis

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Target Hb : 11 g/dl

Target Iron status : TSAT : lower limit > = 20

S.Ferritin : ng/ml

lower limit : 200 – HD CKD

100 – Non HD CKD

> 500 not routinely recommended

Check Hb monthly while on ESAs

Iron studies monthly when started on ESA

On stable ESA Therapy : Iron studies can be done 3 monthly

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Ferrous sulphate 325 mg bid – tid

IV Iron Dextran

IV Iron Sucrose

IV Sodium Ferric Gluconate Complex

Folic acid and Vitamin B 12 supplements

Erythropoetin Stimulating Agents : Epoetin alfa

Epoetin beta

Darbepoetin alfa Epoetin alfa / beta : 50 -100 IU / Kg SC per week 

Darbepoetin alfa : 40 mcg SC every 2 weeks

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Osteitis Fibrosa Cystica

Osteomalacia

Adynamic bone disease

Mixed osteodystrophy

Secondary

Hyperparathyroidism

Vitamin D deficiency Acidosis

Aluminium accumulation

Osteoporosis in elderly

Osteopenia caused by

steroids

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Renal bone disease – significantly increase mortality in

CKD patients

Hyperphosphatemia – one of the most important risk 

factors associated with cardiovascular disease in CKD

 patients

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K/DOQI recommends :

CKD Stage III & IV : S.Phosphorus : 2.7 - 4.6 mg / dl

CKD Stage V : S.Phosphorus : 3.5 - 5.5 mg / dl

CKD STAGE GFR RANGE INTACT PTH ( pg/ml )

3 30 – 59 35 – 70

4 15 – 29 70 – 110

5 < 15 / Dialysis 150 – 300

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CKD STAGE GFR RANGE PTH LEVELS S.Calcium &

S.Phosphorus

3 30 -59 Every 12 months Every 12 months

4 15-29 Every 3 months Every 3 months

5 < 15 / dialysis Every 3 months Every month

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Reduce dietary phosphate intake

Phosphate binders : calcium carbonate

calcium acetate

aluminium hydroxide

magnesium carbonate ( rarely used )

sevelamer hydrochloride

lanthanum carbonate

The use of calcium salts is limited by development of 

hypercalcemia Calcium acetate poses a less problem as less calcium is

absorbed

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Calcimimetics –  Cinacalcit :

Agent that increase calcium sensitivity of the calciumsensing receptor expressed by parathyroid gland

Down regulating the parathyroid hormone secretion

Reduce hyperplasia of parathyroid gland

Calcitriol 0.25 mcg OD

Paricalcitol 1 mcg daily or 2mcg 3 times a week 

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Vitamin D deficiency :

< 5 ng/ml –  Ergocalciferol 50000 IU orally weekly for 

12 weeks and then monthly thereafter 

5 – 15 ng/ml –  Ergocalciferol 50000 IU orally weekly for 

4 weeks and then monthly thereafter 

16 – 30 ng/ml –  Monthly Ergocalciferol

Acidosis : K/DOQI – total Co2 >=22 mEq/L

Sodium bicarbonate 650 – 1300 mg bid – tid

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A major risk factor for cardiovascular morbidity &mortality

Prevalence of hyperlipidemia increases as renal functionsdiminish

All patients with CKD must be evaluated for 

Dyslipidemia

Fasting lipid profile – annually

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Stage V CKD patients with dyslipidemia should always beevaluated for secondary causes :

 Nephrotic syndrome

Hypothyroidism

Diabetes mellitus

Excessive alcohol consumption

Liver disease

Drugs : oral contraceptives , haart etc… 

Goal : LDL – Cholesterol < 100 mg / dl

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LDL : 100 – 129 mg/dl : Lifestyle changes

 Not responded : Low dose statin

LDL >= 130 mg/dl : Lifestyle changes + Statins

TG >= 200 mg/dl : Lifestyle changes + Statins

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  Control BP : ACEI / ARB

Treat dyslipidemia : Lifestyle changes + Statins

Good Glycemic control

Treat anemia

Correct hyperphosphatemia

Treat hyperparathyroidism

Correct hyperkalemia

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Hepatitis B vaccination : 3 doses (0,1,2 months )

higher dose ( 40 mcg / ml )

Pneumococcal vaccination : single doseone time revaccination 5 yrs

after initial vaccination

Influenza vaccination : recommended annually for adults

> 50 yrs age

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Patients of CKD Stage IV approaching Stage V should be referredfor 

Vascular access if hemodialysis is preferred

Peritoneal dialysis catheter placement if peritoneal dialysis is preferred

AVF is most preferred access for HD patients

Ideally created 6 months prior to start of HD

 Non dominant upper extremity

And that arm is to be preserved – no iv lines

AVG : 3-6 weeks prior to start of HD

PD Catheter : 2 weeks prior to start of HD

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GFR not below 15 ml/min.1.73m2 but in presence of 

Intractable volume overload

Hyperkalemia

Hyperphosphatemia

Hypercalcemia / Hypocalcemia

Metabolic acidosis

Anemia

Uremic encephalopathy

Uremic pericarditis

Severe hypertension , acute pulmonary edema

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