{"id":384,"date":"2022-04-07T09:34:49","date_gmt":"2022-04-07T09:34:49","guid":{"rendered":"https:\/\/kidneydiseaseclinic.net\/blog\/?p=384"},"modified":"2022-04-07T09:34:49","modified_gmt":"2022-04-07T09:34:49","slug":"management-of-chronic-renal-failure","status":"publish","type":"post","link":"https:\/\/kidneydiseaseclinic.net\/blog\/management-of-chronic-renal-failure\/","title":{"rendered":"Management of chronic renal failure"},"content":{"rendered":"\n
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Management of chronic failure is divided into two protocols, depending on remaining kidney functions.<\/p>\n\n\n\n

Pre dialysis protocol and dialysis protocol<\/p>\n\n\n\n

Why to separate into two protocols, it is due to the objectives of management<\/p>\n\n\n\n

Pre dialysis objectives<\/td>Dialysis objectives<\/td><\/tr>
Slow down the disease progression<\/td>Keep the patient healthy<\/td><\/tr>
Manage the sign and symptoms<\/td>Minimize mortality and morbidity<\/td><\/tr>
 <\/td> <\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Slow down the disease progression<\/p>\n\n\n\n

The progression of CKD, regardless of its underlying cause, is associated with poorly controlled hypertension. Consequently, the control of hypertension is considered the single most important intervention to slow the progression of CKD. Target levels of BP have been set by different organizations and societies at <130\/80mmHg; lower targets have been advocated in those with moderate to heavy proteinuria (>1 g\/24 h) and in those with diabetic nephropathy. In these diabetic and proteinuric patients, with a faster rate of decline in GFR, the use of inhibitors of the angiotensin system such as ACEIs and ARBs has been recommended. In nondiabetic and nonproteinuric nephropathies, there is little evidence that these agents have a therapeutic advantage and national BP control recommendations should be followed. The initial combination of a diuretic and calcium antagonist is thought to have the best risk benefit profile and be the most cost-effective for nondiabetic and nonproteinuric nephropathies<\/p>\n\n\n\n

Reduce proteinuria hence, the use of ACEIs and ARBs alone or in combination in proteinuric CKD patients with or without diabetic nephropathy. The addition of a diuretic or dietary salt restriction (<60 mmol\/day) enhances the antiproteinuric effect of angiotensin inhibition. CKD patients should be advised to reduce their dietary salt intake. It is also important to closely monitor CKD patients started on ACEIs or ARBs, as these agents can seriously compromise kidney function in susceptible individuals (those with renal artery stenosis) as well as induce hyperkalemia. It is therefore advised that renal function test should be repeated within 1 week of treatment initiation and again at 4 weeks. An increase in serum creatinine value exceeding 25% of the baseline value should lead to immediate discontinuation of the treatment<\/p>\n\n\n\n

  • Treat any reversible causes such as obstruction with early ultrasound imaging, particularly in the elderly.<\/li><\/ul>\n\n\n\n

    \u2022 Establish the rate of progression by calculating the rate of fall of eGFR (mL\/min\/1.73 m2\/year).<\/p>\n\n\n\n

    \u2022 Optimize BP control :< 130\/80 mmHg and possibly lower in diabetic nephropathy and proteinuric nephropathies (>1 g\/24 h).<\/p>\n\n\n\n

    \u2022 Start with ACEIs or ARBs in proteinuric and diabetic nephropathies (with proteinuria).<\/p>\n\n\n\n

    \u2022 If BP is uncontrolled and\/or if proteinuria > 1 g\/24 h, increase the dose of ACEI or ARB and add diuretic (loop diuretic if GFR < 30 mL\/min) and dietary salt restriction (<60 mmol\/day).ACEIs and ARBs can be administered in combination<\/p>\n\n\n\n

    • Closely monitor changes in serum creatinine\/GFR. Stop ACEI or ARB if the GFR falls by more than 25% at 1\u20134 weeks after initiation or change of regimen.<\/li><\/ul>\n\n\n\n

      \u2022 In nonproteinuric, nondiabetic CKD, calcium antagonist and diuretic are an alternative antihypertensive treatment.<\/p>\n\n\n\n

      \u2022 Third-line therapy could consist of alpha or beta-blockade, depending on associated comorbidities; a cardio selective beta blocker would be preferred in patients with a history of CVD.<\/p>\n\n\n\n

      \u2022 If BP remains uncontrolled, consider the underlying diagnosis of renovascular hypertension and atherosclerotic renal artery stenosis\/ischemic nephropathy.<\/p>\n\n\n\n

      \u2022 Avoid acute decline of GFR precipitated by intercurrent illnesses such as volume depletion in diarrheal states or vomiting as well as by the use of NSAIDs, aminoglycosides, and contrast agents in diagnostic imaging. The latter should be avoided if there is any alternative approach for diagnosis; otherwise, use precautions judiciously in these circumstances<\/p>\n\n\n\n

      Management guidelines for reducing CKD complications.<\/p>\n\n\n\n

      • CVD control Hypertension, dyslipidemia, smoking, anemia, renalosteodystrophy<\/li>
      • Hypertension control blood pressure less than 130\/80 mmHg<\/li>
      • Hypercholesterolemia: usage of Statins, target total cholesterol < 5 mmol\/L and LDL cholesterol < 2.1 mmol\/L<\/li>
      • Anemia: Correct deficiencies, Hemoglobin: 11\u201312 g\/dL, Serum ferritin: 500\u2013800 \u00b5mol\/L and serum folic acid 2\u20135 mg\/mL, erythropoietin 4000\u201310,000\/units\/week according to hemoglobin level<\/li>
      • Calcium (Ca): 2.1\u20132.3 mmol\/L, treat, hypocalcemia, administer Vitamin D<\/li>
      • Phosphorus: 1.2\u20131.7 mmol\/L, Correct hyperphosphatemia, use phosphate binders<\/li>
      • Parathyroid hormone2\u20133 times upper limit (PTH) of normal (150\u2013300 pg\/mL)<\/li>
      • Nutrition: Avoid malnutrition, Serum albumin >40 g\/L Protein intake 0.8 g\/kg\/day (CKD stages 3\u20135) Calories: 35 kcal\/kg\/day<\/li>
      • Infections: give Immunization against, Chest infections: influenza and pneumococcus, Hepatitis B Vaccination CKD<\/li><\/ul>\n<\/div><\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

        Management of chronic failure is divided into two protocols, depending on remaining kidney functions. Pre dialysis protocol and dialysis protocol Why to separate into two protocols, it is due to the objectives of management Pre dialysis objectives Dialysis objectives Slow down the disease progression Keep the patient healthy Manage the sign and symptoms Minimize mortality […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-384","post","type-post","status-publish","format-standard","hentry","category-med"],"_links":{"self":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/384","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/comments?post=384"}],"version-history":[{"count":1,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/384\/revisions"}],"predecessor-version":[{"id":385,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/posts\/384\/revisions\/385"}],"wp:attachment":[{"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/media?parent=384"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/categories?post=384"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/kidneydiseaseclinic.net\/blog\/wp-json\/wp\/v2\/tags?post=384"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}