Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download available now - grandstrandapna.org
Document related concepts
Transcript
Renal Failure Mary 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, Cryoglobulinemiarelated 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, antiviral 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, noncompliance***) 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
