|Stage 0||>=90 with risks (diabetes, HTN, history)|
|Stage 1||>=90 w/damage|
|Stage 2||60-89 w/damage|
|Stage 3||30-59 w/damage|
|Stage 4||15-29 w/damage|
All in damaged kidneys.
- Goal BP in CKD = 130/80 in some guidelines, especially with marked albuminuria.
- ACEI or ARB should be used in any degree of proteinuria, even if not hypertensive.
- Calcium channel blockers are second line after ACEI/ARB.
- DASH Diet: limit salt to 1500-2300 mg daily
- Assess hyperlipidemia and treat, unless on dialysis.
Stage 3 CKD: monitor every 12 months.
Stage 4-5 CKD: monitor every 6 months.
Stage 5 + dialysis CKD: monitor every 3 months.
Renal Replacement Therapy
A: Acidosis (not responding to bicarb)
E: Electrolyte abnormality (hyperkalemia, hyperphosphatemia)
I: Intoxication (theophylline, boric acid, ethylene glycol, lithium, methanol, phenobarbital, salicylate)
O: Overload of fluid (symptomatic, pulmonary HTN)
U: Uremia (pericarditis and weight loss)
Complications of CKD
- Anemia: Treating with erythropoiesis-stimulating agents (ESA) increases cardiovascular events.
- Only initiate if hemoglobin less than 10.
- Use in caution with patients with a history of cancer or stroke.
- Hold or reduce dose if hemoglobin is greater than 10 or greater than 11 in dialysis.
- Do not exceed hemoglobin greater than 13.
- Most patients receiving ESAs also need iron. Dialysis pts usually need 1000 mg per dialysis, usually IV.
- Calcium and Phosphorus homeostasis: Can cause hyperphosphatemia, reduced absorption of calcium in the gut, decreased free calcium.
- Calcium and phosphorus go together: calcium binds phosphorus
- Treatment: Restrict phosphorus to 800-1000 mg/day or remove with dialysis. Can take phosphate binders with meals (calcium carbonate, calcium acetate, sevelamer, lanthanum, sucroferric, aluminum hydroxide, ferric citrate)
- Supplement with vitamin B if needed.
- Calcitriol: Manage hypocalcemia, but can cause hyperalcemia.
- Paricalcitol: Vitamin D analog
- Doxercalciferel: Vitamin D analog, lower incidence of hypercalcemia than calcitriol
- Cinacelet: 30 mg daily. Calcium mimic, especially useful in patients with high calcium and phosphate concentrations and high PTH.
Drugs in hemodialysis:
- Large molecules like vancomycin will be removed.
- Water-soluble drugs are more likely to be removed.
- Protein-bound drugs can’t pass through the membrane
- Drugs with a small volume of distrubution cannot be removed, even if they are not protein bound