1. Renal Failure
Mary Rose G. Tantoco

2. How do we assess renal function?
What markers can we use to assess renal function
Inulin (Gold standard)
Iothalmate
Iohexol
Urea
Cystatin C**
CREATININE***

3. 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**

4. How reliable is using creatinine and eGFR?

5. 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?

6. 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.

7. 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

8. 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.

9. NSAID

10. Chronic Kidney Disease (KDOKI website)

11. Causes for CKD Diabetes Mellitus Hypertension Other chronic disease
Drug therapy
Toxin exposure
Recurrent infections/ATN GN

12. Management of CKD Dependent on stage ALL stages: Stage 3 and up
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

13. 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**

14. 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***

15. Foods High in Potassium

16. Renal Diet: why low Phosphorus
Generalized itching
Can cause abnormal mineralization with dire consequences e.g. Calciphylaxis

17. Foods High in Phosphorus**

18. Other considerations:
NSAID

19. Other considerations Anemia of Chronic Disease
Iron stores
Need for Epogen
CKD related mineral bone disease
Vitamin stores
Parathyroid activity

20. Getting ready for dialysis
Education, education, education!!!
Is the patient a candidate?
Big lifestyle change
What about transplant?
Dialysis access: AVF/AVG/ PC/ PD***

21. Hemodialysis

22. 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.

23. Peritoneal Dialysis Access management: drainage/placement/infection
2 types: Automated or Manual

24. 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

25. 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

27. NSAID