Renal replacement therapy - indications.

1. Renal replacement therapy - indications. S. Zmonarski

2. Chronic renal failure – risk factors of progression The speed of destruction of functioning renal parenchyma depends on the activity of underlying disease, but in many diseases loss of renal function progressing deteriorates subclinically even if the underlying disease is not active.

3. Chronic renal failure – risk factors of progression The factors, that influence the attempts to slow down progression of renal disease. • Early and correct diagnosis. • Good treatment of acute renal disease. • Prevention of conversion of acute to chronic disease – the proper diagnosis of chronic condition. • Good estimation of current renal function (stage of renal insufficiency).

4. Risk factors of chronic renal failure progression. • Chronic renal failure (CRF)is a multisymptomatic diseases caused by reduction of the number of working nephrons destructed by various renal parenchymal diseases. • Nearly all renal diseases (without respect to undelying mechanisms) can lead to chronic renal failure and result in a set of typical symptoms (common way).

5. Chronic renal failure progression • Activity of underlying disease. • Loss of active nephrons. • Hypertension in capilaries of nephron. • Glomerular hypertrophy of remaining nephrons. • Microalbuminuria and proteinuria. • Loss of endocrine, metabolic and regulatory function of kidneys.

6. Chronic renal failure progression • Risk factors of progressive destruction of nephrons. • Inherited low number of nephrons. • Man sex. • Hypertension. • Hiperlipidemia. • Animal protein reach food. • Increased sympathetic activity. • Calcium-phosphate disturbances. • Tobacco smoking.

7. Chronic renal failure progression • Accompanying diseases • diabetes, • obesity, • nephrotoxicity of drugs and environment al factors, • obstruction of urinary tract, • gravidity.

8. CRF progression

9. Periods of CRF and symptoms (1)Period 1 – Subclinical CRF • GFR: • 80-40 ml/min/1.73 m2b.w. • Pcr: at first norm., than 1.2 – 2.0 mg/dl (106-177 mmol/L) • Symptoms • Most cases without any. • Aunderlying renal disease. • Polyuria or nycturia. • Hypertension (mild) 30-50% cases.

10. Periods of CRF and symptoms (2)Period 2 – balanced CRF • GFR: • 40-25 ml/min/1.73 m2 p.c. • Pcr: >2-5 mg/dl (>177-442 mmol/L) • Objawy • polyuria > 2L/24h, nycturia polydypsja • Bad taste, nausea, • Decrease of physical strength • 60% hypertension. • Increased concentration of: phosphate, urea, uric acid • anemia, low Fe.

11. Periods of CRF and symptoms (3)Terminal CRF • GFR: • <10 ml/min/1.73 m2 • Pcr: >10 mg/dl (>884 mmol/L) • Symptoms • General uremic toxicity: the malfunction of gastrointestinal tract, circulatory system, skeletal, muscular weakness, endocrine problems, immune resistance, bone marrow, skin. • 90% of hypertension, high urea, creatinine, uric acid and phosphorus, low calcium concentration.

12. Predialysis care The survival of patients depends mostly on their condition on beginning of dialysis therapy. The mos important aspects of good care is monitoring of: • Blood preassure, • Anemia, • Calcium-phosphate balance, • Nutritional parameters. Creation of dialsysis access at proper time.

13. First line CRF prevention – primary care Family physician - every year : creatinine and urea concentration examination in every adult patient. Basic diagnostics of renal disease and consultation by nephrologist. Correct diagnosis of renal disease and renal failure period. Continous nephrologic supervision.

14. CRF prevention – slowing down the progression. Blood pressure optimization. Reduction of proteinuria to <1.0g/24h(<0.3g/24h) Balanced diet, protein 1.0-0.8 g/kg bw/24h, phosphate capacity reduction. Ca-P balance correction (hiperphosphatemia, secondary hyperparathyroidism) Water-electrolyte balance, correction of acidosis.

15. CRF prevention – slowing down the progression. Early anemia diagnosis and correction. Treatment of inflammation and infection. Hepatitis B (and A) vaccination. Nephrotoxic drug avoidance. Correct passage of urine. Hyperlidemia prevention and treatment.

16. CRF prevention – slowing down the progression. Obesity - treatment and prevention. Avoidance of accidental dehydration and infection. . Cardiovascular care. Blood suger monitoring and rigid insulin administration in diabetic patient. CRF education and preparation to renal replacement therapy.

17. Dialysis – when we need to begin? Every patient who has his creatinine clearence (CCr) between 9-14 ml/min./1,73 m2 body surface(~ 14 ml/min/1,73m2 in diabetics) or even earlier if the daily protein consumption decreases below 0,8 g/kg/24h or if first symptoms of uremia appear. The survival of dialysis patients is influenced by their nutritional status at the beginning of chronic dialysis treatment. It can be estimated by albumin concentration.

18. Dialysis treatment – the beginning. The DOQI require the calculation of weekly urea Kt/V. (It is suggested to begin dialysis when weekly urea Kt/V is < 2,0). It paralels CCr = ~~ 9-14 ml/min.

19. Good predialysis care The benefits: • Lower frequency of acute dialysis session. • Shorter hospitalization time at first month. • Lower cost of care.

20. Acute dialysis The CRF patients with CCr < 20-25 ml/min/1,73 m2 body area): The symptoms typical for uremia: • Nausea, vomiting, undernutritioned patient with loss of apetite; symptoms of gastritis, gastrointestinal bleeding, enteritis with or without bleeding.

21. When dialysis therapy need to be started? The uremic symptoms usually occur when CCr is < 10 ml/min/1,73 m2 body area. All diabetics are proned to experience uremic complications (when CCr is < 15 ml/min/1,73 m2 body area). In CRF reduced reduced protein intake, features of anamia, deviated calcium –phosphate –parathormone balance can be detected when creatinine clearence is between 30-40 ml/min/1,73 m2 body area).