1. RENAL FAILURE DR. HANIN

2. Goals of therapy • The aim of medical care is to: • Delaying or halting the progression of CKD • Treating the pathologic manifestations of CKD • Timely planning for long-term renal replacement therapy

3. 1. Delaying or Halting Progression of Chronic Kidney Disease • Treatment of the underlying condition if possible • Aggressive blood pressure control with ACE inhibitors • Treatment of hyperlipidemia with Statins • Aggressive glycemic control target HbA1C < 7% • Avoidance of nephrotoxins • Use of ACEIs /ARBs in patients with diabetic kidney disease and proteinuria • Use of ACEIs or angiotensin-receptor blockers (ARBs) in patients with proteinuria

4. 2. Treating Pathologic Manifestations of Chronic Kidney Disease • Anemia: • When the HB < 10 g/dL, treat with Erythropoietin • Before starting erythropoietin, check iron stores.

5. Management of mineral and bone disorder • Lowering high serum phosphorus levels: Treat with dietary phosphate binders (calcium acetate, sevelamer carbonate) and dietary phosphate restriction. • Maintaining serum calcium levels: Treat with calcium supplements with or without calcitriol

6. Lowering serum parathyroid hormone levels: Treat with calcitriol, vitamin D analogues, or calcimimetics (mimics calcium at the parathyroid hormone (PTH) receptor and reduces PTH levels. Cinacalcet is the only drug in this class) • Providing osteoporosis prophylaxis

7. 3. Diet • Protein restriction; 0.8g/kg body weight • Salt restriction and water restriction: salt 2 g/d, water 1-1.5 L/day • Phosphorus restriction 600-800 mg/day • Potassium restriction 40-70 mEq/day

8. 4. Management of hyperkalemia • Continuous monitoring of ECG • Restrict dietary potassium • Discontinue potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers . • Sodium polystyrene sulfonate (SPS) enhance GI excretion. SPS can be administered orally or rectally. It is not used for emergency treatment. • Calcium gluconate 10% to ameliorate cardiac toxicity if present. • Drugs that lowers serum potassium: Insulin + 50% dextrose, Nebulized Salbutamol, Loop diuretic • Emergency dialysis

9. 5. Others • Volume overload: Treat with loop diuretics or ultrafiltration • Metabolic acidosis: Treat with oral alkali supplementation • Uremic manifestations: Treat with long-term renal replacement therapy • Cardiovascular complications: Treat as appropriate • Growth failure in children: Treat with growth hormone

10. 3. Renal Replacement Therapy • long-term renal replacement therapy include; • Hemodialysis • Peritoneal dialysis • Renal transplantation

11. Indications for renal replacement therapy in patients with chronic kidney disease (CKD) • Severe metabolic acidosis • Hyperkalemia • Pericarditis • Encephalopathy • Intractable volume overload • Failure to thrive and malnutrition • Peripheral neuropathy • Intractable gastrointestinal symptoms • In asymptomatic adult patients, a glomerular filtration rate (GFR) of 5-9 mL/min/1.73 m², irrespective of the cause of the CKD or the presence of absence of other comorbidities

12. Considerations • Early patient education regarding natural disease progression, different dialytic modalities, renal transplantation. • Timely placement of permanent vascular access (arrange for surgical creation of primary arteriovenous fistula, if possible, and preferably at least 6 months in advance of the anticipated date of dialysis for patients in whom transplantation is not imminent) • Timely elective peritoneal dialysis catheter insertion • Timely referral for renal transplantation

13. GOOD LUCK