Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Kidney Disease 331

creatinine >1.8 mg/dl), calcium channel blocker, central-

acting alpha-agonist/peripheral alpha-blocker/beta-blocker,

then vasodilator (e.g., minoxidil) and dietary Na restriction

(2 g/day).

➣Treat hyperkalemia and acidosis (see below).

specific therapy

■eGFR or Ccr 25–75 ml/min/1.73 m2, see “Preserve renal function”

■eGFR or Ccr <25 ml/min/1.73 m2, consult access surgeon, dietician

and social worker to assist in preparing for dialysis

■eGFR or Ccr <20 ml/min/1.73 m2, place vascular access (hemodial-

ysis) or plan peritoneal catheter in 6–12 months

■eGFR or Ccr in range of 8–12 ml/min/1.73 m2, initiate mainte-

nance renal replacement therapy unless: a) patient’s weight is stable;

b) serum albumin is at least at lower limit of normal range for

laboratory; c) patient is symptom-free

Preserve (Remaining) Renal Function for All Levels of CKD

■Treat underlying disease process – e.g. treat SLE, relieve obstruction,

identify and discontinue nephrotoxin (e.g., lithium) whenever pos-

sible

■Normalize BP using ACE inhibitor unless: a) patient has known

allergy; b) cough intolerable; c) hyperkalemic with K≥6.0 on K-

restricted diet; d) known or suspected critical renal artery stenosis

■Optimize glycemic control in diabetic (HgbA1c≤6.5%)

■Cease cigarette smoking (hard evidence)

■Improve dyslipidemia with low-saturated-fat diet and statin drug for

LDL-cholesterol (≤70 for highest risk [e.g., diabetic] and≤100 mg/dl

for non-diabetic) and triglyceride <150 mg/dl

■Dietary protein intake: 0.8 g/kg/day prior to dialysis. After initiation

of dialysis 1.0–1.4 g/kg/d for hemodialysis and 1.4–1.6 g/kg/d for

peritoneal dialysis.

Preserve Cardiac Function

■50% of deaths in patients with ESRD are cardiac in origin.

■Normalize BP, manage dyslipidemia with statins (see above); fibric

acid derivative for uncontrolled hypertriglyceridemia, stop smoking,

folic acid 5 mg/day to reduce risk of hyperhomocysteinemia

Manage Acid-Base and Electrolyte Disturbances

■Hyperkalemia:+EKG changes: IV Calcium gluconate, insulin,

inhaled beta-2 agonist, oral or rectal Kayexalate and dietary potas-

sium restriction (0.8 mEq/kg/day). - EKG change: diet/Kayexalate.