0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
332 Chronic Kidney Disease■Acidosis: Check ABG, treat with oral sodium bicarbonate: 1 mEq/
kg/day as Shohl’s solution (1 mEq/ml); baking soda (60 mEq/tsp)
or NaHCO3 tabs (8 mEq/650 mg tab). For pH <7.15. consider intra-
venous NaHCO3 therapy. Renal osteodystrophy: Goal to normalize
calcium and phosphorus, lower PTH and increase vitamin D: Dietary
phosphate restriction to 12 mg/kg/day. Add Ca- based binder (Ca
Acetate of Ca Carbonate) or non-Ca-based binder such as sevalemer
HCl (Renalgel) 1–4 tablets with meals. Measure PTH and 25(OH)2
vitamin D3. If PTH elevated and 25 (OH)2 vitamin D3 low, admin-
ister ergocalciferol 50,000 units monthly for 6 months and repeat
PTH. If still elevated, administer active vitamin D such as calcitriol
or paricalcitriol.
■Avoid malnutrition: 0.8 g/kg/day protein, 35 kcal/kg/day prior to
dialysis (see above). Monitor body weight, muscle mass, serum albu-
min, BUN (protein intake) and Scr (muscle mass).Anemia
■Measure serum Fe, TIBC and ferritin.
■Treat hemoglobin <11 g/dl with subcutaneous erythropoietin or dar-
bepoietin subcutaneously along with oral or intravenous iron ther-
apy.
■No contraindications; BP may increase in 20–25% of patients.follow-up
■Every 3 months for patients with eGFR or Ccr≤25 ml/min/1.73 m^2
■Increase frequency as needed as patient approaches ESRD
■Labs at visit: chemistries, iron stores, hemoglobin, spot urine albu-
min or protein/creatinine ratio. Goals: urine albumin/creatinine
ratio <300 mg/g, urine protein/creatinine <200 mg/g.complications and prognosis
Adverse drug events:
■ACE inhibitors: cough, hyperkalemia, rarely angioedema (more com-
mon in African-Americans)
■HMG-CoA reductase inhibitors: rhabdomyolysis, muscle pain or
asymptomatic CK elevation
■Active vitamin D3 (e.g., calcitriol) may cause hypercalemia.
■Loop diuretics: hypokalemia, hypomagnesemia, hypochloremic
metabolic alkalosis
■ESRD: nearly all patients with Ccr <25 ml/min/1.73 m^2 reach ESRD
within 2 years. Mortality rate on dialysis at 5 years is about 50%.