0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Chronic Renal Failure 349➣Treat hypertension (present in >80% of cases)
Target blood pressure 120–130/70–80 mmHg with (in order):
ACE inhibitor/angiotensin II receptor blocker +thiazide
(serum creatinine≤1.8 mg/dl) or loop diuretic (serum creati-
nine >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 grams/
day).
➣Treat hyperkalemia and acidosis (see below)specific therapy
■Ccr 25–75 ml/min/1.73 m2, see “Preserve renal function”
■Ccr is <25 ml/min/1.73 m2, consult access surgeon, dietician and
social worker to assist in preparing for dialysis.
■Ccr <20 ml/min/1.73 m2 place vascular access (hemodialysis) or
plan peritoneal catheter in 6–12 months
■Ccr in range of 8–12 ml/min/1.73 m2 initiate maintenance renal
replacement therapy unless: a) patient’s weight is stable; serum
albumin is at least at lower limit of normal range for laboratory;
c) patient is symptom-freePreserve (Remaining) Renal Function for all Levels of CRF
■Treat underlying disease process, e.g. treat SLE, relieve obstruction,
discontinue nephrotoxin whenever possible
■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 steno-
sis
■Optimize glycemic control in diabetic (HgbA1c≤5.5%)
■Cease cigarette smoking (hard evidence)
■Improve dyslipidemia, i.e. LDL-cholesterol (≤100 mg/dl for diabetic
and≤130 mg/dl for non-diabetic) and triglyceride <250 mg/dl
■Dietary protein intake: 0.8 g/kg/day represents minimal restriction,
no malnutrition in clinical trialsPreserve Cardiac Function
■50% of deaths in patients with ESRD are cardiac in origin.
■Normalize BP, manage dyslipidemia with HMG coA reductase
inhibitor or fibric acid derivative, stop smoking, folic acid 5 mg/day
to reduce risk of hyperhomocysteinemia