0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
350 Chronic Renal FailureManage 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 (1 mEq/kg/day). – EKG change: diet/kayexalate
■Acidosis: Check ABG, treat with oral sodium bicarbonate: 1 mEq/
kg/day as Shohl’s solution (1 mEq/ml); baking soda (60 mEq per tsp)
or NaHCO3 tabs (8 mEq/650 mg tab). 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 sevalemer HCl (Renalgel) 1–
2 tablets with meals. Measure PTH and 1,25(OH)2 vitamin D3 and
if elevated and reduced respectively, initiate 1,25(OH) vitamin D3
0.5–1.0 mg/day.
■Avoid malnutrition: 0.8 g/kg/day protein, 35 kcal/kg/day. Monitor
body weight, muscle mass, serum albumin, BUN (protein intake)
and Scr (muscle mass)Anemia
■Measure serum Fe, TIBC and ferritin and
■Treat Hct <33% with erythropoietin (EPO) and oral or intravenous
iron therapy. EPO SC once or twice weekly.
■No contraindications; BP may increase in 20–25% of patients.follow-up
■Every 3 months for patients with Ccr≤25 ml/min/1.73 m^2
■Increase frequency to as needed as patient approaches ESRD
■Labs at visit: chemistries, iron stores Hgb, spot urine protein/
creatinine ratio, goal is ratio of <1.0.complications and prognosis
Adverse drug events:
■ACE inhibition: cough, hyperkalemia, rarely angioedema (more
common in African-Americans)
■HMG-CoA reductase inhibitors: rhabdomyolysis, muscle pain or
asymptomatic CK elevation
■Vitamin D3 may cause hypercalemia.
■Loop diuretics: hypokalemia, hypomagnesemia, hypochloremic
metabolic alkalosis.
■End-Stage Renal Disease: nearly all patients with Ccr <25 ml/min/
1.73 m2 reach end-stage renal disease within 2 years. Mortality rate
on dialysis at 5 years is about 50%.