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can’t eliminate them all. The phosphate binds with calcium Pathophysiology: fibrosis – no more compensation in
leading to a decrease in ionized calcium leading to whatever aspect of excretion
secondary hypoparathyroidism
Erythropoietin Production
• In DM, anemia occurs early Management of ESRD
A. Supportive
Management of Chronic Renal Failure 1. Nutrition
2. Psychological
A. Comprehensive strategy for renoprotection in 3. Control BP
patients with chronic renal disease 4. Maintain Hb at 110-120 g/dl with
Intervention Therapeutic Goal erythropoietin oral iron is not absorbed very\well
by uremic patient; it’s better to give it to them IV
Specific renoprotective
therapy Proteinuria <0.5 g/day 5. Fluid and electrolyte balance
ACE inhibitor or ARB GFR decline <2 6. Acid-base homesotasis
treatment ml/min/year 7. Maintain Ca and Phosphate balance – give
Calcium carbonate or Calcium acetate with meals.
Adjunctive cardiorenal You eat meat, and meat has phosphate. Para habang
protective therapy nakakapagbigay ka ng calcium, nakakapag prevent
Additional <130/80 mm Hg ka na rin ng absorption ng phosphate. You “shoot two
birds with one stone”
antihypertensive
B. Renal Replacement Therapy
therapy
1. Dialysis
Dietary protein restriction
2. Hemodialysis
Dietary salt restriction 0.6-0.8 g/kg/day
3. Peritoneal Dialysis
Tight glycemic control 3-5 g/day
4. Transplant
in diabetes
5.
Reduce elevated AIC < 6.05 % - Consider dialysis if creatinine clearance is about 20ml/min
calcium-phosporous Normal values - Uremic symptoms present with nausea and vomiting. If the disease
is not ESRD, consider other etiologies for the said symptoms
Lipid lowering therapy LDC-C <100mg/dl - Excess fluid in the body – volume overload – diuretics won’t help
coz kidneys are already sclerosed
Anti-platelet therapy Thrombosis prophylaxis
Consider correction of Hb > 12g/dl Renal Replacement Therapy in CRF
anemia - indicated when metabolic abnormalities can no
Smoking cessation Abstinence longer be controlled with conservative
Weight control Ideal body weight management or when signs and symptoms of
uremia developed
• Level of proteinuria determines the level of dietary protein
restriction in patients
- No absolute value in terms of CR by which you will
• Reduce elevated electolyte Ca and P if <25%, it merits
start your RRT
checking
• The lecturer considers correction of anemia if Hb 11-12g/dl Indications for Dialysis
• Lipid lowering therapy (Statins) - volume overload
- intractable metabolic acidosis
B. Avoid insults to the kidney - hyperkalemia
- uremic state (encephalopathy, pericarditis)
•Volume depletion- diarrhea - azotemia without uremic manifestations
•Nephrotoxins- aminoglycosides, radiocontrast material
CASE
•NSAID- COX2 inhibitors, mefenamic acid, naproxene,
indomethacin
A 24-year old male diagnosed with chronic
C. Preparation for ESRD management glomerulonephritis was admitted for nausea and
vomiting. Maintenance of ACE inhibitors with HCTZ
• Psychological
(Hydrochlorothiazide) was given.
• Renal Replacement Therapy, options
o Dialysis – Vascular Access His last follow-up a week ago showed a Cr 1.8 mg%.
o Transplant – Recipient Donor Work-Up Three days PTA he had copious diarrhea and was
* with a creatinine clearance of 20 or 25, you unable to take anything including medicines. He noted
can start discussing dialysis with the patient decreased urine output. He felt weak and later
developed nausea and vomiting.
End Stage Renal Disease
Please see table on first page PE: BP = 90/60 PR = 110/min RR = 25/min
Excretory function:
Sunken eyeballs, dry skin and mucous membranes
Nausea and vomiting- SSX of accumulation of BUN, creatinine
Maintenance of Acid-Base Balance: BUN 80mg/dL; Cr 10mg/dL; K 6meq/L; Na 132 meq/L
• metabolic acidosis ABG: pH 7.2; HCO3 11meq/L; CO2 20meq/L
Maintenance of Fluid & Electrolyte Balance: Hgb: 15gm/dl (N14-17)
• body can’t eliminate waste products because it can’t Hematocrit: 45 (hemoconcentrated)
compensate; arrhythmia due to increased K Urinalysis: Sp gr = 1.010, (4+) protein, (–) sugar
Maintenance of Calcium-Phosphate Balance 4-5 RBCs/hpf, 10-15 WBCs/hpf
• Phosphate retained, binds to Ca, absence of Vit D3 decreased
gut absorption of Ca
Vitamin D Production What is your diagnosis?
Erythropoietin Production a. Acute renal failure
b. Chronic renal failure
•Anemia insidious in onset so you may have SSX in ESRD c. End stage renal failure
d. Acute on chronic renal failure
page
OS 214 CHRONIC RENAL FAILURE 3/3
EXCRETORY dR. IRMINGARDA GUECO, MARCH 6, 2005
GROUP
What finding tells us that the patient has renal If anemic (Hb 10g/dl), what is the mgt?
failure?
a. K Answer: Give erythropoietin. If <10 g/dl, transfusion
b. pH
c. creatinine
From block B:
d. urinalysis –just a reflection that something’s wrong, but
not specific for renal failure Hyperkalemia – don’t give diuretics because patient is
dehydrated; give sodium bicarbonate -> push K inside
the cell, decrease K levels contraindication of sodium
Answer: Creatinine bicarbonate: presence of NVE, crackles, edema
Hydration removes hemoconcentration. After hydration,
What is the cause of the ABG finding? observe true level of Hgb. If low Hgb -> address
anemia.
e. Chronic GN
If Pt does not improve -> Ultrasound, check for other
f. Diarrhea renal problems
g. Vomiting
h. Acute renal failure
Decreased ionized
Ca2+
Decreased
expression
of calcium-
sensing Hyperparathyroidism
receptor
Hyperplasia
of the
parathyroid
glands