What are the complications of Stage 5 CKD (GFR<15)?
Mineral metabolism abnormalities (osteodystrophy, Calciphylaxis)
How should anemia be managed in CKD5?
Treat the Fe defeciency
Maintain Hb between 90-110
What drugs should be used for management of CKD in diabetics or non-diabetic proteinuria?
Preferred agents: ACEi or ARB
Drugs reducing CVD risk: Diuretic, CCB or BB
What are the mineral abnormalities in CKD?
Minerals abnormal usually when GFR<40
Decreased phosphate excretion (Hyperphosphatemia)
Reduced Vitamin D activation (Hypocalcemia)
Reduced Vitamin D levels
Increased PTH hyperplasia
What are the bone abnormalities in CKD?
Adynamic bone disease --> Osteitis fibrosa cystica
Weakness, bone pain, fractures, anemia
What are the consequences of Calciphylaxis in CKD?
- Calcification of arterioles ==> Ischemia and subcute necrosis
- Thrombotic vaso-occlusion
How are the mineral abnormalities in CKD managed?
Eliminate Phosphate from the body
- Phosphate binders
- Mg, Al
Replaced Vit D (Provide activated Vit D)
Ca-sensing R analogue to counteract HyperPTH
How should calciphylaxis in CKD be managed?
Avoid calcium based phosphate binders
Normalize PTH: Cinacalet or parathyroidectomy
What is are CVD risk factors in CKD?
Increased CV risk and mortality
•Cardiovascular risk factors
-Traditional: hypertension, lipids
-Non traditional: inflammation, uremia, homocysteine
What are the indications of initiating kidney replacement therapy in CKD?
Uncontrolled HyperKalemia or Metabolic acidosis
Uncontrolled Pulmonary edema/Volume overload
What are the different Kidney replacement therapy options available?
What is the basic principle behind hemodialysis?
◦Diffusive transport - function of concentration difference
◦Convective transport - solute drag with ultrafiltration
◦Performed by creating hydrostatic pressure across the dialyzer membrane (TMP)
What are the basics behind peritoneal dialysis?
•Diffusive transport -
•surface area and membrane characteristics of the peritoneal membrane
•molecular size of the solute
•Convective transport -
-solute drag with fluid across membrane
-Due to oncotic pressure of the dialysate within the peritoneum
What is the general approach to toxicology?
A = Airway
B = Breathing
C = Circulation
D = Decontamination
E = Eliminate
What are the contraindications and complications of urinary alkalization?
Contraindicated in Pulmonary edema, Cerebral edema, severe renal failure
Complications: Alkalosis, hypoKalemia, hypoCalcemia
HD is preferred for removal of which elements?
Preferred for: water-soluble, LMW, non-protein bound
Hemoperfusion is preferred for removal of which elements?
Lipid soluble, highly protein bound and large MW
What are the indications for hemodialysis in ASA overdose?
ASA level > 6 mmol/L at >6h post ingestion
Chronic overdose with altered LOC
Noncardiogenic pulmonary edema
Severe refractory metabolic acidosis
Confusion or worsening neurologic symptoms
Renal failure (since ASA excreted by kidney)
Deterioration in condition despite supportive care
How can enhanced elimination of MeOH or ethylene glycol be ensured?
Alcohol Dehydrogenase Inhibitor
- methylpyrazole inhibits conversion of methanol to toxic metabolites
- Ethanol drip: methanol eliminated by kidney and lungs slowly
Folate, Thiamine, pyridoxine
- Removes methanol AND its toxic metabolites