Medical Management Of CRF

Medical Management

The three treatment options for CKD are medical management, dialysis or transplant

• All patients with CKD are treated initially by medical management (medicine, dietary advice and monitoring)
• Severe damage in CKD (ESKD) requires kidney replacement by dialysis or transplant.

Why is medical management very important in CKD?

There is no cure for CKD. Advanced CKD needs dialysis or kidney transplant to maintain life. Because of the high cost and problems of availability, in India only 5 -10% of kidney patients get treatment like dialysis and kidney transplant, while the rest die without getting any definitive therapy. Therefore, early detection and meticulous conservative medical management is the only feasible and less expensive way to manage CKD and delay the need for dialysis or transplant.

Initiation of proper therapy at early stages of CKD is most rewarding. Most patients are asymptomatic or feel very well with proper therapy in early stages. Because of the absence of symptoms many patients and their families fail to recognize the seriousness of the disease and discontinue medicine and dietary restrictions. Discontinuation of therapy may lead to rapid worsening of kidney function requiring expensive dialysis or kidney transplantation.

In CKD with early medical management patients can live a long life.

In CKD with early medical management patients can live a long life.

What are the goals of medical management in CKD?

CKD is a progressively deteriorating condition with no cure. The aims of medical management are to:

• Slow down the progression of the disease.
• Treat underlying causes and contributing factors.
• Relieve symptoms and treat complications of the disease.
• Reduce the risk of developing cardiovascular disease.
• Delay the need for dialysis or transplant.
 

What are the treatment strategies in different stages of CKD?

Treatment strategies and recommended actions in different stages of chronic kidney disease are summarized in this table.

Chronic kidney disease is not curable, but early treatment is most rewarding.

Nine Steps for Medical Management of CKD

1. Management of Primary Aetiology

Identifying and treating these underlying primary conditions may help prevent, delay or reverse the progression of CKD

• Diabetes mellitus and hypertension.
• Urinary tract infection or obstruction.
• Glomerulonephritis, renovascular disease, analgesic nephropathy etc.

2. Strategies to Slow Down the Progression of CKD

Your doctor may prescribe important and effective measures to slow down the progression of CKD such as:

• Strict blood pressure control and ACE inhibitor or angiotensin II receptor–blocker therapy.
• Protein restriction.
• Lipid lowering therapy.
• Correction of anaemia.

3. Supportive and Symptomatic Treatment

• Water pill (diuretics) to increase volume of urine and reduce swelling.
• Drugs to control nausea, vomiting and gastric discomforts.
• Supplementation of calcium, phosphate binders, active form of Vitamin D and other drugs to prevent and correct CKD related bone disease.
• Correction of low haemoglobin (anaemia) with iron, vitamins and erythropoietin injections.
• Prevention of cardiovascular events. Start daily aspirin advised unless contraindicated.

In CKD treatment of underlying causes delay the progression of CKD.

 

4. Management of Reversible Factors

Search and treat reversible factors that may have aggravated or exacerbated the degree of kidney failure. By correction of reversible factors kidney failure may improve, and kidney function may return to stable base level of function. The common reversible causes are:

• Volume depletion.
• Kidney failure due to drugs (non steroidal anti-inflammatory drugs or NSAIDs, contrast agents, aminoglycosides antibiotics).
• Infection and congestive heart failure.

5. Identify and Treat Complications of CKD

Complications of CKD require early diagnosis and immediate treatment. The common complications which need attention are severe fluid overload, high potassium level in blood (potassium > 6.0 mEq/L), and severe ill effects of advanced kidney failure on heart, brain and lungs.

6. Life Style Modification and General Measures

These measures are important in reducing overall risk:

• Stop smoking.
• Maintain healthy weight, exercise regularly and remain physically active on a regular basis.
• Limit alcohol intake.
• Follow a healthy eating plan and reduce dietary salt intake.
• Medications should be taken as directed by the doctor. They may be adjusted according to the severity of the kidney damage.
• Regular follow up and treatment as directed by a nephrologist.

Treatment of infection and volume depletion is most rewarding in chronic kidney disease.

7. Dietary Restrictions

Depending on the type and severity of kidney disease, dietary restrictions are needed in CKD (discussed in detail in Chapter 25).

• Salt (sodium): To control high blood pressure and swelling, salt restriction is advised. Salt restriction includes: not adding salt to foods at the table and avoiding salt rich food such as fast food, papad, pickles and minimizing the use of most canned foods.
• Fluid intake: Decreased urine volume in CKD patients can cause swelling and in severe cases even breathlessness. Therefore, fluid restriction is advised for all CKD patients with swelling.
• Potassium Blood potassium levels usually rise in CKD patients. This can have life-threatening effects on the heart activity. To prevent this, intake of potassium-rich foods (such as dry fruit, coconut water, potatoes, oranges, bananas, tomatoes etc.) should be restricted as advised by a doctor.
• Protein: Patients with CKD should avoid high-protein diets which may accelerate the rate of kidney damage.

8. Preparation for Kidney Replacement Therapy

• Protect veins of the non-dominant forearm as soon as CKD is diagnosed.
• Use of the veins of this arm should be avoided for blood collection or IV infusions.
• As kidney function deteriorates and ESKD approaches, dialysis or transplantation will be indicated. A nephrologist will discuss further treatment options with patients and their families, depending on the medical needs of the patient as well as personal preference. Dialysis modalities include haemodialysis or peritoneal dialysis.
• If haemodialysis is preferred, patients and their families should be educated and advised to have an AV fistula created – preferably 6 to 12 months prior to the anticipated need for initiating haemodialysis.
• A CKD patient may also qualify for pre-emptive kidney transplantation. Here, the patient receives a kidney transplant form a live donor prior to the initiation of dialysis.
• Administration of Hepatitis B vaccination in the early stage of CKD reduces risk of Hepatitis B infection during dialysis or kidney transplantation. Four double doses of recombinant Hepatitis B vaccine at 0, 1, 2 & 6 months should be given, intramuscularly in the deltoid region.

In CKD dietary restrictions may delay the progression and prevent complications.

9. Referral to a Nephrologist

A person with CKD needs early referral to a nephrologist and pre- dialysis education to decrease morbidity and mortality. Early referral reduces the rate of progression to ESKD and may delay the need to initiate kidney (renal) replacement therapy.

Which is the most important treatment to prevent or delay the progression of CKD?

Whatever the underlying cause of CKD, strict control of blood pressure is the most important treatment to prevent or delay the progression of CKD. Uncontrolled blood pressure leads to rapid worsening of CKD and complications such as heart attack and stroke.

Which drugs are used to control high blood pressure?

The nephrologist or physician will select appropriate agents to control

In CKD protect veins of non-dominant forearm by avoiding blood collection or IV infusions.

Treatment of High Blood Pressure and Anaemia

Which is the most important treatment to prevent or delay the progression of CKD?

Whatever the underlying cause of CKD, strict control of blood pressure is the most important treatment to prevent or delay the progression of CKD. Uncontrolled blood pressure leads to rapid worsening of CKD and complications such as heart attack and stroke.

Which drugs are used to control high blood pressure?

The nephrologist or physician will select appropriate agents to control high blood pressure. The most common drugs used are angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, beta blockers and diuretics.

ACE inhibitors and ARBs are recommended as first line therapy to reduce blood pressure and also helps by slowing the progression of kidney damage, thereby, protecting the kidneys.

What is the goal of blood pressure control in CKD?

It is recommended to keep blood pressure below 130/ 80 mmHg.

Which is the best method to assess and monitor blood pressure control in CKD?

Periodic visits to a doctor help to know the blood pressure status. But buying a blood pressure instrument and using it regularly at home may be helpful to assess and monitor blood pressure control in CKD. Maintaining a chart of blood pressure recordings may help , the doctor adjust drug dosages and times of administration.

How do diuretic drugs help CKD patients?

Doctors may prescribe diuretic which are medicines that help to increase the volume of urine and reduce swelling and breathlessness in some patients. It is important to remember that these medicines may increase the volume of urine but do not improve the function of the kidney.

 

Why does anaemia occur in CKD and how is it treated?

When kidneys are functioning properly, they produce a hormone called erythropoietin, which stimulates the bone marrow to produce red blood cells. In CKD with reduction of kidney function, erythropoietin production also decreases, leading to anaemia.

Iron tablets, vitamins and, at times, intravenous iron injections are the first steps to treat anaemia due to CKD. Severe anaemia, or anaemia not responding to drug therapy, needs injections of synthetic erythropoietin, which help bone marrow to produce oxygen-carrying red blood cells. Erythropoietin injections are safe, effective and the preferred method of treating anaemia due to CKD. Transfusion of blood is quick and effective to correct anaemia in an emergency but is not the preferred method due to the risk of infection and allergic reactions.

Why does anaemia in CKD need treatment?

Red blood cells carry oxygen from lungs to all parts of the body. Anaemia (low haemoglobin) in CKD leads to weakness, fatigue, poor exercise capacity, breathlessness, rapid heartbeat, loss of concentration, intolerance to cold and chest pain and therefore, this needs early and proper treatment.

The most important treatment to delay the progression of CKD is strict control of blood pressure (less than 130/80).

Dialysis

Dialysis is a procedure by which waste products and excess water that accumulate in renal failure are removed from the body artificially. It is a life-saving technique for patients with End Stage Kidney Disease (ESKD) or Acute Kidney Failure.

How does dialysis help people with severe kidney failure?

Dialysis helps the body by performing the following functions of failed kidneys:

• Purification of blood by removal of waste products such as creatinine, urea etc.
• Removal of excess fluid and maintenance of the right amount of water in the body.
• Correction of electrolyte and acid-base balance disturbances.

However, dialysis cannot replace all the functions of a normal kidney such as production of the hormone erythropoietin needed to maintain haemoglobin levels.

 

When is dialysis needed?

When the kidney function is reduced by 85-90% from the normal (ESKD) waste products and fluids build up in the body. The accumulation of toxins such as creatinine and other nitrogenous waste products leads to symptoms such as nausea, vomiting, fatigue, swelling and breathlessness. These are collectively termed as uraemia. At this point, medical management becomes inadequate and the patient will need to start dialysis.

Can dialysis cure chronic kidney disease?

No. Chronic kidney disease is irreversible and once a patient reaches Stage 5 (ESKD), lifelong dialysis treatments will be needed unless successful kidney transplantation is performed. On the other hand, a patient with AKI may need dialysis support only for a short period until kidney function recovers.

Dialysis is a prompt and effective treatment modality in symptomatic patients with severe kidney failure.

 

Types of Dialysis

What are the types of dialysis?

There are two main types of dialysis

1. Haemodialysis:

In haemodialysis (HD), waste products and excess fluids are removed from the blood by passing the blood through a special filter or artificial kidney called a dialyzer, aided by a dialysis machine.

2. Peritoneal Dialysis:

In peritoneal dialysis (PD), a soft tube or catheter is inserted through the skin, into the abdominal cavity and dialysis solution is infused into the abdominal cavity to remove waste products and excess fluid from the body. This is done at home, usually without a machine.

Which factors determine selection of dialysis modality in ESKD patients?

Haemodialysis and peritoneal dialysis both are effective modalities in ESKD patients. No single dialysis modality is best suited for all patients. After considering advantages and disadvantages of each dialysis modality, selection of HD or PD is made jointly by the patient, family members and the nephrologist. Major factors determining this selection are cost of therapy, age, comorbid conditions, distance of haemodialysis center, educational status, physician bias and the patient’s preferences and lifestyle. Because of low cost and easy availability, haemodialysis is preferred by a large number of patients in India.

Dialysis can not cure kidney failure, but helps patients to live comfortably in spite of kidney failure.

Do dialysis patients need to restrict their diet?

Yes. Common dietary recommendations for dialysis patients are restriction of sodium, potassium, phosphorus and fluid intake. Dialysis patients must follow these dietary advices but dietary restrictions are reduced after dialysis is initiated in CKD.