General Strategies In Retardation Of Chronic Kidney Disease

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General Strategies In Retardation Of Chronic
Kidney Disease
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Goals of CKD management

• RETARD CKD PROGRESSION
• BP control
• RAS blockade Proteinuria reduction
• Glycaemic control
• Lipidaemic control
• Smoking cessation
• Protein restriction
• Avoid nephrotoxic

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Hypertension in CKD

• HIGH PREVALENCE IN CKD
• OPTIMAL BP CONTROL have been shown to
• Retard progression of renal disease
• Regress LVH
• Reduce Cardiovascular morbidity and mortality

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Optimal BP
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Choice of anti-hypertensives
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Choice of anti-hypertensives
K/DOQI Hypertension and Antihypertensive agents
in CKD, CPG 2004
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Proteinuria/microalbuminuria in CKD
Marker of circulatory disease!!

• Early marker of diabetes nephropathy
• Marker for and a mechanism of kidney disease
  progression
• Independent risk factor for CVD
• Predictor of CVD mortality
• (Mogensen CENEJM 198410356-60)

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Proteinuria/microalbuminuria in CKD
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Management of proteinuria
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Initiation of ACEI/ARB treatment
ACE/ARB commenced
Check Cr and K within 7-14 days
Cr rise lt 30 BP not achieved No hyper K
Cr rise gt 30
Hyper K
stop drugs
mild
severe
assess for bilateral RAS
Increase ACEI dose
Low K diet
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Glycaemic Control

• Target
• HbA1C lt7.0
• FBS lt 6.0 mmol/l

• Intervention
• Diet
• Exercise
• OHGA
• Insulin

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Dyslipidaemia in CKD

• COMMON
• (Kasiske AJKD 1998(32)s142)
• High LDL
• High TG
• Low HDL
• High lipoprotein (a)

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Dyslipidaemia in CKD

• Experimental studies
• Hyperlipidaemia may accelerate the progression
  of CKD
• Meta-analysis (Friedman et al,JASN 2001)
• Lipid lowering could retard renal disease
  progression
• MDRD study
• Low HDL independent predictor of more rapid
  decline of GFR
• Large RCT are required to investigate the effect
  of lipid lowering on renal protection

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Dyslipidaemia in CKD

• CKD patients are at increased risk of
  cardiovascular disease (CHD risk equivalent)
• ? justify policy of active dietary
  pharmacologic intervention

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Smoking
Smoking
Vasoconstriction
thrombosis
direct toxic effects
vascular endothelium
increases in urine protein excretion
induces decline in renal function
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Smoking

• Independent risk factor for progression of

• inflammatory renal diseases
• eg Ig A disease
• non inflammatory renal diseases
• eg ADPKD
• diabetic nephropathy

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Smoking Cessation

• Strategies
• Counselling
• Nicotine replacement therapy

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Dietary Protein Restriction

• Meta-analysis
• 1413 pts, non diabetic
• Relative risk of renal failure/death -
• 0.67 (low vs usual)
• Protein restriction
• slow progression by 0.5 ml/min/yr.
• (Pedrini MT et al)

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Strategies for Renoprotection
Dietary Protein Restriction
Moderate restriction 0.6-0.8 g/kg/day
one matchbox sized cooked protein source is
equivalent to 7g of protein
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Avoid NSAIDS

• Non steroidal anti-inflammatory drugs

• acute usually reversible decline in GFR
• idiosyncratic forms of membranous nephropathy
• interstitial nephritis
• progressive nephrotoxicity - from chronic usage

• Use aspirin, tramadol

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Summary

• RETARD CKD PROGRESSION
• BP control
• RAS blockade Proteinuria reduction
• Glycaemic control
• Lipidaemic control
• Smoking cessation
• Protein restriction
• Avoid nephrotoxic

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TREAT TO TARGET
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THANK YOU