PreESRD Education

PreESRD Education: for Doctors

http://nephron.com/fkg.html

by Stephen Z. Fadem, M.D., FACP

Medical Director

Houston Kidney Center

Integrated Service Network

Specific Diseases

The Curriculum

Goals

Slow or retard kidney disease progression
Enable a smooth transition to dialysis or transplant therapy
Reduce dialysis morbidity and mortality through better health initiatives in the preESRD period
Give the patient the best chance for a permanent access - and reduce access morbidity
Avoid emergency dialysis
Reduce utilization of hospital and emergency room

Recommend

Start working with patient when serum creatinine is greater than 1.5 mg/dl (women) or greater than 2.0 mg/dl (men) - (NIH Criteria)
Start working with high risk patients (ie. diabetics) when urine albumin/creatinine ratio is abnormal (>30)
Patients see the team of physician, renal nurse, physician assistant, dietitian and social worker

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Stage 1

Asymptomatic
Hypertension
Microalbuminuria or proteinuria
Normal to mildly decreased GFR

Recommend

How the kidney works and preESRD lectures

The PreESRD Class

The PreESRD class is divided into Stage 1 and Stage 2/3 sessions.

Stage 1 focuses on preventitive aspects of kidney disease

Stage 2 and 3 focus on decreasing renal disease complications such as anemia, acidosis or hypoalbuminemia, making a decision as to modality and placement of an access.

Low protein diet - 0.6 to 0.8 grams/kg/bw
ACE Inhibitors -
Reduce dose of meds metabolized by kidney if creatinine greater than 2.0 mg/dl
Blood pressure control and monitoring - target mean arterial pressure 92 (126/75
Strict diabetic control if diabetic - monitor hbA1C levels, keep in the 6 range
Encourage good lifestyle (no smoking, low fat diet, exercise) - reduce cardiovascular risk factors
Folic acid to reduce homocysteine levels
Avoid NSAIDS (non-steroidal antianti-inflammatory drugs)
Instruction of all medical staff regarding vein preservation for AV Access
Follow-up urine albumin/creatinine ratio, urine urea nitrogen
Monitor diabetics for foot ulcers or wounds
Diabetic retina examiniation
Baseline Quality of Life Survey

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Stage 2a

Impaired renal function (Cr > 2.5) - creatinine clearance less than 25 cc/min
Metabolic acidosis (HCO3 < 24)
Anemic (Hct < 36%)

Recommend

If albumin falls, stop protein restriction (target albumin 4.0 g/dl)
Erythropoietin (Procrit) injections and iron supplements - target Hct of 36%
Bicarbonate tablets or citrate solution (taraget bicarbonate level - CO2 content - 24 meq/l)
Continued ACE inhibition, blood pressure control - check potassium levels
Calcium supplements,
Calcitriol tablets if parathyroid hormone is elevated
In diabetics - continued strict diabetic education and monitoring
Education as to various modes of renal replacement therapy
Tour of dialysis facility
Review Educational Videos - NKF's People Like US
Make modality decision
Meet with transplant coordinator - begin evaluation
When serum creatinine is 2.5 to 3.0 or creatinine clearance is 20 to 25 cc per minute, place AV Fistula - preferred over AV Graft

The AV Fistula

There are many advantages to having an arteriovenous fistula placed. However, it takes around two to three months to fully mature, and is more difficult to create.

Patients should decide what modality of therapy they desire in stage 2, early in the course of their disease, If hemodialysis is their choice, an a-v fistula should be created.

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Stage 2b

Creatinine clearance less than 20 cc/minute
Patient desires hemodialysis -

Recommend

Placement of AV fistula. If expected time to dialysis is too short, patient

may also require a tunneled cuffed catheter

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Stage 3

Creatinine clearance < 17 cc/minute
Albumin levels starting to decline
Measure nPNA and PCR - see NKF DOQI Guidelines and algorithm
Metabolic acidosis
Hyperphosphatemia

Recommend

Maintain adequate nutrition - Target albumin is 4.0 gm/dl
nPNA > 0.8 gm/kg/day
A V fistula or peritoneal dialysis catheter if not placed earlier
Continue erythropoietin (Target hematocrit = 36%)
Bicarbonate supplements (Target C02 content or bicarb level = 24 meq/l)
Maintain good blood pressure control (target dBP - in 70s)
Monitor potassiums closely
Monitor calcium and phosphorus levels

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ESRD

Initiate hemodialysis or peritoneal dialysis training when GFR (mean of urea and creatinine clearance) is below 10 cc/min (15cc/min in diabetics) - earlier if albumin is < 4.0 or when nPNA is < 0.8 gm/kg/day see NKF-DOQI algorithm
Begin hemodialysis as an outpatient with functioning A V access or
Begin peritoneal dialysis training with functioning peritoneal dialysis catheter
Ideally - Hematocrit = 36%, Serum albumin at 4 gm/dl and diastolic blood pressure <80 mm/hg or lower.
Repeat QOL survey