DISEASE INFLUENCING FACTORS : DIET, LIFE STYLE, ENVIRONMENT, SMOAKING, ALCOHOL, DRUG ABUSE & LACK OF EXERCISE
ASSOCIATED WITH SEVERAL BONE DISEASES :
OSTEITIS FIBROSA CYSTICA, MIXED RENAL OSTEODYSTROPHY, RICKETS, OSTEOMALACIA
Medical Care: Medical care of the patients with CKD should focus on the following:
" Delaying or halting progression of CKD
o Treatment of the underlying condition if possible
o Aggressive blood pressure control to target values per current guidelines
o Use of ACE inhibitors as tolerated, with close monitoring for renal deterioration and for hyperkalemia (avoid in advanced renal failure, bilateral renal artery stenosis [RAS], RAS in a solitary kidney)
o Aggressive glycemic control per the American Diabetes Association (ADA) recommendations; target HbA1C <7.0%
o Protein restriction - Controversial
o Treatment of hyperlipidemia to target levels per current guidelines
o Avoidance of nephrotoxins - IV radiocontrast, nonsteroidal anti-inflammatory agents, aminoglycosides
" Treating pathologic manifestations of CKD, including the following:
o Anemia with erythropoietin
o Hyperphosphatemia with dietary phosphate binders and dietary phosphate restriction
o Hypocalcemia with calcium supplements +/- calcitriol
o Hyperparathyroidism with calcitriol or vitamin D analogs
o Volume overload with loop diuretics or ultrafiltration
o Metabolic acidosis with oral alkali supplementation
o Uremic manifestations with chronic renal replacement therapy (hemodialysis, peritoneal dialysis, or renal transplantation): Indications include severe metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable volume overload, failure to thrive and malnutrition, peripheral neuropathy, intractable gastrointestinal symptoms, and GFR less than 10 mL/min.
o Cardiovascular complications
" Timely planning for chronic renal replacement therapy
o Early education regarding natural disease progression, different dialytic modalities, renal transplantation, patient option to refuse or discontinue chronic dialysis
o Timely placement of permanent vascular access (arrange for surgical creation of primary arteriovenous fistula, if possible, and preferably at least 6 months in advance of anticipated date of dialysis)
o Timely elective peritoneal dialysis catheter insertion
o Timely referral for renal transplantation
Diet:
" Protein restriction early in CKD as a means to delay a decline in GFR is controversial; however, as the patient approaches CKD stage 5, this is recommended to delay the onset of uremic symptoms. Patients with CKD who already are predisposed to becoming malnourished are at higher risk for malnutrition with overly aggressive protein restriction. Malnutrition is a well-established predictor of increased morbidity and mortality in the ESRD population and must be avoided if possible.
" Phosphate restriction starting early in CKD
" Potassium restriction
" Sodium and water restriction as needed to avoid volume overload