Azotemia: Treatment & Medication Treatment Medical Care Prerenal azotemia o If volume depletion is due to free water loss,

, the serum sodium is often greater than 10 mEq/L. The amount of fluid repla ement in liters !free water defi it" an #e estimated from serum sodium !patients $a%1&0/1&0 ' 0.( ' weight in )g". The free water defi it should #e administered intravenousl* over +%, hours and should onsist of h*potoni solutions, su h as 0.(- $a.l or /(0. 1lert patients should #e en ouraged to drin) free water as mu h as tolerated2 otherwise, free water an #e administered via a nasogastri tu#e. 3erum sodium should #e measured ever* 4%, hours, and fluid repla ement should #e ad5usted to avoid a pre ipitous de line. The rate of de rease in serum sodium should #e no more than 0.6 mEq/h !16 mEq/+& h" to avoid #rain edema. 7olume depletion due to #lood loss requires I7 saline and transfusion to maintain pressure !as well as interventions to halt further loss". o /iarrhea often auses isotoni volume loss requiring repla ement with normal saline. $ormal anion gap meta#oli a idosis o urring with diarrhea requires #i ar#onate in 0.(- normal saline infusion. o /iureti indu ed volume depletion, espe iall* in the elderl*, manifests as deh*dration, h*ponatremia, and, o asionall*, h*po)alemia. The treatment of hoi e is normal saline infusion and orre tion of h*po)alemia. o /e reased ardia output requires optimizing ardia performan e #* areful use of diureti s, an 1.E inhi#itor, #eta%#lo )ers, nitrates, positive inotropi agents !in luding do#utamine", and, when indi ated, spe ifi therap* for the ause of impaired ardia fun tion. 0hen 1.E inhi#itors are ontraindi ated #e ause of h*per)alemia, the om#ination of nitrates and h*dralazine offers an alternative. 1s these patients tend to have ris) fa tors for ma rovas ular disease, the diagnosis of is hemi nephropath* or atheroem#oli disease should #e entertained when renal fun tion ontinues to worsen despite optimization of ardia fun tion. o /e reased effe tive arterial volume due to s*stemi shunting an result from sepsis or liver failure !hepatorenal s*ndrome 89:3;". These patients often pose a management pro#lem #e ause of severe edema, h*ponatremia, and h*poal#uminemia. /e reased on oti pressure and in reased vas ular permea#ilit*, as well as e<aggerated salt and water retention, shift the 3tarling for es toward formation of interstitial fluid. Effe tive treatment of sepsis with the appropriate anti#ioti s and h*potension with dopamine and norepinephrine is mandated. .r*stalloid repla ement an #e tried, #ut it often leads to more edema. o =or the severel* h*poal#uminemi patient, salt%poor al#umin infusion an #e underta)en, #ut there is no on lusive eviden e of #enefit. 1dequate nutrition and effe tive treatment of sepsis ma* improve on oti pressure and normalize vas ular permea#ilit*, there#* de reasing the s*stemi shunting. The net result is improved renal perfusion, de reased salt and water retention, improved output, and edema. In the 9:3, the average survival is 1%+ wee)s2 however, there is eviden e that the )idne*s will re over with earl* liver transplantation. > asionall*, renal fun tion is advan ed, requiring repla ement therap*. Intrarenal azotemia o 1 ute renal failure Is hemi or nephroto<i 1T$ The initial approa h is to restore pressure !with fluid repla ement" and to withdraw nephroto<i drugs. If oliguria persists, al#umin in om#ination with high%dose furosemide should #e tried. The use of al#umin in this onte<t allows more lasi< to #e #ound to al#umin for deliver* to the organi anion transporter in the )idne*, there#* allowing more lasi< to enter the tu#ule than would otherwise. >ther approa hes that have no on lusive #enefit in lude renal dose dopamine and s*ntheti atrial natriureti peptide. The renal failure phase usuall* lasts 6%+1 da*s if the primar* insult an #e orre ted. Postis hemi pol*uria an #e seen in the re over* phase and represents an attempt to e< rete e< ess water and solute. 3aline

ma* #e repla ed !6(- of output" as maintenan e fluid #e ause of salt wasting during this phase. 9*po)alemia ma* result from the saline diuresis. 9owever, mat hing the hourl* output with intravenous repla ement is not re ommended. :e over* is mar)ed #* the return of ?@$ and reatinine levels to near #aseline values. 1 ute interstitial nephritisA Banagement is #* withdrawal of the offending nephroto<in, avoidan e of further nephroto<i e<posure, and deh*dration. The reatinine level #egins to improve within C%( da*s. :enal #iops* ma* #e indi ated if renal failure is severe or azotemia is not improving. >n e the diagnosis is onfirmed, a trial of oral prednisone !starting at 1 mg/)g/d and tapering over 4 w)" or intravenous pulse meth*lprednisolone !1 g for C d" in severe ases an #e onsidered. If the patient is a poor andidate for #iops* #ut the diagnosis is strongl* suspe ted, therap* should #e started. :adio ontrast%indu ed azotemiaA This #e omes evident C%( da*s after e<posure. It is #est prevented with adequate h*dration with half%normal saline at 1 mL/)g/h 1+ hours prior to administration of ontrast and the use of smaller amounts of ontrast. .learl* e<plain the ris)s of su h pro edures to the patient. The #enefits of N %a et*l *steine and sodium #i ar#onate are still #eing de#ated. @ntil further eviden e is derived from lini al trials, there are no ontraindi ations for using these agents to help prevent ontrast%indu ed nephropath*. o .hroni )idne* disease It is important that patients with .D/ #e referred earl* to a nephrologist for the management of ompli ations and for the transition to renal repla ement therap* !ie, hemodial*sis, peritoneal dial*sis, renal transplantation". There is some eviden e that earl* referral of patients with .D/ improves short%term out ome. /isease progression an #e slowed #* various maneuvers, su h as aggressive ontrol of dia#etes, h*pertension, and proteinuria, and dietar* protein and phosphate restri tion, as well as spe ifi therapies for some of the glomerular diseases, su h as lupus. 1nemia, h*perphosphatemia, a idosis, and h*po al emia should #e aggressivel* managed prior to renal repla ement therap*. Postrenal azotemia o :elief of the o#stru tion is the mainsta* of therap*. o In anuria, #ladder atheterization is mandator* to rule out #ladder ne ) o#stru tion, whereas in progressive azotemia, atheterization should #e done after the patient has voided to determine the postvoid residual volume. 1 postvoid residual volume of 100 mL or more is suggestive of o#stru tive uropath*, and the ause should #e further investigated. Surgical Care @nilateral or #ilateral per utaneous nephrostom* o If h*dronephrosis is due to ureteral o#stru tion, unilateral or #ilateral stents or per utaneous nephrostom* is performed. :e over* of renal fun tion ta)es 6%10 da*s, #ut renal fun tion ma* #e severel* impaired, requiring dial*sis until su h time that partial re over* is adequate for withdrawal of dial*sis. o @p to (00%1000 mL/min of posto#stru tive pol*uria an #e seen with relief of o#stru tion, whi h is appropriate and represents an attempt to e< rete the e< ess fluid during the period of o#stru tion. o ?e ause of salt wasting during this phase, deh*dration and h*po)alemia are li)el*. Thus, two thirds of the urine output should #e repla ed with half%normal saline and potassium hloride if h*po)alemi . .lose monitoring is indi ated to prevent h*potension and prerenal azotemia. o Bat hing the hourl* urine output with intravenous fluids is not re ommended sin e e< ess water retention during the period of o#stru tion annot #e lost if hourl* urine output is mat hed. Medication The goals of therap* are to in rease renal perfusion and to maintain urine output. 3pe ifi therap* for various s*stemi onditions affe ting the )idne* is dis ussed in other arti les. Diuretics To indu e urine output in 1T$, treat edema and h*pertension. These drugs in rease urine e< retion #* inhi#iting sodium and hloride rea#sorption at different sites in the nephron.

Furosemide (Lasix) /rug of hoi e as a diureti . Inhi#its sodium hloride rea#sorption in the thi ) as ending lim# of the loop of 9enle. Dosing Interactions Contraindications Precautions Adult 1%+ mg/)g/dose, 1 or + doses P>/I7 qd2 ma<imum 400 mg/d is rarel* used due to ris) of ototo<i it*2 ontinuous I7 infusion an #e given at 0.1 mg/)g/h Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Metolazone (M !rox" #aroxol n) 1d5un t to furosemide in severe edematous states or when furosemide alone does not a hieve adequate diuresis. In reases e< retion of sodium, water, potassium, and h*drogen ions #* inhi#iting rea#sorption of sodium in distal tu#ules. Betolazone ma* #e more effe tive in impaired renal fun tion. Dosing Interactions Contraindications Precautions Adult (%+0 mg P> qd Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Adrenergic agents These agents stimulate vasodilation of the renal vas ulature and enhan e perfusion.

Do$amine (Intro$in) 1#ove a riti al dose !renal dose", this drug #e omes a potent vaso onstri tor. :enal dose dopamine is used widel*, #ut #enefit has not #een esta#lished learl*. Dosing Interactions Contraindications Precautions Adult 1%( m g/)g/min ontinuous I7 infusion for renal vasodilation2 (%+0 m g/)g/min I7 for treatment of sho ) Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Plasma %olume ex$anders In rease plasma on oti pressure and mo#ilize fluid from the interstitial spa e into the intravas ular spa e in h*poal#uminemi patients. Enhan e deliver* of furosemide to distal tu#ule. Al&umin (Al&uminar" Al&umisol" Al&unex" Al&utein) 3upplied as a (- solution in +(0 mL or +(- in (0 mL. Preferen e is #ased on whether patient requires additional fluid repla ement. $ot used for nutritional supplementation2 thus, attempts should #e made to improve patientEs nutrition. Dosing Interactions Contraindications Precautions Adult 0.(%1 g/)g/dose I7 not to e< eed 4 g/)g/d in severe depletion in intravas ular volume when h*poal#uminemia is present Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Corticosteroids Potent anti%inflammator* agent and immunosuppressant. 3uppresses humoral and ellular response to tissue in5ur*, there#* redu ing inflammation. Prednisone (Deltasone" 'rasone" Meticorten" Stera$red) @sed ommonl* for man* forms of glomerulonephritis and interstitial nephritis Dosing Interactions Contraindications Precautions Adult 0.(%+ mg/)g/d, P> at least 40 mg/d for man* forms of glomerulonephritis2 for interstitial nephritis, dose is ontinued for + w) and tapered over 4 w) Pediatric $ot esta#lished %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% C(ronic )enal Failure: Treatment & Medication Treatment Medical Care The medi al are of patients with hroni )idne* disease should fo us on the followingA /ela*ing or halting the progression of hroni )idne* disease o Treatment of the underl*ing ondition if possi#le o 1ggressive #lood pressure ontrol to target values per urrent guidelines. 3*stoli #lood pressure ontrol is onsidered more important and is also onsidered diffi ult to ontrol in elderl* patients with hroni )idne* disease. o @se of 1.E inhi#itors or angiotensin re eptor #lo )ers as tolerated, with lose monitoring for renal deterioration and for h*per)alemia !avoid in advan ed renal failure, #ilateral renal arter* stenosis 8:13;, :13 in a solitar* )idne*". /ata support the use of 1.E inhi#itors/angiotensin re eptor #lo )ers in dia#eti )idne* disease with or without proteinuria. 9owever, in nondia#eti )idne* disease, 1.E inhi#itors/angiotensin re eptor #lo )ers are effe tive in retarding the progression of disease among patients with proteinuria of less of than (00 mg/d. o 1ggressive gl* emi ontrol per the 1meri an /ia#etes 1sso iation !1/1" re ommendations !target 9#11. F6-" o Protein restri tion % 1lthough the Bodifi ation of /iet in :enal /isease !B/:/" 3tud* failed to show the effe t of protein restri tion in retardation of the progression of )idne* disease, a meta% anal*sis suggests a #enefi ial role for protein restri tion. The $ational Didne* =oundation !$D=" guidelines suggest that if a patient is started on protein restri tion, the ph*si ian needs to losel* monitor the patientEs nutritional status. Predial*sis low serum al#umin is asso iated with a poor out ome among dial*sis patients. o Treatment of h*perlipidemia to target levels per urrent guidelines o 1voidan e of nephroto<ins % I7 radio ontrast, nonsteroidal anti%inflammator* agents, aminogl* osides o En ourage smo)ing essation, as smo)ers tend to rea h E3:/ earlier than nonsmo)ers. Treating the pathologi manifestations of hroni )idne* disease, in luding the followingA o 1nemia with er*thropoietin, with the goal #eing 11%1+ g/dL, as normalization of hemoglo#in in patients with hroni )idne* disease stages &%( has #een asso iated with an in reased ris) of om#ined out ome. ?efore starting Epogen, iron stores should #e he )ed, and the aim is to )eep iron saturation at C0%(0- and ferritin at +00%(00. o 9*perphosphatemia with dietar* phosphate #inders and dietar* phosphate restri tion o 9*po al emia with al ium supplements with or without al itriol o 9*perparath*roidism with al itriol or vitamin / analogs o 7olume overload with loop diureti s or ultrafiltration

Beta#oli a idosis with oral al)ali supplementation @remi manifestations with hroni renal repla ement therap* !hemodial*sis, peritoneal dial*sis, or renal transplantation"A Indi ations in lude severe meta#oli a idosis, h*per)alemia, peri arditis, en ephalopath*, intra ta#le volume overload, failure to thrive and malnutrition, peripheral neuropath*, intra ta#le gastrointestinal s*mptoms, and the G=: less than 10 mL/min. o .ardiovas ular ompli ations Timel* planning for hroni renal repla ement therap* o Earl* edu ation regarding natural disease progression, different dial*ti modalities, renal transplantation, patient option to refuse or dis ontinue hroni dial*sis o Timel* pla ement of permanent vas ular a ess !arrange for surgi al reation of primar* arteriovenous fistula, if possi#le, and prefera#l* at least 4 months in advan e of anti ipated date of dial*sis" o Timel* ele tive peritoneal dial*sis atheter insertion o Timel* referral for renal transplantation Consultations Earl* nephrolog* referral !de reases mor#idit* and mortalit*" :enal dietitian 7as ular surger* for permanent vas ular a ess General surger* for peritoneal atheter pla ement :eferral to renal transplant enter Diet Protein restri tion earl* in hroni )idne* disease as a means to dela* a de line in the G=: is ontroversial2 however, as the patient approa hes hroni )idne* disease stage (, this is re ommended to dela* the onset of uremi s*mptoms. Patients with hroni )idne* disease who alread* are predisposed to #e oming malnourished are at higher ris) for malnutrition with overl* aggressive protein restri tion. Balnutrition is a well%esta#lished predi tor of in reased mor#idit* and mortalit* in the E3:/ population and must #e avoided if possi#le. Phosphate restri tion starting earl* in hroni )idne* disease Potassium restri tion 3odium and water restri tion as needed to avoid volume overload 3ee related .BE at $ew Guidelines 1ddress $utritional $eeds of .hildren 0ith .hroni Didne* /isease. Medication P(os$(ate*lo+ering agents 9*perphosphatemia is treated with dietar* phosphate #inders and dietar* phosphate restri tion. 9*po al emia is treated with al ium supplements and possi#l* al itriol. 9*perparath*roidism is treated with al itriol or vitamin / analogs.
o o

Calcium acetate (Cal$(ron" P(osLo) =or treatment of h*perphosphatemia in hroni )idne* disease. .om#ines with dietar* phosphorus to form insolu#le al ium phosphate, whi h is e< reted in fe es. Dosing Interactions Contraindications Precautions Adult 1CC& mg P> with ea h meal2 in rease to #ring serum phosphate value to 4 mg/dL as long as h*per al emia does not develop2 ma* require as mu h as +44, mg Pediatric $ot esta#lished Dosing Interactions Contraindications

Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Calcium car&onate (Caltrate" ' stercal) =or treatment of h*perphosphatemia or as a al ium supplement in hroni )idne* disease. 3u essfull* normalizes phosphate on entrations in patients with hroni )idne* disease. .om#ines with dietar* phosphate to form insolu#le al ium phosphate, whi h is e< reted in fe es. Bar)eted in a variet* of dosage forms and is relativel* ine<pensive. Dosing Interactions Contraindications Precautions Adult 1%+ g P> divided #id/qid2 with meals as a phosphorous #inder2 #etween meals as a al ium supplement Pediatric &(%4( mg/)g/d P> divided qid Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Calcitriol ()ocaltrol" Calci,ex) @sed to suppress parath*roid produ tion and se retion in se ondar* h*perparath*roidism and for treatment of h*po al emia in hroni )idne* disease #* in reasing intestinal al ium a#sorption. Dosing Interactions Contraindications Precautions Adult 0.+( m g P> qd/qod 0.( m g I7 qd C times/w) In rease at &% to ,%w) intervals #* 0.+(%m g/d to a hieve target PT9 level and to maintain serum al ium levels at H%10 mg/dL Pediatric InitialA 1( ng/)g/d P> Baintenan eA (%&0 ng/)g/d P> Dosing

Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Doxercalci-erol (.ectorol) 1 vitamin / analog !1%alpha%h*dro<*ergo al iferol" that does not require a tivation #* the )idne*s. Indi ated for the treatment of se ondar* h*perparath*roidism in end%stage renal disease. Dosing Interactions Contraindications Precautions Adult 10 m g P> C times/w) at dial*sis2 ad5ust dose as needed to lower #lood iPT9 to 1(0%C00 pg/mL2 in rease dose #* +.( m g/, w) if iPT9 is not lowered #* (0- and fails to rea h the target range2 not to e< eed +0 m g/C times/w) 1lternativel*, & m g I7 C times/w)2 ma* ad5ust dose #* 1%+ m g/, w) to maintain iPT9 levels Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Lant(anum car&onate (Fosrenal) $on al ium, nonaluminum phosphate #inder indi ated for redu tion of high phosphorus levels in patients with end%stage renal disease. /ire tl* #inds dietar* phosphorus in upper GI tra t, there#* inhi#iting phosphorus a#sorption. Dosing Interactions Contraindications Precautions Adult InitialA +(0%(00 mg P> tid p ! hewa#le ta#s"2 ad5ust dose q+%Cw) to target serum phosphorus level Baintenan eA (00%1000 mg P> tid p Pediatric $ot esta#lished Dosing

Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Se%elamer ()enagel) Indi ated for the redu tion of serum phosphorous in patients with E3:/. ?inds dietar* phosphate in the intestine, thus inhi#iting its a#sorption. In patients on hemodial*sis, it de reases the frequen * of h*per al emi episodes relative to patients on al ium a etate treatment. Dosing Interactions Contraindications Precautions Adult InitialA ,00%1400 mg P> tid with meals Baintenan eA In rease or de rease #* &00%,00 mg per meal q+w) to maintain serum phosphorous at 4 mg/dL or less Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Paricalcitol (#em$lar) =or treatment of se ondar* h*perparath*roidism in E3:/. :edu es PT9 levels, stimulates al ium and phosphorous a#sorption, and stimulates #one mineralization. Dosing Interactions Contraindications Precautions Adult 0.0&%0.1 m g I7 #olus C times/w)2 ad5ust dose #ased on PT9 levels Pediatric $ot esta#lished Dosing Interactions

Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions /ro+t( -actors @sed to treat anemia of hroni )idne* disease #* stimulating :?. produ tion.

0$oetin al-a (0$ogen" Procrit) 3timulates division and differentiation of ommitted er*throid progenitor ells. Indu es release of reti ulo *tes from #one marrow into #lood stream. Dosing Interactions Contraindications Precautions Adult (0%1(0 @/)g I7/3. C times/w) Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Iron salts $utritionall* essential inorgani su#stan es used to treat anemia. Ferrous sul-ate (Feosol" Ferata&" Slo+ F0) @sed as a #uilding #lo ) for hemoglo#in s*nthesis in treating anemia of hroni )idne* disease with er*thropoietin. Dosing Interactions Contraindications Precautions Adult C+( mg P> qd/tid Pediatric F1( )gA ( mg/)g/d P> 1(%C0 )gA 140 mg P> qd Dosing

Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Iron dextran (DexFerrum" InFed) @sed to treat mi ro *ti , h*po hromi anemia resulting from iron defi ien * when oral administration is unfeasi#le or ineffe tive. @tilized to replenish iron stores in individuals on er*thropoietin therap* who annot ta)e or tolerate oral iron supplementation. 1 0.(%mL !0.+( mL in hildren" test dose should #e administered prior to starting therap*. 1vaila#le as (0 mg iron/mL !as de<tran". Dosing Interactions Contraindications Precautions Adult I(0 )gA 100 mg I7 !+ mL"2 not to e< eed + mL/d Pediatric (%10 )gA (0 mg I7 !1 mL" Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Iron sucrose (1eno-er) @sed to treat iron defi ien * !in on5un tion with er*thropoietin" due to hroni hemodial*sis. Iron defi ien * is aused #* #lood loss during the dial*sis pro edure, in reased er*thropoiesis, and insuffi ient a#sorption of iron from the GI tra t. Iron su rose has shown a lower in iden e of anaph*la<is than other parenteral iron produ ts. Dosing Interactions Contraindications Precautions Adult ( mL !100 mg elemental iron" I7 #* slow in5e tion or infusion during dial*sis session2 t*pi all* requires a minimum umulative dose of 1000 mg of elemental iron over 10 onse utive dial*sis sessions to a hieve a favora#le hemoglo#in or hemato rit response2 not to e< eed C doses per w)

Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Ferric gluconate (Ferrlecit) :epla es iron found in hemoglo#in, m*oglo#in, and spe ifi enz*me s*stems. 1llows transportation of o<*gen via hemoglo#in. Dosing Interactions Contraindications Precautions Adult 1+( mg elemental iron/10 mL I72 ma* require umulative dose of 1 g elemental iron to a hieve favora#le response in patients re eiving hemodial*sis Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions )ecom&inant .uman 0r t(ro$oietin 3timulates development of er*throid progenitor ells. Dar&e$oetin (Aranes$) Er*thropoiesis stimulating protein losel* related to er*thropoietin, a primar* growth fa tor produ ed in )idne* that stimulates development of er*throid progenitor ells. Be hanism of a tion is similar to that of endogenous er*thropoietin, whi h intera ts with stem ells to in rease red ell produ tion. /iffers from epoetin alfa !re om#inant human er*thropoietin" in ontaining ( $%lin)ed oligosa haride hains, whereas epoetin alfa ontains C. 9as longer half%life than epoetin alfa !ma* #e administered wee)l* or #iwee)l*". Dosing Interactions Contraindications Precautions

Adult 0.&( m g/)g I7/3. qw) initiall*2 ad5ust dose !not to e< eed C m g/)g/w)" or frequen * !eg, q+w)"2 to maintain target 9g# !not to e< eed 1+ g/dL"2 do not in rease dose more frequentl* than qmo 3wit hing from epoetin alfaA ?ase dose on total wee)l* er*thropoietin dose and frequen * of administration Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Calcimimetic agents These agents redu e parath*roid hormone levels. Cinacalcet (Sensi$ar) /ire tl* lowers inta t parath*roid hormone !iPT9" levels #* in reasing sensitivit* of al ium sensing re eptor on hief ell of parath*roid gland to e<tra ellular al ium. 1lso results in on omitant serum al ium de rease. Indi ated for se ondar* h*perparath*roidism in patients with hroni )idne* disease on dial*sis. Dosing Interactions Contraindications Precautions Adult C0 mg P> qd initiall*2 titrate upward slowl* !no more frequent than q+%&w) intervals" #* C0 mg in rements to target iPT9 of 1(0%C00 pg/mL Ta)e with meals or immediatel* following2 do not rush, hew or ut ta#lets Pediatric $ot esta#lished 0nce$(alo$at( " 2remic: Treatment & Medication Treatment Medical Care $o medi ations are spe ifi to the treatment of en ephalopath*. The presen e of uremi en ephalopath* in a patient with either a ute renal failure or hroni renal failure is an indi ation for the initiation of dial*ti therap* !ie, hemodial*sis, peritoneal dial*sis, ontinuous renal repla ement therap*". 1fter #eginning dial*sis, the patient generall* improves lini all*, although EEG findings ma* not improve immediatel*. In patients with end%stage renal disease !E3:/", EEG a#normalities generall* improve after several months #ut ma* not ompletel* normalize. 1ddress the following fa tors when treating uremi en ephalopath*, whi h are also in luded in the standard are of an* patient with E3:/A o 1dequa * of dial*sis o .orre tion of anemia o :egulation of al ium and phosphate meta#olism

Consultations .onsult a neurologist if s*mptoms do not improve upon initiation of dial*sis therap*. .onsult a vas ular surgeon for pla ement of vas ular a ess in patients with E3:/. :efer patients with E3:/ to a dietitian familiar with renal diseases. Diet

To avoid malnutrition in patients with E3:/, maintain adequate protein inta)e !I1 g/)g/d" and initiate dial*sis !despite the presen e of en ephalopath*".

Acti%it Instru t patients with signifi ant s*mptoms to ontinue #ed rest. Pericarditis" 2remic: Treatment & Medication Treatment Medical Care The development of peri arditis in a patient with severe a ute or hroni renal failure is an a#solute indi ation for dial*sis. In most patients, relief of hest pain and redu tion in the size of an* effusion o urs within 1%+ wee)s. ?oth hemodial*sis and peritoneal dial*sis are effi a ious in the treatment of uremi peri arditis, though ea h te hnique has unique advantages and disadvantages. o 9emodial*sis ma* ause h*potension, whi h ma* #e dangerous in the setting of tamponade. In addition, some ph*si ians advo ate heparin%free hemodial*sis to redu e the ris) of intraperi ardial hemorrhage. o Peritoneal dial*sis ma* ompromise respirator* fun tion #e ause of the effe t of intraperitoneal fluid on the diaphragm. In dial*sis%asso iated peri arditis, an in reased intensit* of dial*sis for 10%1& da*s is re ommended. .lose monitoring of fluid volume and ele trol*tes is mandator* to dete t and orre t h*pophosphatemia and h*po)alemia, whi h ma* o ur with intensive dial*sis. The response of dial*sis%asso iated peri arditis is not predi ta#le. In some instan es, onsider a swit h to peritoneal dial*sis if heparin%free dial*sis annot #e performed. $onsteroidal anti%inflammator* drugs !$31I/s" and steroids ma* offer s*mptomati relief #ut are not effe tive without dial*sis. Indometha in ameliorates fever, #ut it does not a elerate resolution of the effusion. Surgical Care People with effusions larger than +(0 mL, effusions in whi h size in reases despite intensive dial*sis for 10%1& da*s, or effusions with eviden e of tamponade are andidates for peri ardio entesis. Peri ardial window is a modifi ation of #alloon valvuloplast* in whi h an uninflated #alloon is passed inside the peri ardial spa e, where it is opa ified, inflated, and then pulled through the peri ardium to reate a window through whi h peri ardial fluid drains into the peritoneal or pleural spa e. 3u#<iphoid peri ardiotom* ma* #e performed under lo al anesthesia and has a lower ris) of ompli ations ompared to peri ardie tom*. .onsider su#<iphoid peri ardiotom* for large effusions that do not resolve. Peri ardie tom* is the most effe tive surgi al pro edure for managing large effusions #e ause it has the lowest asso iated ris) of re urrent effusions. Peri ardie tom* requires general anesthesia and a thora otom*2 therefore, peri ardie tom* should #e onsidered onl* if peri ardiotom* annot #e performed or has #een unsu essful. Consultations .onsult with a ardiologist for evaluation with e ho ardiogram. .onsult with a ardiothora i surgeon for all patients with large effusions. /evelopment of tamponade is unpredi ta#le, and it is important for the surgeon to #e aware of the patient if an emergent pro edure is ne essar*. Diet Patients on dial*sis require a dail* diet restri ted to 1.+ g/)g of protein, + g of sodium, and + g of potassium. Patients on peritoneal dial*sis ma* require less stringent protein restri tion.

Acti%it 1 tivit* should #e limited to avoid strenuous a tivities or trauma, whi h ma* in rease the ris) of h*potension or arrh*thmias. Medication The goals of pharma otherap* are to redu e mor#idit* and to prevent ompli ations. 3onsteroidal anti*in-lammator drugs Ba* offer s*mptomati relief #ut are ineffe tive in a#sen e of dial*sis. Indomet(acin (Indocin) >ften onsidered the first hoi e. :apidl* a#sor#ed, and meta#olism o urs in liver #* demeth*lation, dea et*lation, and glu uronide on5ugation. Inhi#its prostaglandin s*nthesis. /emonstrated to ameliorate fever #ut does not a elerate resolution of effusion. Dosing Interactions Contraindications Precautions Adult +(%(0 mg P> q4h Pediatric 1%+ mg/)g/d P> divided #id/qid2 not to e< eed & mg/)g/d or 1(0%+00 mg/d Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Corticosteroids Ba* offer s*mptomati relief #ut are ineffe tive in the a#sen e of dial*sis. Prednisone (Deltasone" Stera$red" 'rasone) Ba* de rease inflammation #* reversing in reased apillar* permea#ilit* and #* suppressing PB$ a tivit*. Dosing Interactions Contraindications Precautions Adult (%40 mg/d P> or divided #id/qid, taper over + w) as s*mptoms resolve Pediatric &%( mg/m+/d P>2 alternativel*, 0.0(%+ mg/)g P> divided #id/qid2 taper over + w) as s*mptoms resolve 2remia: Treatment & Medication Treatment Medical Care The ultimate treatment for uremia is dial*sis. Initiate dial*sis when signs or s*mptoms of uremia !eg, nausea, vomiting, volume overload, h*per)alemia, severe a idosis" are present and are not treata#le #* other medi al

means. Patients with uremia must have dial*sis initiated as soon as s*mptoms are present, regardless of G=:. =or as*mptomati patients, dial*sis is generall* initiated when their reatinine learan e is 10 mL/min ! reatinine level of ,%10 mg/dL" or less or, for dia#eti patients, when their reatinine learan e is 1( mL/min ! reatinine level of 4 mg/dL". Earl* referral to a nephrologist for evaluation !when reatinine level is I C mg/dL" is essential for patient edu ation and preparation for dial*sis or transplantation. Patients ma* de ide on peritoneal dial*sis or hemodial*sis, a de ision dependent on their preferen e and level of motivation. Peritoneal dial*sis is preferred for patients who are highl* motivated, need fle<i#ilit* in their dial*sis s hedule, and who ma* have underl*ing ardiovas ular disease. 9emodial*sis requires a fun tioning arterial venous dial*sis a ess and ma* #e a omplished at home or in a enter. :egardless of whether a patient hooses peritoneal dial*sis or hemodial*sis, dial*sis a ess must #e dis ussed and pla ed earl*. $ewer methods of dial*sis in lude dail* hemodial*sis and no turnal hemodial*sis, the advantages of whi h in lude improved volume ontrol, improved ardiovas ular disease, improved al ium%phosphate #alan e, improved dietar* parameters, and improved qualit* of life. :enal transplantation is the #est renal repla ement therap* and results in improved survival and qualit* of life. Transplants from living, related donors are #est, #ut transplants from living, unrelated donors should also #e onsidered. .onsider transplantation prior to the need for dial*sis #e ause the waiting list for adaver transplants often e< eeds +%C *ears. 9*per)alemiaA Patients with renal failure asso iated h*per)alemia of 4.( mEq/L or greater are andidates for emergent dial*sis therap*, parti ularl* if the h*per)alemia is asso iated with E.G hanges !eg, pea)ed T waves, atrioventri ular #lo ), #rad* ardia". 3hort%term temporizing measures in lude intravenous infusion of al ium glu onate to sta#ilize ardia mem#ranes, #i ar#onate, insulin and glu ose administration, or inhaled or intravenous #eta%agonists. $onemergent h*per)alemia an #e treated with oral potassium #inders !eg, sodium pol*st*rene sulfonate 8Da*e<alate;". .orre tion of a idemia ma* improve potassium #alan e. 1lso, it is imperative to dis ontinue an* medi ine that might #e ontri#uting to the h*per)alemia, in luding 1.E inhi#itors, angiotensin%re eptor #lo )ers, #eta%#lo )ers, potassium%sparing diureti s, and nonsteroidal anti%inflammator* drugs. 1nemiaA ?egin the wor)up for anemia when the hemoglo#in level is less than 11 g/dL or the hemato rit value is less than CC- in premenopausal females and prepu#ertal patients or when the hemoglo#in level is less than 1+ g/dL or the hemato rit value is less than C6- in men and postmenopausal women. In patients found to have anemia of hroni )idne* disease, it is important to he ) iron studies and to #egin the initial treatment with iron repla ement if there is eviden e of iron defi ien *. The serum ferritin level should #e greater than 100 m g/mL. o =or patients with E3:/ and .D/, the goal hemoglo#in level should #e 11%1C g/dL. There is insuffi ient eviden e to re ommend routinel* maintaining hemoglo#in levels at 1C g/dL or greater in E31%treated patients, espe iall* as several re ent trials have demonstrated a potential for in reased ardia events in su#5e ts treated to higher hemoglo#in levels.&, ( o If the anemia is not orre ted, then #egin treatment with 1 of + su# utaneous er*thropoiesis stimulating agents, re om#inant human er*thropoietin !Epo" or dar#epoetin, a unique mole ule that stimulates er*thropoiesis and has a longer half%life than er*thropoietin. o Initiate iron therap* on urrentl* with dial*sis therap*. 3tart with one of several intravenous iron preparations as these #etter a#sor#ed than oral formulations. These an #e administered with ea h dial*sis treatment to load the patient with iron or on e wee)l* to maintain iron stores. o =or patients not *et on dial*sis, oral iron preparations are used initiall*. =or signifi ant iron defi ien *, intravenous iron !In=e/ In5e tion" ma* #e administered slowl* !(00 mg over &%4 h" after the administration of a test dose !+( mg". 9*perparath*roidism, h*po al emia, h*perphosphatemia, and renal osteod*stroph*A Evaluate and treat se ondar* h*perparath*roidism, manifested #* low al ium levels, high phosphate levels, and low levels of 1,+(!>9"+ vitamin /%C, earl* #e ause it is one of the first manifestations of renal osteod*stroph*. 9*po al emia an #e treated with oral al ium ar#onate or al ium a etate at a dose of (00 mg to 1 gram orall* C times a da* ta)en in #etween meals. If 1,+(!>9"+ vitamin /%C levels are depressed, al ium levels are de reased, and parath*roid levels are elevated !IC00", onsider initiating oral vitamin / therap*. The dosage of al itriol is 0.+( m g orall* on e dail* or C times a wee), depending on the levels of 1,+(!>9"+ vitamin /%C and PT9.

0hen the reatinine learan e falls #elow +(%C0 /min, the )idne* #egins to lose the a#ilit* to ompletel* e< rete e< ess amounts of phosphorus. Thus, it is not un ommon for man* patients with .D/ and E3:/ to #e ome h*perphosphatemi . Initial treatment is dietar* ounseling and modifi ation. If this fails, treatment then onsists of administration of oral phosphate #inders given with meals. These an in lude al ium% #ased formulations, su h as al ium ar#onate or al ium a etate, or non al ium%#ased formulations, su h as sevelamer or lanthanum ar#onate. 1 idemiaA 1 idemia should #e treated in patients with a serum #i ar#onate level onsistentl* less than +0 mEq/dL. >ral #i ar#onate solution or ta#lets an #e used, and most patients will require 0.(%1 mEq/)g of #od* weight of #i ar#onate. @se this therap* autiousl* in persons with signifi ant fluid retention and h*pertension #e ause of the ris) of worsening the fluid retention. Surgical Care 3urgi al referral is ne essar* for dial*sis a ess pla ement after the de ision regarding dial*sis has #een made. :enal repla ement therap* an #e a omplished #* hemodial*sis, peritoneal dial*sis, or transplantation. :eferral to an appropriate surgeon !ie, vas ular, general, transplant" is made after the modalit* for renal repla ement therap* has #een determined. In general, referral to a vas ular surgeon for onsideration of dial*sis a ess is initiated #* the nephrologist earl* in the patientEs ourse of renal failure to avoid emergent dial*sis a ess pla ement. /ial*sis a ess an #e ondu ted through either an arteriovenous fistula for hemodial*sis or a peritoneal dial*sis atheter for hroni am#ulator* peritoneal dial*sis or ontinuous * ling peritoneal dial*sis. 1rteriovenous fistulas are the dial*sis a ess of hoi e for hemodial*sis. o 1void arteriovenous Gore%Te< grafts if at all possi#le #e ause of their poor longevit*. 1void long% term use of tunneled atheters #e ause of the in reased ris) of infe tion and poor dial*sis adequa *. 1void su# lavian atheters #e ause of their asso iation with in reased venous stenosis, throm#osis, or #oth. o Peritoneal dial*sis a ess an #e a omplished #* the pla ement of a Ten )hoff peritoneal dial*sis atheter #* either an e<perien ed nephrologist or a surgeon. /ire t visualization of the peritoneum is asso iated with fewer ompli ations and #etter fun tion of the atheter. Peritoneal dial*sis allows patients more ontrol and fle<i#ilit* with their dial*sis treatment regimen. .onsider an* surger* arefull* in patients with uremia #e ause of the in reased ris) for uremi #leeding, ardiovas ular events, 1:=, respirator* depression, and de reased meta#olism of ertain drugs. 7asopressin ma* #e onsidered if uremi #leeding is su#stantial. Consultations .onsider onsulting a nephrologist as soon as possi#le in the ourse of the patientEs disease, parti ularl* when renal fun tion test results are onl* mildl* a#normal. 1 ute h*per)alemia, volume overload, severe a idemia, or a hange in mental status, whi h an progress to stupor or oma, requires emergent onsultation with a nephrologist and, possi#l*, the initiation of dial*sis. Diet /ietar* hanges should #e made onl* with the help of a dietitian )nowledgea#le in renal diet treatment, parti ularl* in patients who have not *et started dial*sis therap*. 1 low%protein diet has #een advo ated for persons with mild%to%moderate renal failure, although this matter remains ontroversial. Low%protein diets ma* alleviate some of the s*mptoms of uremia, su h as nausea2 however, data regarding the renoprote tive effe t of low%protein diets are onfli ting. The B/:/ stud* anal*zed (,( patients with nondia#eti hroni renal disease and a mean G=: of CH mL/min. Patients were randomized to protein inta)es of either 1.1 g/)g/d or 0.6 g/)g/d. /espite good omplian e, there appeared to #e little overall #enefit with the low%protein diet. 1lso, low%protein diets an ause the patient to #e ome malnourished, whi h has #een asso iated with higher mortalit* upon the initiation of dial*sis. .urrent re ommendations for a low%protein diet prior to the initiation of dial*sis are 0.,%1 gram of protein/)g of weight, with an additional gram of protein added for ea h gram of protein lost in the urine !for patients with nephroti s*ndrome". Patients with advan ed uremia or malnutrition are not andidates for a low%protein diet. Patients with .:= should #e on a low%potassium !+%C g/d", low%phosphate !+ g/d", and low%sodium !+ g/d" diet. Acti%it

1 tivit* for patients with uremia is self%restri ted #ased on their level of fatigue. Earl* treatment of anemia with iron and EP> improves the qualit* of life and energ* levels even #efore the patient needs dial*sis. ?leeding se ondar* to uremia ma* o ur2 dangerous a tivities ma* need to #e restri ted and potential #leeding sites assessed in the event of a fall !eg, for a su#dural hematoma". Medication @suall*, medi ations used for uremia are indi ated to treat asso iated meta#oli and ele trol*te a#normalities, su h as anemia, h*per)alemia, h*po al emia, h*perparath*roidism, and iron defi ien *. Bedi ation sele tion and dosage depend on the patientEs lini al state, whi h ma* hange with the a ute lini al setting. /ial*sis is the primar* treatment for uremia, #ut medi ations an effe tivel* treat some of the asso iated s*mptoms and lini al a#normalities !eg, anemia, h*po al emia". Colon *stimulating -actors In rease reti ulo *te ount, hemato rit value, and hemoglo#in levels. 0$oetin al-a (0$ogen" Procrit) Purified gl* oprotein produ ed from mammalian ells modified with gene oding for human EP>. ?iologi al a tivit* mimi s human urinar* EP>, whi h stimulates division and differentiation of ommitted er*throid progenitor ells and indu es release of reti ulo *tes from #one marrow into the #lood stream. Indi ated for treatment of anemia asso iated with .:= or renal insuffi ien *. Dosing Interactions Contraindications Precautions Adult (0%1(0 @/)g I7/3. C times/w) Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Calcium su$$lements @sed to orre t h*po al emia and improve s*mptoms asso iated with renal osteod*stroph*. 1lso ma* #e used to #ind phosphate in patients with h*perphosphatemia. Calcium car&onate (Caltrate" 's*Cal 455" Al!a*Mints" Tums) Indi ated for treatment of h*perphosphatemia se ondar* to .:=. Effe tivel* normalizes phosphate on entrations in dial*sis patients. .om#ines with dietar* phosphate to form insolu#le al ium phosphate, whi h is e< reted in fe es. Bar)eted in a variet* of dosage forms and is relativel* ine<pensive. Dosing Interactions Contraindications Precautions Adult

1%+ g P> divided #id/qid ta)en with meals Pediatric &(%4( mg/)g/d P> divided qid ta)en with meals Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Calcium acetate (P(osLo" Cal$(ron) Indi ated for treatment of h*perphosphatemia se ondar* to .:=. Effe tivel* normalizes phosphate on entrations in dial*sis patients. .om#ines with dietar* phosphate to form insolu#le al ium phosphate, whi h is e< reted in fe es. Dosing Interactions Contraindications Precautions Adult + ta#s P> tid with meals2 titrate up until serum phosphate is 4 mg/dL, as long as h*per al emia does not develop2 ma* require as man* as & ta# P> tid Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions 1itamins Essential for normal meta#olism of proteins, ar#oh*drates, and fats and normal /$1 s*nthesis. @sed in the treatment of h*perparath*roidism, vitamin / defi ien *, and renal osteod*stroph*. Paricalcitol (#em$lar) =or treatment of se ondar* h*perparath*roidism in E3:/. :edu es PT9 levels, stimulates al ium and phosphorous a#sorption, and stimulates #one mineralization. Dosing Interactions Contraindications Precautions

Adult 0.0&%0.1 m g/)g I7 #olus C times/w)2 ad5ust dose #ased on PT9 levels Pediatric F( *earsA $ot esta#lished (%1H *earsA 0.0&%0.0, m g/)g I7 C times/w)2 ad5ust dose #ased on PT9 levels Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Calcitriol ()ocaltrol) Two )nown sites of a tion are intestine and #one. >ther eviden e indi ates that it also a ts on )idne*s and parath*roid gland. 7itamin /%C must #e onverted to al itriol in liver and )idne*s #efore it is full* a tive on its target tissues. 3ome eviden e suggests that uremi patients have vitamin /Jresistant state #e ause of a failure of their )idne* to meta#oli all* a tivate vitamin /%C to al itriol, whi h in reases al ium levels #* promoting a#sorption of al ium in intestines and retention in )idne*s. Dosing Interactions Contraindications Precautions Adult 0.+( m g P> qd, in rease at &% to ,%w) intervals #* 0.+( m g prn Pediatric InitialA 1( ng/)g/d P> Baintenan eA (%&0 ng/)g/d P> Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Iron salts @sed to orre t iron defi ien * s*mptoms. Ferrous sul-ate (Feosol) 1 nutritionall* essential inorgani su#stan e ne essar* for hemoglo#in formation and o<idative pro esses of living tissue. Effe tivel* treats iron defi ien * anemia. Dosing

Interactions Contraindications Precautions

Adult C+( mg P> qd, in rease to tid prn Pediatric F1( )gA ( mg/)g/d P> 1(%C0 )gA 9alf of adult dose IC0 )gA 1dminister as in adults Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Antidotes @sed to redu e serum potassium levels. Sodium $ol st rene sul-onate (6a exalate) E< hanges sodium for potassium, #inds it in the gut !primaril* in the large intestine", and de reases total #od* potassium. P> onset of a tion ranges from +%1+ h and is longer when P:. Dosing Interactions Contraindications Precautions Adult +(%(0 g P> q4h in +(%(0 mL sor#itol +(%(0 g P: q4h in +(%(0 mL sor#itol as retention enema Pediatric 1.0 g/)g P> q4h in sor#itol +.0 g/)g P: q4h in sor#itol as retention enema Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Antidia&etic agents 3timulate ellular upta)e of potassium.

Insulin (.umulin )" 3o%olin )) 3timulates ellular upta)e of potassium within +0%C0 min. 1dminister glu ose along with insulin to prevent h*pogl* emia. Bonitor #lood sugar levels frequentl*. Dosing Interactions Contraindications Precautions Adult 10 @ I7 and (0 mL /(00 #olus or (00 mL /100 over 1 h Pediatric 0.(%1.0 g/)g !as /(00 or equivalent" I7 followed #* 1 @ of regular insulin per C g glu ose Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions P(os$(ate &inders @sed to #ind phosphate when al ium ar#onate or a etate annot #e used #e ause of a high serum al ium level. Se%elamer ()enagel) .ationi pol*mer that #inds intestinal phosphate, whi h is e< reted in the fe es. $ot a#sor#ed and does not ontain al ium or aluminum ions. ?inding of #ile salts ma* also o ur, whi h ma* result in lowered low%densit* lipoprotein holesterol levels. Dosing Interactions Contraindications Precautions Adult ,00%1400 mg P> with ea h meal Pediatric $ot esta#lished Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Lant(anum car&onate (Fosrenal)

$on al ium, nonaluminum phosphate #inder indi ated for redu tion of high phosphorus levels in patients with end%stage renal disease. /ire tl* #inds dietar* phosphorus in upper GI tra t, there#* inhi#iting phosphorus a#sorption. Dosing Interactions Contraindications Precautions Adult InitialA +(0%(00 mg P> tid p ! hewa#le ta#s"2 ad5ust dose q+%Cw) to target serum phosphorus level Baintenan eA (00%1000 mg P> tid p Pediatric $ot esta#lished 6idne -ailure" c(ronic Treatments and drugs .hroni )idne* failure has no ure, #ut treatment an help ontrol signs and s*mptoms, redu e ompli ations, and slow the progress of the disease. If *ou have hroni )idne* failure, *our primar* do tor will li)el* refer *ou to a )idne* spe ialist !nephrologist", if *ou arenEt seeing one alread*. Treating t(e underl ing condition The first priorit* is ontrolling the ondition responsi#le for *our )idne* failure and its ompli ations. If *ou have dia#etes or high #lood pressure !h*pertension", for instan e, that means arefull* following *our do torEs re ommendations for diet and e<er ise and ta)ing an* medi ations as dire ted. Bost people with hroni )idne* failure are treated with medi ations to lower their #lood pressure K ommonl* angiotensin% onverting enz*me !1.E" inhi#itors or angiotensin II re eptor #lo )ers K and to preserve )idne* fun tion. ?e ause these medi ations an initiall* in rease serum potassium and de rease overall )idne* fun tion, *ou ma* have frequent #lood tests to he ) *our potassium levels. >ver the long term, these medi ations tend to #oth lower #lood pressure and preserve )idne* fun tion. To prote t )idne* fun tion, *our #lood pressure ma* need to #e lower than if *our )idne*s were fun tioning normall*. In addition, following a proper diet is e<tremel* important in treating )idne* failure itself. :estri ting the amount of protein *ou eat ma* help slow the progress of the disease. It an also help ease su h s*mptoms as nausea, vomiting and la ) of appetite. LouEll li)el* need to limit the amount of salt in *our diet to help ontrol high #lood pressure. >ver time, *ou ma* also need to restri t the amount of potassium and phosphorus *ou onsume. Lour do tor ma* also re ommend that *ou avoid su#stan es that an #e to<i to *our )idne*s, su h as nonsteroidal anti%inflammator* drugs, some oral phosphate preparations used as la<atives #efore olonos op*, and ontrast d*es used with ertain '%ra*s. Treating com$lications LouEll also need treatment for ompli ations of hroni )idne* failure. =or e<ample, anemia ma* require supplements of the hormone er*thropoietin to indu e produ tion of more red #lood ells. In addition, *our do tor ma* pres ri#e a form of vitamin / ! al itriol" to prevent wea) #ones, as well as a phosphate%#inding medi ation to lower the amount of phosphate in *our #lood. Lowering phosphate will in rease the amount of al ium availa#le for *our #ones so that the* donEt #e ome wea) and vulnera#le to fra ture. Pre%ention .hroni )idne* failure is often impossi#le to prevent. ?ut *ou ma* redu e *our ris) #* following these suggestionsA Don7t a&use alco(ol or ot(er drugs" in luding over%the% ounter pain medi ations su h as aspirin, a etaminophen and i#uprofen. 1void long%term e<posure to heav* metals, su h as lead, as well as to solvents, fuels and other to<i su#stan es. Care-ull -ollo+ all o- our doctor7s recommendations for managing an* hroni medi al ondition that in reases *our ris) of )idne* failure. The 1meri an /ia#etes 1sso iation re ommends *earl* preal#umin urine tests for most people with dia#etes.

Consider a $re*$regnanc consultation if *ou have hroni )idne* failure and are thin)ing of #e oming pregnant. Tal) with a )nowledgea#le o#stetri ian or nephrologist to dis uss *our ris)s. If *ouEre alread* pregnant, #e sure to get omprehensive medi al are K in luding prenatal visits ever* two wee)s for at least the first C+ wee)s.

S m$toms 3igns and s*mptoms ma* in lude some or man* of the followingA 9igh #lood pressure /e reased urine output or no urine output /ar)l* olored urine 1nemia $ausea or vomiting Loss of appetite 3udden weight hange 1 general sense of dis omfort and unease !malaise" =atigue and wea)ness 9eada hes that seem unrelated to an* other ause 3leep pro#lems /e reased mental sharpness Pain along *our side or mid to lower #a ) Bus le twit hes and ramps 3welling of the feet and an)les ?lood* or tarr* stools, whi h ould indi ate #leeding in *our intestinal tra t Lellowish%#rown ast to *our s)in Persistent it hing .hroni )idne* failure an #e diffi ult for *ou or *our do tor to dete t initiall*. 3igns and s*mptoms are often nonspe ifi , meaning the* an also #e attri#uted to other illnesses. In addition, #e ause *our )idne*s are highl* adapta#le and a#le to ompensate for lost fun tion, signs and s*mptoms of hroni )idne* failure ma* not appear until irreversi#le damage has o urred. Causes Lour )idne*s are the )e* organs in the omple< filtration s*stem that removes e< ess fluid and waste material from the #lood. Lour )idne*s re eive #lood through *our renal arteries, whi h #ran h off the main arter* !the a#dominal aorta" arr*ing o<*genated #lood awa* from *our heart. >n entering the )idne*s, #lood is distri#uted through smaller and smaller vessels, finall* rea hing tin* apillar* #lood vessels arranged in tufts !glomeruli". The glomeruli filter *our #lood, e<tra ting fluid, waste and su#stan es *our #od* needs K sugar, amino a ids, al ium and salts. These filtered materials then ross into tin* tu#ules, from whi h the #loodstream rea#sor#s what the #od* an reuse. The rest is waste, whi h is e< reted in *our urine. 1lthough *our )idne*s are usuall* a#le to lear all the waste produ ts *our #od* produ es, pro#lems an o ur if #lood flow to *our )idne*s is disrupted, if the tu#ules or glomeruli #e ome damaged or diseased, or if urine outflow is o#stru ted. Progressive )idne* damage most often results from a hroni illness over a period of *ears. .ommon auses in ludeA Dia&etes8 /ia#etes mellitus is a leading ause of hroni )idne* failure in the @nited 3tates. .hroni )idne* failure is related to #oth t*pe 1 and t*pe + dia#etes. .ig( &lood $ressure (( $ertension)8 Elevated #lood pressure an damage the glomeruli and ultimatel* ause the nephrons ontaining damaged glomeruli to lose their a#ilit* to filter waste from *our #lood.

'&struction o- urine -lo+8 1n enlarged prostate, )idne* stones or tumors, or vesi oureteral reflu< K a ondition that results when urine #a )s up into *our )idne*s from *our #ladder K an #lo ) urine flow, in reasing pressure in *our )idne*s and redu ing their fun tion. 6idne diseases8 These in lude lusters of *sts in the )idne*s !pol* *sti )idne* disease", )idne* infe tion !p*elonephritis" and inflammation of the glomeruli !glomerulonephritis", a ondition that auses *our )idne*s to lea) protein into *our urine and damages nephrons. 6idne arter stenosis8 This is a narrowing or #lo )age of the )idne* !renal" arter* #efore it enters *our )idne*, whi h impairs #lood flow and leads to )idne* damage. Toxins8 >ngoing e<posure to fuels and solvents, su h as ar#on tetra hloride, and lead K in lead%#ased paint, lead pipes, soldering materials, 5ewelr* and even al ohol distilled in old ar radiators K an lead to hroni )idne* failure.

)is! -actors .onditions that in rease *our ris) of )idne* failure in ludeA /ia#etes, whi h is the most ommon ris) fa tor for hroni )idne* failure in the @nited 3tates 9igh #lood pressure !h*pertension" 3i )le ell disease Lupus er*thematosus 1theros lerosis .hroni glomerulonephritis Didne* disease present at #irth ! ongenital" ?ladder outlet o#stru tion >vere<posure to to<ins and to some medi ations =amil* histor* of )idne* disease 1ge 40 or older Com$lications .hroni )idne* failure an affe t almost ever* part of *our #od*. Potential ompli ations ma* in ludeA =luid retention, whi h ould lead to swollen tissues, ongestive heart failure or fluid in *our lungs !pulmonar* edema" 1 sudden rise in potassium levels in *our #lood !h*per)alemia", whi h ould impair *our heartEs a#ilit* to fun tion and ma* #e life%threatening .ardiovas ular disease 0ea) #ones that fra ture easil* 1nemia 3toma h ul ers /r* s)in, hanges in s)in olor Insomnia /e reased se< drive or impoten e /amage to *our entral nervous s*stem /e reased immune response, whi h ma)es *ou more vulnera#le to infe tion Peri arditis, an inflammation of the sa %li)e mem#rane that envelops *our heart !peri ardium" Irreversi#le damage to *our )idne*s !end%stage )idne* disease", requiring either dial*sis or a )idne* transplant for survival Com$lications in c(ildren .hroni )idne* failure an ause hildren to stop growing normall*. This ompli ation o urs partl* #e ause failing )idne*s have redu ed produ tion of er*thropoietin, a hormone that helps generate red #lood ells and meta#olize human growth hormone. The )idne*s also regulate the intera tions of al ium and vitamin /, #oth of whi h are essential for #one growth. In hroni )idne* failure, these intera tions an #e ome im#alan ed, inhi#iting growth.

Com$lications during $regnanc If *ou have hroni )idne* failure and *ou #e ome pregnant, *ouEll fa e a num#er of potential ompli ations. 0hen *ouEre pregnant, the amount of fluid in *our #od* in reases greatl*, so *our )idne*s must wor) espe iall* hard. This ma* lead to worsening high #lood pressure and an in rease in the waste produ ts ir ulating in *our #lood. These hanges affe t #oth *ou and *our #a#*. .hroni high #lood pressure means *our #a#* re eives less #lood through the pla enta, whi h an seriousl* affe t growth. 0aste produ ts in *our #loodstream ma* have an adverse effe t on *our #a#* as well. In addition, pregnant women with hroni )idne* failure are at high ris) of pree lampsia, a serious ondition of late pregnan *. Pree lampsia auses a dangerous rise in #lood pressure. If not treated, it an lead to hemorrhages in the #rain, liver or )idne*s, and ultimatel* ma* #e fatal for #oth *ou and *our #a#*. /ia#eti =oot .are Treatment Sel-*Care at .ome 1 person with dia#etes should do the followingA Foot examination: E<amine *our feet dail* and also after an* trauma, no matter how minor, to *our feet. :eport an* a#normalities to *our ph*si ian. @se a water%#ased moisturizer ever* da* !#ut not #etween *our toes" to prevent dr* s)in and ra )ing. 0ear otton or wool so )s. 1void elasti so )s and hosier* #e ause the* ma* impair ir ulation.

0liminate o&stacles: Bove or remove an* items *ou are li)el* to trip over or #ump *our feet on. Deep lutter on the floor pi )ed up. Light the pathwa*s used at night % indoors and outdoors. Toenail trimming: 1lwa*s ut *our nails with a safet* lipper, never a s issors. .ut them straight a ross and leave plent* of room out from the nail#ed or qui ). If *ou have diffi ult* with *our vision or using *our hands, let *our do tor do it for *ou or train a famil* mem#er how to do it safel*. Foot+ear: 0ear sturd*, omforta#le shoes whenever feasi#le to prote t *our feet. To #e sure *our shoes fit properl*, see a podiatrist !foot do tor" for fitting re ommendations or shop at shoe stores spe ializing in fitting people with dia#etes. Lour endo rinologist !dia#etes spe ialist" an provide *ou with a referral to a podiatrist or orthopedist who ma* also #e an e< ellent resour e for finding lo al shoe stores. If *ou have flat feet, #unions, or hammertoes, *ou ma* need pres ription shoes or shoe inserts. 0xercise: :egular e<er ise will improve #one and 5oint health in *our feet and legs, improve ir ulation to *our legs, and will also help to sta#ilize *our #lood sugar levels. .onsult *our ph*si ian prior to #eginning an* e<er ise program. Smo!ing: If *ou smo)e an* form of to#a o, quitting an #e one of the #est things *ou an do to prevent pro#lems with *our feet. 3mo)ing a elerates damage to #lood vessels, espe iall* small #lood vessels leading to poor ir ulation, whi h is a ma5or ris) fa tor for foot infe tions and ultimatel* amputations. Dia&etes control: =ollowing a reasona#le diet, ta)ing *our medi ations, he )ing *our #lood sugar regularl*, e<er ising regularl*, and maintaining good ommuni ation with *our ph*si ian are essential in )eeping *our dia#etes under ontrol. .onsistent long%term #lood sugar ontrol to near normal levels an greatl* lower the ris) of damage to *our nerves, )idne*s, e*es, and #lood vessels.