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A. Definitions
1. Hyperphosphatemia
4. Bone Evaluation
a. Severe secondary hyperparathyroidism can
lead to osteoporosis
b. Some patients will require parathyroidectomy to
help prevent this
c. Unclear when bone densitometry should be
done on patients with CRF
Pre-Dialysis Treatment
1. Maintain normal electrolytes
b. Potassium, calcium, phosphate are major
electrolytes affected in CRF
c. ACE inhibitors may be acceptable in many
patients with creatinine >3.0mg/dL
d. ACE inhibitors may slow the progression of
diabetic and non-diabetic renal disease [13]
e. Reduce or discontinue other renal toxins
(including NSAIDS)
f. Diuretics (eg. furosemide) may help maintain
potassium in normal range
g. Renal diet including high calcium and low
phosphate
1. Reduce protein intake to <0.6gm/kg body weight
b. Appears to slow progression of diabetic and non-
diabetic kideny disease
c. In type 1 diabetes mellitus, protein restriction reduced
levels of albuminuria
d. Low protein diet did not slow progression in children
with CRF
1. Underlying Disease
H. Hemodialysis
1. Indications
b. Uremia - azotemia with symptoms and/or signs
c. Severe Hyperkalemia
d. Volume Overload - usually with congestive heart failure
(pulmonary edema)
e. Toxin Removal - ethylene glycol poisoning, theophylline
overdose, etc.
f. An arterio-venous fistula in the arm is created surgically
g. Catheters are inserted into the fistula for blood flow to dialysis
machine
1. Procedure for Chronic Hemodialysis
b. Blood is run through a semi-permeable filter
membrane bathed in dialysate
c. Composition of the dialysate is altered to
adjust electrolyte parameters
d. Electrolytes and some toxins pass through
filter
e. By controlling flow rates (pressures), patient's
intravascular volume can be reduced
f. Most chronic hemodialysis patients receive 3
hours dialysis 3 days per week
1. Efficacy
b. Some acids, BUN and creatinine are reduced
c. Phosphate is dialyzed, but quickly released from bone
d. Very effective at reducing intravascular volume/potassium
e. Once dialysis is initiated, kidney function is often reduced
f. Not all uremic toxins are removed and patients generally do not
feel "normal"
g. Response of anemia to erythropoietin is often suboptimal with
hemodialysis
1. Chronic Hemodialysis Medications
b. Anti-hypertensives - labetolol, CCB, ACE
inhibitors
c. Eythropoietin (Epogen®) for anemia in ~80%
dialysis pts
d. Vitamin D Analogs - calcitriol given intravenously
e. Calcium carbonate or acetate to phosphate and
PTH
f. RenaGel, a non-adsorbed phosphate binder, is
being developed for hyperphosphatemia
g. DDAVP may be effective for patients with
symptomatic platelet problems