End-Stage Renal Failure requiring dialysis

One of the challenges facing a Nephrologist is when breaking news about End-Stage Renal Failure to a patient and telling him or her about the need for life-long haemodialysis 3 times every week.

The reactions I often got out of the patients vary from one of despair to denial to anger. Sometimes it is best to let the patient go through the emotions before they settle down with some degree of acceptance of their disease and the unavoidable treatment.

What is High-Efficiency and what is High-Flux ?

Unusually Low or High Endogenous Creatinine

NKF K/DOQI recommended target ranges

Serum phosphorus 3.5 mg/dL–5.5 mg/dL
Serum calcium 8.4 mg/dL–9.5 mg/dL
Ca X P product <55 mg2/dL2
Intact PTH 150 pg/mL–300 pg/mL
Serum total CO3 >22 mmol/L

these are the targets for Bone Metabolism

Summary of Treatment Recommendations for IgAN

All summarised ....

IgAN latest

Management of IgA nephropathy


ACE-inhibitors, ARBs and ACEI/ARB combinations - beneficial

Steroids
Pozzi et al (vs placebo) - better renal survival with steroids
Katafuchi et al (vs placebo) - similar renal survival
A recent metaanalysis also support use of steroids : reduce proteinuria, prevent progression to ESRD

Oral CYC
Ballardie et al. better 5-year renal survival

Fish Oil - conflicting results
Donadio et al. Mayo Clinic. NEJM 1994 (fish oil better)
Pettersson et al (no benefit, in fact worse)
Hogg et al (no benefit)

MMF - no evidence in IgAN

Membranous nephropathy

Management of membranous nephropathy

Chlorambucil } both proven effective by Ponticelli et al
cyclophospamide }

Cyclosporin A (Cattran et al.KI 2001)
CSA + low dose steroids vs steroids only (n=51)
CSA + low dose steroids - more CR/PR (21/28 vs 5/23)

MMF (only uncontrolled trials)
Choi et al. reduced proteinuria
Miller et al. reduced proteinuria

Rituximab (also uncontrolled trials)
Ruggenenti et al. reduced proteinuria up to 1 year.