Kidney disease progressive

FIGURE 23-1. Proposed mechanisms for progression of renal disease. (From Joy MS, Kshirsagar A, Paparello J. Chronic kidney disease Progression-modifying therapies. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 6th ed. New York McGraw-Hill 2005 803, with permission.)... 

Calcium-phosphorus balance is mediated through a complex interplay of hormones and their effects on bone, GI tract, kidney, and parathyroid gland. As kidney disease progresses, renal activation of vitamin D is impaired, which reduces gut absorption of calcium. Low blood calcium concentration stimulates secretion of parathyroid hormone (PTH). As renal function declines, serum calcium balance can be maintained only at the expense of increased bone resorption, ultimately resulting in renal osteodystrophy (ROD) (Fig. 76-7). 

See Chap. 46, Chronic Kidney Disease Progression-Modifying Therapies, authored by Melanie S. Joy, Abhijit Kshirsagar, and Nora Franceschini, and Chap. 47, Chronic Kidney Disease Management of Complications, authored by Joanna Q. Hudson, for a more detailed discussion of this topic. 

Prajczer S et al (2010) Evidence for a role ofuro-modulin in chronic kidney disease progression. Nephrol Dial Transplant 25(6) 1896-1903... 

Chronic Kidney Disease Progression-Modifying Therapies... 

CHAPTER 43 CHRONIC KIDNEY DISEASE PROGRESSION-MODIFYING THERAPIES... 

FIGURE 43-2. Relative risk for kidney disease progression based on current level of systolic blood pressure and current urine protein excretion. From Jafar, with permission. 

In order to define the association between dietary protein restriction and CKD progression, two meta-analyses (comprised of several smaller studies) evaluated the effect of dietary protein restriction in diabetic and nondiabetic kidney diseases. The larger study, comprising over 1000 patients (who were predominantly nondiabetic) from 13 randomized controlled trials, found a weak association between dietary protein restriction and reduction in the rate of kidney disease progression. An analysis of the diabetic group from this... 

CHAPTER 43 CHRONIC KIDNEY DISEASE PROGRESSION-MODIEYING THERAPIES 809 TABLE 43—4. Effects of Anti hypertensive Agents on Renal Blood Flow (RBF) and Glomerular Filtration Rate (GFR)... 

A meta-analysis of 13 prospective controlled trials did conclude that hpid-lowering therapies may decrease proteinuria and slow the rate of GFR decline (by a 0.156-mL/min-per-month). ° It has been suggested that HMG-CoA reductase inhibitors may have some other advantages that may help to reduce kidney disease progression in addition to hpid reduction, such as reduction of monocyte infiltration, mesangial cell proliferation, mesangial matrix expansion, and tubulointerstitial inflammation and fibrosis. ... 

Edema is a common manifestation of volume overload and extracellular fluid volume expansion. Clinicians should evaluate patients for signs and symptoms of volume overload (e.g., pitting edema, rales, ascites, shortness of breath, and increased weight). Blood pressure monitoring in the clinic setting and at home if feasible to detect hypertension is also warranted. As kidney disease progresses dietary intervention and diuretic therapy (based on the degree of kidney function) will likely become necessary. 

Creatinine—The breakdown of protein metabolic by-product obtained from the diet or generated from muscle of the body. Creatinine is removed from blood by the kidneys as kidney disease progresses, the level of creatinine in the blood increases. 

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