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  • Image not available. The number of patients with chronic kidney disease (CKD) is increasing, and it is expected that the number of patients with end-stage renal disease (ESRD) will exceed 780,000 by the year 2020.
  • Image not available. Common complications of stages 4 and 5 CKD include anemia, CKD–mineral and bone disorder (MBD) and renal osteodystrophy, fluid and electrolyte abnormalities, metabolic acidosis, and malnutrition.
  • Image not available. Anemia of CKD, which is primarily caused by a deficiency in the production of endogenous erythropoietin by the kidney, is a common complication observed in patients with stages 4 and 5 CKD.
  • Image not available. CKD-MBD and renal osteodystrophy are common in patients with CKD and contribute to extravascular calcifications and an increased risk of cardiovascular mortality.
  • Image not available. Cardiovascular complications are prevalent in the CKD population and are the leading cause of mortality in patients with ESRD. Thus at the initiation of dialysis, all ESRD patients should be assessed for cardiovascular disease, which includes assessment for coronary artery disease, cardiomyopathy, valvular heart disease, cerebrovascular disease, and peripheral vascular disease in addition to screening for both traditional and nontraditional cardiovascular risk factors.
  • Image not available. The management of CKD and the associated secondary complications should be initiated prior to development of ESRD.
  • Image not available. Guidelines by the National Kidney Foundation Kidney Disease/Dialysis Outcomes Quality Initiative (NKF-K/DOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) provide information to assist health care providers in clinical decisions and the design of appropriate therapy to manage complications.
  • Image not available. Patient education plays a critical role in the appropriate management of patients with stage 4 or 5 CKD and related complications. A multidisciplinary team structure is a rational approach to provide this education and effectively design and implement the extensive nonpharmacologic and pharmacologic interventions required.
  • Image not available. Management of anemia includes administration of erythropoietic-stimulating agents (ESAs) (epoetin alfa and darbepoetin alfa) and regular iron supplementation (oral or intravenous administration) to achieve a target hemoglobin of 11 to 12 g/dL (110–120 g/L; 6.83–7.45 mmol/L). There is now evidence indicating a higher risk of cardiovascular events when hemoglobin is targeted to greater than 12 g/dL (120 g/L; 7.45 mmol/L).
  • Image not available. Management of CKD-MBD includes dietary phosphorus restriction, prudent use of phosphate-binding agents, vitamin D, and calcimimetic therapy.

Upon completion of the chapter, the reader will be able to:

  • 1. Describe the typical clinical presentation of a patient with advanced CKD, including subjective and objective findings.
  • 2. Describe the association between decreased kidney function (decreased glomerular filtration rate) and development of secondary complications.
  • 3. Compare the risk of cardiovascular complications and mortality in patients with advanced CKD to that of the general population.
  • 4. Discuss the fluid and electrolyte abnormalities prevalent in patients with advanced CKD and differences in management compared with patients without kidney disease.
  • 5. Recommend an appropriate regimen for management of anemia of CKD incorporating iron supplementation and the available erythropoietic stimulating agents in individuals with CKD not on dialysis (stage 3 or 4) and in patients with ESRD.
  • 6. State the goal iron indices and Hb in patients treated for anemia ...

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