Section 7. Nephrology

Hypertension

ACEIs/ARBs first line

• Target blood pressure is <130/80 mm Hg
• Most patients will require multiple agents; choose additional agents based on comorbid illnesses (see Table 1.1.2); thiazide diuretic (if CrCl > 30 mL/min) preferred second agent if no other compelling indications; CCB or BB preferred third agents (Am J Kidney Dis. 2004;43(Suppl 1):S1)

Proteinuria

ACEIs/ARBs

• Both ACEIs and ARBs reduce protein excretion by 35–40% (Am J Kidney Dis. 2004;43:S1)
• An ACEI plus ARB regimen can decrease proteinuria greater than either alone but may worsen kidney disease (Lancet. 2008;372:547)
• Spironolactone combined with an ACEI or ARB may reduce proteinuria greater than either alone (Clin J Am Soc Nephrol. 2006;1:256); monitor serum K+ closely with this combination
• Titrate ACE/ARB to maximum tolerated dose (see Table 1.1.1 for dosing), monitor serum K+ and SCr 1 week after initiation

Hyperlipidemia

Statins

• Target LDL-C <100 mg/dL (Am J Kidney Dis. 2005;45:S1–S153)
• There is conflicting data on whether statins decrease CKD progression.

Anemia

Erythropoietin-stimulating agents (ESAs) and iron

• A trial of IV iron or 1–3 months of PO iron can be considered for any patient with TSAT ≤ 30% and ferritin ≤ 500 ng/mL (Kidney Int Suppl. 2012;2:279.)
• Consider ESA if Hgb is between 9–10 g/dL, a maximum Hgb = 11.5 g/dL is appropriate for most patients (Kidney Int Suppl. 2012;2:279.)
• See Tables 11.1.1–11.1.2 for dosing of ESAs and iron products

CKD mineral and bone disorder (CKD-MBD)

Activated vitamin D, vitamin D precursors or analogs; calcimimetic

• See 7.1.2 for indications and dosing
• K/DOQI (2003) treatment goals: PTH = (35–70 pg/mL for CKD stage 3 or 70–110 pg/mL for CKD stage 4); serum phosphate 2.7–4.6 mg/dL; serum Ca++ in normal range; Ca-P product < 55 (Am J Kidney Dis. 2003;42:S1)
• KDIGO (2009) treatment goals: PTH, serum Ca++ and phosphate in normal range for the assay measured (Kidney Int. 2009;76(Suppl 113):S1)

Hyperphosphatemia

Phosphate binders

Metabolic acidosis

• NaHCO3 tablets (650 mg = 7.7 mEq Na+ and HCO3−)
• Na+ citrate solution (Bicitra = 1 mEq/L Na+ and HCO3−)
• Na+/K+ citrate solution (Polycitra = 1 mEq/L Na+ and K+ and 2 mEq/L HCO3−)

• Goal is to maintain serum HCO3 ≅ 24 mEq/L
• Calculate base deficit: [0.5 L/kg × (weight (kg)] × [(normal CO2) – (measured CO2)]
• Replace total deficit over several days to avoid volume overload
• Once base ...