of comorbid conditions, interventions Diagnosis and treatment, treatment reduction of risk factors for CVD to slow disease progression,

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1 Tble 5.1. NKF Clssifiction of Chronic Kidney Disese nd Clinicl Fetures Stge Description GFR (ml/ min/1.73 m 2 ) U.S. Prevlence, b # Affected (%) Clinicl Fetures Action Pln c At incresed risk for CKD >60 (with risk fctors for CKD) d DM, utoimmune diseses, systemic infections, drug exposure, neoplsi, fmily history, HTN Screening, reduction of risk fctors for CKD 1 Kidney dmge with norml or elevted GFR 2 Kidney dmge with mildly decresed GFR million (3.3) Micro-lbuminuri (DM 5 10 yers, retinopthy, rising blood pressure), lbuminuri (DM yers, retinopthy, HTN), cysts, proteinuri, + RBCs, ± WBCs, ± hydronephrosis Dignosis nd tretment, tretment of comorbid conditions, interventions to slow disese progression, reduction of risk fctors for CVD million (3.0) Estimtion of disese progression 3 Modertely decresed GFR 4 Severely decresed GFR million (4.3) DM, HTN, CVD, DM complictions (retinopthy), HTN complictions Evlution nd tretment of disese complictions ,000 (0.2) Preprtion for kidney replcement therpy (dilysis, trnsplnttion) 5 Kidney filure <15 (or dilysis) 300,000 (0.1) DM, DM complictions (retinopthy), CVD, uremi Kidney replcement therpy if uremi is present For stges 1 nd 2, kidney dmge ws estimted by rtio of greter thn 17 mg of lbumin to 1 g of cretinine in men or greter thn 25 mg of lbumin to 1 g of cretinine in women on two untimed (spot) urine tests. Prevlence ge 20 for stges 1 through 4 re bsed on dt obtined from the Third Ntionl Helth nd Nutrition Exmintion Survey ( ) (Sources: Jones CA et l. Am J Kidney Dis 1988;32(6):992 9; for stge 5, from the U.S. Renl Dt Survey, NIDDK, 1998). b Includes ctions from preceding stges. Prevlence of persons t incresed risk for CKD hs not been estimted ccurtely. NKF, Ntionl Kidney Foundtion; GFR, glomerulr filtrtion rte; CVD, crdiovsculr disese; HTN, hypertension; DM, dibetes mellitus; RBCs, red blood cells; WBCs, white blood cells. d CKD, chronic kidney disese; defined s either kidney dmge or GFR <60 ml per minute per 1.73 m 2 for 3 months. Kidney dmge is defined s pthologicl bnormlities or mrkers of dmge, including bnormlities in blood or urine tests or imging studies. Adpted from the Ntionl Kidney Foundtion. Am J Kidney Dis 2002;39(Suppl. 1):S1 S266. c

2 Tble 5.2. Serum Chemistry Lbortory Chnges in Chronic Kidney Disese (CKD) Lbortory Test Norml Rnge Norml Vlues in CKD Signs/Symptoms of Abnormlity Serum cretinine mg/dl Incresed generlly mg/dl (depends on muscle mss) Ftigue, dehydrtion, mentl confusion, shortness of breth Blood ure nitrogen (BUN) 7 21 mg/dl Incresed but <100 mg/dl (depends on protein intke) Ftigue, insomni, nuse, dry or itching skin, urine-like body odor nd breth Cretinine clernce ml/min <10 ml/min Serum clcium (C ++ ) mg/dl Sme but gol is <10 Low: ctrcts, depression, hir loss, muscle twitching/ crmping, seizures High: ftigue, muscle wekness, mentl chnges, thirst Serum phosphorus (PO4) mg/dl Incresed but gol mg/dl High: cuses elevted PTH by lowering C ++, bone frctures Serum sodium (N + ) mmol/l Sme decresed Thirst resulting in drinking more with fluid gin, elevted blood pressure, shortness of breth Serum potssium (K + ) meq/l Sme incresed but <6.0 meq/l Few until >7 meq/l, then wekness preceding crdic rrest Serum chloride (Cl ) meq/l Sme Low: hyperexcitble nervous system, low blood pressure, shllow brething, tetny High: deep brething, ftigue, muscle wekness Serum lbumin g/dl Gol >4.0 g/dl Weight loss, poor ppetite, mediction side effects Prthyroid hormone level (PTH) pg/ml Stge 3; pg/ml Erly: symptomtic Stge 4; pg/ml Lte: itching, bony chnges on X-ry, frctures Stge 5; pg/ml Modified from Dilysis Lb Tests t Glnce. Avilble t:

3 Tble 5.3. Trnsplnttion Immunosuppressnt Medictions Mediction Action Orl Side Effects/Dentlly Relevnt Toxicities Glucocorticoids Glucocorticoid receptor gonists, receptorindependent effects Angioedem, moon fce, orl cndidisis nd orl herpes simplex virus, nemi, neutropeni, possible drenl suppression Cyclosporine Clcineurin inhibitor Gingivl overgrowth Tcrolimus Clcineurin inhibitor Gingivl overgrowth (lower incidence thn cyclosporine) Sirolimus, everolimus Trget of rpmycin inhibitors Mouth ulcers, delyed wound heling, thrombocytopeni Mycophenolte mofetil Purine synthesis inhibitor Neutropeni, mild nemi Azthioprine Antimetbolite Leukopeni, bone mrrow depression Dclizumb, bsiliximb Anti-CD25 ntibody Rre mouth ulcers, orl cndidisis, gingivl overgrowth, thrombocytopeni Horse or rbbit ntithymocyte globulin Polyclonl ntithymocyte globulin Thrombocytopeni, leukopeni Adpted from Hllorhn PF. N Engl J Med 2004;351(26):

4 Tble 5.4. Dentlly Prescribed Mediction Adjustment for Ptients with Kidney Disese Adjustment of Mintennce Dose Intervls (in Hours), Totl Dose, or Timing with Dilysis for Adult Ptients in Renl Filure Drug Usul Dosge Norml Renl Function Mild Renl Filure (GRF > 50) Moderte Renl Filure (GRF 10 50) Severe Renl Filure (GRF < 10) Hemodilysis (HD) Peritonel Dilysis Antibiotics Amoxicillin mg q Dose fter HD 250 mg q12 Ampicillin 250 mg 2 g q Dose fter HD 250 mg q12 Cephlexin mg q Dose fter HD Clindmycin mg q6 Doxycycline 100 mg q12 Erythromycin mg q6 Metronidzole mg q8-12 Dose fter HD Penicillin VK 500 mg q6 Tetrcycline mg q Vncomycin 500 mg 1.25 g q12 1 g q g q g q4-7 dys 1 g q4-7 dys 1 g q4-7 dys Anlgesics Acetminophen 650 mg q Aspirin 650 mg q Avoid use Dose fter HD Ibuprofen mg q8 Ketorolc mg lod; mg q6 100% 50% 25 50% Locl nesthetics Individulized

5 Adjustment of Mintennce Dose Intervls (in Hours), Totl Dose, or Timing with Dilysis for Adult Ptients in Renl Filure Drug Usul Dosge Norml Renl Function Mild Renl Filure (GRF > 50) Moderte Renl Filure (GRF 10 50) Severe Renl Filure (GRF < 10) Hemodilysis (HD) Peritonel Dilysis Codeine mg q4-6 Meperidine mg q3-4 Morphine mg q4 Propoxyphene 65 mg q6-8 Nrcotics 75% 50% No dt No dt 75% 50% Avoid Avoid 75% 50% No dt Avoid Avoid Avoid Brbiturtes Pentobrbitl 30 mg q6-8 Secobrbitl mg q6-8 Benzodizepines Midzolm Individulized 50% Dizepm 2 10 mg q6-24 Lorzepm 1 2 mg q8-12 Trizolm mg qhs Others Dexmethsone mg q24 Diphenhydrmine 25 mg q6-8 Prednisone 5 60 mg q24 Fluconzole q24 50% 50% Dose fter HD 50% Acyclovir 5 10 mg/kg q8 q % q24 Dose fter HD 50% q24 No djustment needed.adpted from Aronoff GR et l. Drugs Prescribing in Renl Filure: Dosing Guidelines for Adults, 4th ed Americn College of Physicins. Phildelphi, PA.