To renal disease and its possible modes
Of treatment and therapy: an overview of processes
And current trends in combating
And treating renal failure
Presented to the Faculty of the University of Nebraska-Omaha Physician Assistant Program in requirement for the degree of Masters of Physician Assistant Studies
University of Nebraska, Omaha, Nebraska
2007
Abstract
This research looks into a brief overview of effects of diabetes and hypertension, to renal disease.
Diabetic Nephropathy and Hypertension could both lead to Renal Failyre. In effect of this, a number of treatments and medical strategies are proposed such as the: KEEP, SCORED, ACE Inhibitions, CALM and COOPERATE.
Chronic Kidney Disease (CDK) is a disease that is noted with azotemia of over months to years, uremia, and hypertension and broad cast in the urinary tract. CKD could be controlled by limiting patient’s intake of sodium as well as decreasing the patients fluid intake to a reasonable amount. Such could also be effectively controlled through the use of Thiazide Diuretics and Non-DHP Calcium Channel Blockers.
Finally, with regard to the treatment of patients with End Stage Renal Disease, the most preferred treatments are Hemodialysis and Kidney Replacement Therapy.
Introduction
End Stage Renal Disease (ESRD) is an ailment that is caused by numerous comorbities; the foci of this paper however were ESRD’s two main causes: hypertension and diabetes mellitus. Currently, these two diseases account for over two-thirds of cases of renal failure. In addition with this, diabetes mellitus has been viewed to be the overall cause of ESRD in the USA to date with 50% of cases, and hypertension being the runner-up.
Corollary with this, studies on how to slow the progression of renal failure on ESRD patients were discussed. It could be significantly noted that on the medical literatures used, there has been a discussion of the findings that showed the importance of ESRD patients’ residence, ethnicity, as well as the location of hemodialysis center in their respective cities. Such factors are then related to compliance rates, and how they could adversely affect the life expectancies and overall clinical outcomes of ESRD patients.
Also there was a short discussion about renal transplantation as a treatment for viable patients with end-stage renal disease and the survival rates of the different types of renal transplants.
Review of Related Literature
The literature review comprised with a brief overview of hypertension and diabetes mellitus and how they lead to renal disease, with the latter being discussed first. Proceeding such is the discussion on chronic renal disease and studies showing how treating this disease can slow down the progression of ESRD as well as improve overall patient clinical outcomes.
Studies made in Non-White Races (i.e. African American, Hispanics and Native Americans respectively) shows that diabetic nephropathy is a disease of albuminuria and secondary hypertension that could lead to renal insufficiency. Moreover, there are about 4000 people per year in the United Sates that are being diagnosed with ESRD; a disease secondary in terms of frequency to diabetic nephropathy, and in sum creates a 44,000- population in need for treatment (2).
Type one diabetics are more likely to be diagnosised with ESRD (30% to 40% in 20 years) than their type two counterparts (15% to 20% in 20 years) due to fewer deaths and comorbidities before its development. In addition, statistics also showed that the numbers of incident and prevalent cases of end stage renal diseases are projected to reach a total of 136,166 and 712,290 by 2015 (10).
From the study that was taken, approximately thirty-six months after the diagnosis of diabetes, renal biopsy shows signs of how the kidneys are affected. The sign that is most commonly seen with damage of the kidneys is the thickening of glomerular membranes, as well as capsular drop deposits. These collective findings are known to be under the Kimmelstiel-Wilson disease in the diabetic nephropathic patient (13). Some other signs and adverse affects are glomerulosclerosis, an initial hypertrophy of the kidneys in size, and an increased glomerular filtration rate. It should be noted that these findings in turn lead to a decrease in serum creatinine and blood urea nitrogen levels.
In 10- 15 years, the body is expected to reveal signs of renal damage such as microalbumenia. It should also be recognized that the amount of protein spilled in the beginning of microalbumenia will initially be a minute quantity and will be something below of what can be detected by routine tests for evaluating for urinary protein. It is when the amount of albumin spilled reaches 30-300 mg per day that the progression to ESRD is highly likely to be recognized.
Common signs of advanced diabetic nephropathy are hyperkalemia, metabolic acidosis, and an increase in serum creatinine. Such is the result of the increase of blood urea nitrogen levels up to the point that the kidneys are no longer able to concentrate and clean the urine effectively. The primary reason for this is rooted on the damaged nephrons which resulted due to constant hyperfilitration caused by the initial enlargement of the kidneys.
Moreover, it should be noted that diabetics with these complications are more likely to die from a myocardial infarction than the end stage renal disease that they suffer. Hyperlipidemia associated secondary to complications of having diabetes has been speculated to be a cause of this finding, and such has been pushed by researchers to start statin treatment in patients with mild renal insufficiency; however there has been no formal advisement in doing so in patient populations with severe kidney disease, secondary to not knowing how these drugs will react in patients with severe diabetic nephropathy. The reader should also be aware that renal insufficiency itself causes an abnormal lipid panel that can put these patients at higher risk for artherogenisis.
Furthermore, it should be noted that dyslipidemia causes patients with end stage renal disease to be 10 to 20 times more likely to die from cardiac complication as well as microvascular complications secondary to arthrosclerosis than their counterparts without kidney disease even when there are adjustments made for race, sex, and diabetes. To further worsen matters, it has been suggested that in animal model studies, dyslipidemia itself can worsen the kidney function in patients with even minimal kidney damage. This finding, even if only in animal models studies, should alert the provider to treat hyperlipidemia aggressively as reasonable as they can, for not only the possible preservation of renal function but also for the cardiovascular decreasing in morbidity and mortalities from disease processes such as peripheral vascular disease, myocardial infarction, stroke and numerous others that have been mentioned.
Some of the treatments and preventive medicinal strategies in conserving renal function in the diabetic patient with renal disease are yearly 24-hour albumin excretion testing, treatment of urinary tract infections in susceptible patients, reduction of protein intake to 0.8 g/kg body weight per day, and the removal of nephrotoxic substances from the patient’s drug regimen as deemed necessary (13). If there might be instances wherein a patient is spilling protein, the blood pressure of the former should be tried to be lowered in the following ranges: systolic pressure <125mm Hg and a diastolic pressure that is lower than 75mm Hg .
Also, such types of patients should start on Angiontension Converting Enzyme Inhibitors (ACEI) and Angiotension II Receptors Blockers (ARBs) if their GFRs are adequate enough to prevent them from becoming hyperkalemic with such a therapy. The aforementioned patient treatment helps to delay progression of renal disease in diabetic and nondiabetic populations. The ACEI and the ARB therapy is perceived to bring about a specific dilation of the glomerular efferent arteriole, which in turn reduces the glomerular filtration pressure that causes a decrease in the amount of protein being spilled by the kidneys into the urine.
Also it have been shown that metabolic control, and keeping serum glucose as close to normal as possible (Hemoglobin A1C of less than seven) can help slow the progression of diabetic nephropathy and other microvascular complications (12). In addition with this, according to the studies done by the National Kidney Foundation, patients with such types of disease should also have targets of low LDL cholesterol, and a blood pressure in the range of 130/80mmHg or less (14).
It was found in the KEEP study that only 20-25% of patients with kidney disease reach the goals of the use of antihypertensive drugs and even with such a small number, clinical experts still have the difficulty reaching such. According to the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Larsartan Study, it was speculated that the maximal systolic blood pressure for renal function preservation is 120, and the hypertensive drugs that are being used currently are not potent enough to do this at the dosages that are being prescribed
It should be noted that, once a serum creatinine of six has been given to a diabetic nephropathy patient, kidney replacement therapy (i.e. dialysis or renal transplantation) should be started immediately secondary to the increased rate of vascular complications (13). However it should be taken into consideration that even with hemodialysis, it could be the case that the patient’s overall clinical prognosis will still poor hence making renal transplantation the preferred treatment of choice (5).
Hemodialysis is rarely used for treatment of a diabetic with ESRD because of the latter primarily being a large vessel disease. Albeit there are still a number of researches which show that a Peritoneal Dialysis could also be a relatively better therapy and could replace a kidney replacement therapy as it has been shown to have fewer complications (5).
Hypertension and Diabetes could lead to a full-blown renal disease. Hypertension creates a direct damage to the vessels in the nephrons of the kidneys which causes the latter to lose their ability to autoregulate the filtration rate of the blood for cleaning. In turn such causes a hyperfiltration where albumenimia and proteinuria are abundant. In the long run, such causes the activation of the rennin-angiotension system, which results in fluid overload that could further increases the severity of the hypertension as well as further damaging and destroying nephrons in the kidney. If the severity of the hypertension (i.e. the higher that the patients blood pressure is above of what is considered to be normal) further duration of such an elevation can unfortunately lead to a diagnosis of end stage renal disease. Such a disposition could be accelerated at a very fast pace not unless the patient’s blood pressure can be lowered with appropriate antihypertensive therapies.
The SCORED study took place over a period of four years with an evaluation approximately 10,000 patients with the final data set consisting of the data from approximately 8500 patients due to missing data from the initial group studied (1). The study helped to develop a rubric for drawing a serum creatnine for the evaluation in a patient population with the following morbidities: falling into a certain age range as described by the study, hypertension, diabetes mellitus, cardiovascular diseases, protienuria, and lastly anemia.
This study helped to show that only a very small number of patients with diabetes mellitus that is 22% and only a marginally higher number of patients suffering from hypertension (approximately 28%) are randomly screened by the United States for occult renal disease even though it has been well publicized in the medical community that these two disease processes cause over 70% of all cases of end stage renal disease (1).
The SCORED (Screening for Occult Renal Disease) Study suggests the use of a glomuler filtration rate of 60 ml per minute on patients diagnosed with kidney disease. In this research, it was determined that when factoring in a patient population with multifactorial risk factors for kidney diseases, a serum creatinine should be drawn first before a patient could be subjected to an evaluation of a chronic kidney disease.
A patient with a score of four or more risk factors should be screened for kidney disease by drawing a serum creatinine Moreover, the sensitivity of finding a patient with kidney disease with these findings is 92% and a negative prediction rate of 99% can be appreciated. Unfortunately, the specificity and positive predictive rates of finding a patient with kidney disease using the morbidities mentioned earlier is found in only 18% of patients tested.
Furthermore, this low finding in itself should not avert the clinician from drawing a serum creatinine in a patient population with a score of four or higher secondarily to the inexpensiveness and reliability of a serum creatine. Also economically it is cheaper to the healthcare system to find-out these problems early and slow the progression of the disease
The next study that the author focused on involves the usage of ACE inhibitors in the treatment of kidney disease. In the ramipril efficacy in nephropathy study it was shown in the nondiabetic patient hypertensive patient, which patients who received ramipril therapy had a higher glomerular filtration rate, and a lower rate of its decline didn’t received any treatment (3). These findings in turn show the importance of not only using an ACE inhibitor in a hypertensive patient with renal disease but also that some other members of the general population (i.e. nonhypertensive patients) with a renal decline may benefit with the addition of an ACE to their drug regimen.
Another study that strengthened this point was the CALM (candesartan and lisinopril microalbuminuria) study. The study includes a patient population of 200 which were randomly selected to receive candesartan 16mg, lisonopril 20mg daily or both drugs combine. The study lasted for twelve weeks long.
The study revealed that when these two drugs are combined there could be a greater reduction in the patients’ blood pressure, and a further decrease microalbuminemia than with either drug alone (9). It should be noted that this treatment is approximately eighteen percent better in the reduction of the forementioned findings.
The COOPERATE (combination treatment of ARB and ACE inhibitors in nondiabetic renal disease) study, further strengthens the finding that the combined usage of an ARB and ACE Inhibitor provided a greater reduction in both proteinuria and blood pressure the use of either class alone (6). In this study, approximately 10% of patients placed on combination therapy reached the goals set forth by the study; which could further strengthen the claim that a combination therapy is a safe route to slow the progression of renal disease in patients.
This in turn, proves again that angiotension type 1 receptor blockers and angiotension converting enzyme inhibitors are of the utmost importance in patients with kidney disease as such helps to delay further kidney damages as well as decreasing cardiovascular complications like left ventricular hypertrophy, stroke, and other vascular disease such as arteriosclerosis.
In relation with this, an important finding with the discovery of using ACE inhibitors and Angiotension Type 1 Receptor Blockers reveals the benefits of decreasing the proteinuria among patients. Also, further intake of dosages can result to significant decrease in blood pressure.
For example, lisonpril can be given in a dosage of eighty milligrams per day for renal protective factors where the normal antihypertensive treatment dosages range from 2.5 milligrams daily up to forty milligrams per day. Also the ACEI or ARB’s can be changed to one, with more tissue penetration which in turn can help decrease the amount of protein being spilled by the kidney as such could lower the blood pressure. Again, lisonpril would be a good choice when compared to other ACE inhibitors, such as captopril, as the former has been documented to have less tissue uptake and more side effects such as metallic taste than lisinopril.
Unfortunately, even though ACEI and ARB’s have been proven to slow the progression of renal disease by decreasing proteinuria, only 37% -68% of viable candidates who can tolerate these drugs are undertaking such a treatment. Furthermore, only 75% -80% members of the patient population who suffers from renal disease are being treated with these drugs; and these said patients did not reached a systolic blood pressure of even 130.
The next area of interest of discussion is an overall overview of Chronic Kidney Disease (CKD). CKD is a disease that is noted with azotemia of over months to years, uremia, and hypertension and broad cast in the urinary tract. The test that could effectively diagnose such a disorder is through the use of bilateral small kidneys with ultrasound. CKD is a disease that is very common in the United States, and affects approximately 11% of the general population. It should be noted like many other diseases, that CKD patients are asymptomatic until the disease has became severe in nature. This disease is one that leads to a continuous decline in renal function even when the cause of the damage to the kidneys is being treated.
Patient’s that are near ESRD (GFR<15 ml/min) possess different symptoms such as nausea, vomiting, itching secondarily to an increase in phosphorous. These patients encounters irritation on the skin, and also a decreases in libido and concentration due to increasing in urea in their blood that could not longer be filtered by the kidney. (8).
Chronic kidney disease is divided into four stages with each stage having a definitive plan of action(8). ( Insert Table 1 here). Furthermore, the renal failure can also be diagnosed through the patients’ abnormal laboratory findings such as elevation of blood urea nitrogen and serum creatinine over time. It should also be noted that hypertension can also be developed to a nonhypertensive patient that is progressing to renal failure secondarily to fluid and sodium retention.
CKD could also be controlled by limiting patient’s intake of sodium as well as decreasing the patient’s fluid intake to a reasonable amount based on his or her estimated daily urinary output. Patients are also advised to increase exercise and loose weight to help control blood pressure. The latter is deemed as an acceptable part of overall therapy, however in certain cases, a patient should be first cleared by their clinician to take part in physical activities.
Also another mode of treatment that could be used with regard to problems on both blood pressure and fluid retention is through diuretics. Thiazide diuretics are often chosen in order to effectively lower blood pressure as well as decreasing fluid retention, which is primarily done through diuressing. Thiazides work until the GFR in a particular patient reaches less than 10-15 ml/min. After such a diuretic therapy with loop diuretics such as furosemide may be instituted. Through the use of loop diruectics the clinician can give the patient with higher doses in order to increase its diurectic effect as the GFR declines (16).
Another class of anti-hypertensives that can be used to used to lower blood pressure as well as help decrease the amount of proteinuria noted with patients suffering from kidney disease is the non-DHP calcium channel blockers such as diltiazem and verapamil. In a study conducted on a duration of six year noted that the calcium channel blockers where of equal statue to the more commonly used ACE inhibitors that has the capacity of decreasing the amount of protein being spilled by the kidneys into the urine (16).
More importantly, blood pressure was perceived to decrease through the use of a non-DHP calcium channel blocker that was closely similar to an ACE inhibitor. It should also be noted that when an ACE inhibitor and a non-DHP calcium channel blocker are taken together, the amount of protienuria in the urine can be decreased even more, than using either class alone. Such a form of treatment has been deemed as very reasonable for non-diabetic patients with kidney disease by the National Kidney Foundation.
On the other hand, the commonly prescribed older DHP calcium channel blockers such as nifedipine and amlodipine have not been shown to decrease the amount of proteinuria nor the decline of renal function in neither diabetic or nondiabetic patients suffering from kidney disease. In fact the said drugs can impair the autoregulatory abilities of the kidneys which can cause damage with small increase of blood pressure than if autoregulation were still intact in the kidneys (15). Also, the drug manidipine,a third generation DHP, offers renoprotective abilities not seen with its older counterparts. Such a drug offers vasodilatation of the efferent renal arterioles, thereby allowing the kidneys to keep their autoregulative properties that in turn protects the as well as offering even more protection due to the blood pressure lowering effects of the drug itself.
It should be noted that when patients were studied in a trial and were given either ten to 20 milligrams of manidipine or ten to 20 milligrams of enalapril, there has been no perceived statistically significant difference between improving renal hemodynamics. Also, such a trial which was a 12-month head-to-head comparison and randomized controlled trials were also preformed in order to confirm their results.
Closely related to this, a later study involving 136 hypertensive patients over a year period showed that enalapril was an overall better drug in decreasing protienuria. However, both drugs showed to slow down the rate of renal function failure, as shown by serum creatinine. Also, the authors of this study speculated that the significantly lower blood pressures gained by patients through using enalapril may have been the cause of the greater decreases of proteinuria in the patient population taking enalapril versus the patients taking manidipine.
In relation with this, another study that further proves that manidipine is superior to its older DHP counterparts is a study which involved the participation of 101 hypertensive patients that suffered from chronic kidney disease. The study, which took place over three months, noted that proteinuria actually increased in the patients that were receiving nifedipine by approximately 35% higher than baseline, while the patients receiving mandipine decreased their spillage of protein by an average of 25%. However the research claimed that such results were not that statistically significant.
This section of the research elaborates on hemodialysis and renal transplantation and how they could significantly contribute to a patient suffering the terminal stage in renal failure.
Hemodialysis is a process wherein the blood goes through hyperfilitration into a semipermiable membrane, and latter being calibrated in such a fashion, that waste products like urea, ammonia, and excess water will be cleaned and will be removed from the body. Dialysis is initiated due to several factors which also include hyperkalemia, metabolic acidosis, pulmonary edema or congestive heart failure on chest x-ray as well as others (4). In a dialysis, the patient goes through the treatment of approximately three to four hours in three different sessions within a week. It should be noted that dialysis itself can not do away with certain risks such as hypertension, cramping and septicemia. Another common complication of this therapy is prolonged bleeding due to dysfunctional clotting factors of the platelets as well as the usage of heparin in this patient population in the prevention of clotting during therapy. Hemodialysis could also be done through either the use of an intravenous catheter, arteriovenous (av) fistula or synthetic graft. It should be noted that out of these three choices the av fistula is the most favorable due to the latter being accredited to greater patient survival rates, lower infection rates, as well as greater access patency for an extended period of time. These said findings were perceived to be highly relevant in nature that the Centers for Medicare and Medicaid has pushed for av fistulas to be used more in patients that can tolerate this type of access placement and usage.
One ten-year study done on end stage renal disease patients looks into how well Black Americans responded to being treated in a center where the majority of the patients were Caucasians. The study showed that these patients developed worse clinical outcomes. Black Americans receiving care in a dialysis treatment center where the patient composition was less than 25% Black. On the other hand, the research also reveals that although both Black and Whites had their highest mortality rates, the poorest clinical outcomes in studied facilities which accounts to more than75% are composed of Blacks (11). It should be noted that in this study found out that treatment centers that had more Black residents have poorer management of diseases such as anemia and were more likely to have inadequate dialysis.
The last area that the author looked upon in this research is renal transplantation as kidney replacement therapy. Kidney Replacement Therapy is the most favorable treatment of end stage renal disease in patients that can tolerate the said surgery. Such starts by conducting a HLA testing for the patient, as well as doing a full cardiac workup to see if they are viable candidates. Also the patient’s family members if any, or viable candidates or choose to become candidates, are tested to see if they are a potential match, and screened for health conditions that could limit them being viable donors. It should be noted that up to 50% of patients who are in end stage renal disease are viable candidates for transplantation; and currently the survival rate for transplanted kidneys are approximately 76% at five years for a related living donor and 65% for non-related living donors (8). The survival rate for cadaver donors is currently at 58%, and the wait time to receive this type of transplant ranges from 2-4 years. It should be noted that the increase of the demands for organ donors is due to the fact that more people are being diagnosed with end stage renal disease without a proportional increase in the deceased donor pool to provide a compensation for these new patients’ being diagnosed with end stage renal disease.
Discussion
The aforementioned studies discussed in this research have been perceived by the author to provide clinicians a better understanding of how to treat patients with kidney disease as well as the comorbidities that are associated with such like hypertension or diabetes mellitus. The COOPERATE, KEEP, and CALM studies all have proven that it is in the best interest of the patients that suffer from protienuria that clinicians should be treating the former with an ARB or an ACE inhibitor which in turn could provide two benefits:
1.) A reduction in systolic and diastolic blood pressures which can help prevent further damage from uncontrolled hypertension.
2.) The decrease in the amount of protein being spilled by the kidneys into the urine which again has a positive affect on patient outcomes. Such drugs offer a renoprotective affect through several mechanism mentioned earlier.
Also these studies have shown the importance of treating hyperlipidemia in patients with kidney disease due to cardiac dysfunction. The latter has been widely viewed as the cause of the majority of deaths in patients with end stage renal disease, as well as hyperlipidemia. In addition such has also been proposed to worsen kidney functions that are already damaged. Moreover, the author wanted to emphasize that it is advisable to treat the lipids through diet, exercise as well as medication in order to reach a level of low density lipids of less than 100mg/dl. Patients who can tolerate such are perceived to be appropriate to participate to various forms of patient therapy (4).
In addition with these, the studies and the medical literature findings that were discussed have show that it is of the utmost importance to control blood glucose, restrict protein, and give an ACE or ARB to diabetic patients to slow the patients’ progression to both diabetic nephropathies. More importantly, such could also be hoped as to reduce the rate of progression of the diabetic patient populations to end stage renal disease. More importantly, the studies have helped to show that there are major disparities in race when it comes to mortality, clinical outcomes in dialyzing patients, and transplanting them when these forementioned things are gathered and looked at as statistical data and are looked at as independent patient variables.
Conclusion
This paper has shown that renal disease will continue to increase throughout the United States due to the increasing number of diabetic patients. In relation with this, the research showed that hypertension and hyperlipidemia in the United States are also not being optimally controlled. Furthermore, for those patients that are taking hemodialysis, the author perceived that the best access for them would be through an AV fistula in order to lower the amounts of complications and also to be able to increase patients’ survival rates.
These findings have great significance due to the fact that there are indeed a number of preventable and or controllable factors that could prevent or slow down the progression of a kidney disease. If a clinician, for instance can treat a patient’s hypertension and prevent them from reaching ESRD then one can in turn help create a cost-effective approach for the healthcare as well as improve patients’ quality of life. In addition with this, if one would treat patients’ hyperlipidemia in a more aggressive manner, one can significantly decrease the number of cardiac events patients could have experience. Such a state of affairs could again in turn add to the evaluative inclinations of the patients and the financial goals of the institutions.
Furthermore, the author perceived that there must be a more in-depth study that should be created with regard to the locations of where people are dialyzed, as well as the racial disparities in the adequacy of the their dialysis treatments. In addition with this, adverse clinical outcomes due to the location and racial composition of the centers should also be further evaluated.
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Appendix
Tables
Table 1: Stages of chronic kidney disease: a clinical action plan. 1,2
Stage
Description
GFR
Action 3
1
Kidney damage with normal or increased GFR
; 90
Diagnosis and treatment of comorbid conditions to slow progression. Reduction of cardiovascular risks.
2
Kidney damage with mildly decreased GFR
60-89
Estimation of progression.
3
Moderately decreased GFR
30-59
Evaluating and treating complications.
4
Severely decreased GFR
15-29
Preparation for kidney replacement therapy.
5
Kidney failure
;15 (or dialysis)
Replacement(if uremia is present)
1 From the NFK,KDOQI, chronic kidney disease guidelines
2 CKD is defined as either kidney damage or GFR; 60 for 3 or more months.
3 Includes actions from preceding stages.
;
