Multiple studies have suggested that in-hospital mortality is significantly higher in patients developing contrast induced kidney damage especially those who require hemodialysis.
Risk Factor
1. Hx of Chronic Kidney Disease
2. Congestive heart failure
3. Older age
4. Hypotension
5. Volume depletion
6. Concomitant use of nephrotoxins such as nonsteroidal anti-inflammatory agents also increase the risk for contrast induced kidney damage.
In the majority of patients with contrast induced kidney damage, the serum creatinine value begins to rise within 24–48 hours after contrast media exposure, peaks within 3–5 days, and returns to baseline levels within 7–10 days. The majority of patients are nonoliguric and often have low urine sodium concentration. The urinalysis in patients with contrast induced kidney damage typically demonstrates coarse granular casts, renal tubular epithelial cells, and amorphous debris, findings characteristic of acute tubular necrosis.
Most studies, although not all, suggest that exposure to larger volumes of parenteral contrast causes greater predisposition to contrast induced kidney damage. In addition, the type of contrast material (specifically its osmolality) influences the development of contrast induced kidney damage. Contrast media formulations occur in three types: High-osmolar contrast media (also termed ionic), which have an osmolality of approximately 2000 mOsm/L, low-osmolar contrast media (also termed nonionic), which have an osmolality of 600–900 mOsm/L, and iso-osmolar contrast media (also a nonionic composition), which have an osmolality of 300 mOsm/L. Multiple studies in high-risk patients with CKD have demonstrated that low-osmolar contrast media results in less contrast induced kidney damage than high-osmolar contrast media, and there is some evidence that iso-osmolar contrast media may be less nephrotoxic than low-osmolar contrast media.
Differential Diagnosis
1. Acute Tubular Necrosis
2. Renal atheroembolism
3. Allergic interstitial nephritis
Prophylaxis
1. Begin an infusion of isotonic sodium bicarbonate at 1ml/kg/hr for 12 hours pre- and post-procedure
2. The most commonly employed dose of NAC is 600 mg by mouth twice daily the day prior to and the day of contrast administration. Initially, this finding was greeted with widespread enthusiasm and the use of NAC quickly became common in clinical practice. Subsequent studies of its efficacy have been mixed, as have meta-analyses of those studies. To date, it remains uncertain if NAC is an effective preventative measure, but it is nonetheless often used in clinical practice, based on its safety, simplicity, and low cost.
3. Although acute administration of diuretics has been shown to increase the risk of contrast-induced acute kidney injury, the discontinuation of chronic diuretic therapy has not been demonstrated to be beneficial.
4. Discontinuation of ACE Inhibitors has not been clearly shown to decrease the risk of contast induced acute kidney injury.
Treatment
There is no specific therapy for contrast induced kidney damage once it occurs. The best strategy is one of prevention. Preemptive nephrologic consultation to ensure that optimal prophylactic strategies are provided may be of value in certain high-risk azotemic patients.
Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328
Demand for organs has always exceeded supply. In order to resolve the shortage of donors, some have advocated financial payments being made to donors. Despite being illegal in most countries, the trade appears to be booming in nations such as Turkey, Russia, and South Africa In 2008, the legislative branch of the Israeli government, approved a law that provides for various benefits to living organ donors, such as: 1. Reimbursement for medical expenses and lost work up to $5,000 2. Priority on the transplant list should they require a future organ donation 3. Waived self-participation fee for any medical service resulting from the donation 4. Attainment of a "chronic patient" status, which entitles the holder to additional medical benefits. 5. If two patients have the same medical need, priority will now go to the patient who has signed an organ donor card, or whose family members have donated an organ (though medical necessity is still takes precedence). One of the few countries that has legalised the sale of organs is Iran. A third-party independent association was set up to arrange contact between donors and recipients. This agency is staffed on a voluntary basis by end-stage renal failure patients. Within the first year of the establishment of this system, the number of transplants had almost doubled; nearly four fifths (80%) were from living unrelated sources. Donors receive:
1. A Payment from the government
2. Free health insurance
3. Often payment from the recipient or a charity
The receiver of the ‘new’ kidney is provided with highly subsidized immunosuppression and charitable organizations allow those unable to pay for the transplant themselves to receive a new organ. Importantly, it is illegal for the medical and surgical teams involved or any ‘middleman’ to receive payment. A potential donor is also not allowed to contact anyone on the waiting list. Despite, this, anecdotal stories of young men touting their ‘spare’ kidney in dialysis clinics are common.
While still illegal in ‘Western’ nations, could the ‘Iranian model’ of payment for kidney donation be used in Unites States to solve the problems of kidney donor shortages?
Pros:
1. The advocates for legalization argue that each of us has autonomy over our own body in every aspect of our health and that from this stems the right to donate a kidney to a related or non-related patient. Payment for sperm and eggs is legal in many countries, even though they arguably have greater long-term implications due to the potential to create a whole new individual. Similarly to compensation received for participation in some clinical trials, the individual also gains no immediate benefit from putting themselves at risk.
2. After the initial peri-operative risk, the donor has no long term increased risk of mortality.
3. Most importantly, in the longer term, there is no significant acceleration in decrease in glomerular filtration rate (beyond that expected due to aging) in kidney donors fifteen years after transplantation.
4. Charitable organizations allow those unable to pay for the transplant themselves to receive a new organ
5. Advocates of the Iranian model insist that where there was once a significant waiting time in excess of the length in ‘Western’ nations, there is now no waiting time.
6. The Iranian system is known to have ethical and legal loopholes which have been exposed and exploited.
7. There are “no significant differences” in groups of donors and recipients when compared in terms of socioeconomic background (wealth and education level). Thus significant social exploitation is not occurring.
8. One of the earliest problems involved patients from abroad travelling to Iran to receive a kidney donation from an Iranian. This practice was outlawed to prevent the development of true ‘transplantation tourism’ and international exploitation of Iranian donors. In addition, refugee groups (such as those from Afghanistan) are offered transplants but are not allowed to donate to people outside of their ethnic groups, further decreasing potential exploitation of vulnerable groups.
9. As ESRD continues to grow in prevalence, the problem of unregulated organ markets and brokers is likely to become more severe. It is argued that the setting up of regulated markets would ‘cut out the middleman’ and reduce the exploitation of individuals and developing nations.
10. Inferior surgical and medical practice, common on the black market, leave both the donor and recipient at greater risk whilst the broker pockets a large cut of the proceeds.
11. The end-stage renal failure population continues to increase in most countries, putting an increasingly heavy load on medical infrastructure. Using economic cost-effectiveness analyses, a figure of approximately $90,000US has been proposed, much less than the estimated cost of dialysis of up to $70,000US per annum per patient. Government intervention would also guarantee adequate post-operative care and follow-up for the donor, something which is currently limited.
Cons:
1. The downside of legalizing Kidney trade is that the majority of those selling kidneys in Iran are disproportionately poor.
2. Opponents argue that the donation of a kidney is permanent.
3. Iranian system insist that the systemis not as perfect as it seems.
4. There is evidence to suggest Iran’s system has not cleared its waiting list and that trading between socioeconomic classes is a substantial problem.
5. Critics of the Iran model would argue that even this well developed system has major flaws and that a ban on payment to kidney donation should be maintained in other parts of the world.
A possible compromise
1. A non-monetary reward system. For instance, patients who have previously agreed to be on the transplant list could receive priority health care.
2. It has also been suggested that governments should control the monetary aspects of the transactions rather than payment passing directly from individual to individual. The donor would effectively sell their organ to the state which would then allocate it on the basis of clinical need. By making the process more medically transparent, it may placate to some degree those who accuse pro-monetary transplantation advocates of disregarding the exploitation of the poor by the rich. It is also likely that a ‘fair’ standard price could be set to prevent those in desperate financial need from being even further exploited.
As the pressure of demand for organs continues to increase rapidly, the idea of financial compensation for kidney donation will continue to rise.
Sexual dysfunction is very common in patients with chronic kidney disease. Kidney disease can cause chemical changes in the body affecting circulation, nerve function, hormones and energy level. The condition has been found to be significantly more common in men and women with chronic kidney disease (CKD) than in the general population. Approximately 50% of male predialysis CKD patients and 80% of male dialysis patients have erectile dysfunction. Multiple factors contribute to the frequent occurrence of sexual dysfunction in CKD patients, including hormonal disturbances such as hyperprolactinemia, hypogonadism in males.
Causes of erectile dysfunction in chronic kidney disease: 1. Diabetes 2. High Blood pressure 3. Men with renal disease may find their hormone levels changing 4. Side effect of medicines, particularly those taken to control blood pressure 5. Symptoms such as breath and body odor, weight gain or unusual facial or body hair may be present 6. A man on hemodialysis may feel self conscious about how his vascular access site looks and feels 7. Men on peritoneal dialysis may worry about the size of their abdomens 8. Some men with kidney disease are afraid sexual activity may be harmful to their condition or harmful to their partners. 9. Anemia due to kidney disease 10. Chronic kidney disease mineral and bone disorder
Treatment must start with determining and treating the underlying causes. Honest evaluation of alcohol, tobacco, and recreational drugs is essential. Assessment of emotional life, i.e. how well the patient gets along with his partner is vital. He may benefit from a referral to a psychotherapist, or the couple may be advised to seek marriage guidance. For men in whom vascular problem appears to predominate: Doppler studies, pharmacocavernosometry, pharmacocavernosography, dynamic infusion studies, and colour Doppler response studies may be helpful.
Once erectile dysfunction is diagnosed and psychosexual component is ruled out a review of the drugs, haemoglobulin levels and dialysis adequacy should be corrected. They should have hormonal studies, including testosterone, LH, FSH, and prolactin. Correction of these hormones may not necessarily restore libido. The use of testosterone injections have shown only a small and variable response in erectile function. Using clomiphene in uraemic males may correct the androgen deficiency and increase the sense of well‐being, libido, and potency, similarly to testosterone administration; however, its long‐term use in uraemia is inconclusive. To treat erectile dysfunction, bromocriptine in doses of 2.5–5 mg has been shown to improve libido and potency; the mechanism, however, remains unclear and it is possible that bromocriptine may influence potency directly as a result of its dopaminergic properties.
Treatment of erectile dysfunction in chronic kidney disease: 1. Your doctor can perform blood work to determine if your lack of interest in sex is due to your changing hormone levels. He may prescribe medicine to bring your levels to a normal range. 2. Talk to your doctor about the blood pressure medications you are taking if you are experiencing impotence. 3. Phosphodiesterase-5 inhibitors (PDE5i) such as viagra compared with placebo significantly increases sexual performance. 4. Oral zinc supplementation results in a significant increase in plasma testosterone concentration along with an increase in the potency and frequency of intercourse. 5. Only sparse data are available for vitamin E, bromocriptine, and dihydroxycholecalciferol in CKD patients and no trials assessed intracavernous injections, transurethral injections, mechanical devices, or behavioral therapy in CKD.
Therapies that have been used to treat sexual dysfunction include phosphodiesterase-5 inhibitors (PDE5i), intracavernosal injections, intraurethral suppositories, hormonal therapy, mechanical devices, and psychotherapy. Studies have also identified significant associations between sexual dysfunction in chronic kidney disease patients and depression, impaired quality of life, and adverse cardiovascular outcomes. Effective treatment of sexual dysfunction in CKD patients may therefore potentially lead to improvement in these patient-level outcome. There are now many new assessment techniques and treatments. There are encouraging reports in the use of phosphodiestrase 5‐inhibitors use in patients with CKD. A greater awareness of this common problem should be encouraged so that patients and their partners do not feel embarrassed about broaching this subject with their physicians. Although renal transplant may effectively reverse many of the hormonal and psychological changes of chronic renal failure, many patients will remain on a transplant waiting list for a considerable length of time. Patients who develop significant vascular disease may still remain impotent even after a successful transplant.
Mortality remains high for seriously ill patients who develop ARF, and dialysis in this population is generally not cost effec- tive. Little is known about the long-term outcome and quality of life of survivors of ARF in ICUs but most patients appear to recover kidney function and enjoy acceptable quality of life. Scoring systems to estimate prognosis in such patients are not perfect but often provide information useful in medical deci- sion-making. The RPA/ASN guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis provides general recommendations to follow when withholding and withdrawing dialysis is considered. Time-limited trials of dialysis with predetermined measures of improvement, reason- able goals and duration of the trial, and ongoing assessment and communication of clinical status with patients, families, and care providers may enhance decision-making, reduce dis- comfort among providers and families, and lead to fewer cases of extended intensive care for seriously ill patients with poor prognoses. Greater awareness and dissemination of the RPA/ ASN guidelines may facilitate decision-making and care of seriously ill patients who develop ARF.
For more information please visit:
http://cjasn.asnjournals.org/content/3/2/587.long
http://jasn.asnjournals.org/content/11/7/1340.full
One in five patients with chronic kidney disease is depressed, even before beginning long-term dialysis therapy or developing end-stage renal disease. Chronic kidney disease patients with depression have poorer health outcomes than those without depression, even after adjusting for other factors that determine poor outcomes in these patients.
However, only a minority of CKD patients with depression are treated with antidepressant medications or nonpharmacologic therapy. Reasons for low treatment rates include a lack of properly controlled trials that support or refute efficacy and safety of various treatment regimens in CKD patients.
When you learn that your kidneys no longer work, it is normal to feel angry, fearful, and sad. Your doctor or nurse can answer medical questions, and a social worker at your unit can help you during this hard time. You have a lot to learn, and many changes to fit into your life. Write down your questions, so you can get them answered and reduce your worrying. You will have ups and downs as you adjust to kidney failure. This is normal. After you get used to your new life and get answers to your questions, you should start to feel better. Even though your dialysis schedule and new eating plan may be hard to get used to, they should start to feel like normal part of who you are and what you do each day.
Here are 9 effective ways to overcome depression with kidney disease:
1. Talk to social worker in your dialysis center.
2. Surround yourself with sights, sounds and smells that give you happiness.
3. Join depression and dialysis support groups
4. Start exercising, even a little.
5. Spend at least 10 minutes every day outside in the fresh air.
6. Reach out past yourself to help someone else.
7. Reach out to your family and friends for support.
8. Seek professional help - ask for a referral to a counselor.
9. Ask your nephrologist about depression medications that can be used based on your kidney limitations.
Proposed algorithm for management of depression in patients with CKD and ESRD. Alternative therapies include psychotherapy, counseling, social support, and music therapy. CKD, chronic kidney disease; ESRD, end-stage renal disease; MDE, major depressive episode
http://www.aakp.org/ has great article on this issue. For more information please click here
http://www.nature.com/ also has many good information for providers. please click here
When do you feel more depressed? During dialysis or before dialysis?
Chronic kidney disease (CKD) is a common disorder with an increasing prevalence. Cardiovascular disease is the most common cause of premature death in the CKD population. Individuals with CKD have a 10-20 times greater risk of cardiac death than those without CKD. The risk of death, cardiovascular events, and hospitalization increases in a graded fashion as the GFR decreases to less than 60 mL/min/1.73 m2. As a result, the majority of patients with chronic kidney disease die of cardiovascular disease before dialysis becomes necessary.
Lowering cholesterol medications such as statins have the strongest evidencebased association with reduced cardiovascular disease risk. The Study of Heart and Renal Protection (SHARP study) was the first large-scale, long-term, placebo-controlled trial of statins for primary prevention of cardiovascular disease in patients with advanced chronic kidney disease. Treatment with the combination of simvastatin plus ezetimibe was associated with an average reduction in LDL-C of 15.3 mg/dL and a 17% reduction in majoratherosclerotic events. No difference in adverse outcomes was identified (specifically cancer andmyopathy). The clinical implication of the SHARP study is that the combination of low-dose simvastatin (20 mg) and ezetimibe (10 mg) is safe and effective, even in patients with advanced chronic kidney disease. Moreover, if high doses are avoided, statins can be used safely to reduce cardiovascular risk in patients with chronic kidney disease.
What is your current cholesterol level, and are you taking any lowering cholesterol medications?
The American Osteopathic Association, Georgia Osteopathic Medical Society, North
Carolina Osteopathic Medical Association, South Carolina Osteopathic Medical Society, and Impact Education, LLC. has great article about chronic kidney disease and a whole patient approach. For more information, please Click Here
According to the government data, every year, around 2,600 to 2,800 kidneys are recovered from the deceased donor and then they are discarded because the medical staff is unable to transplant them before it gets destroyed. At the same time, it becomes quite shocking to know that hundreds of people are kept on waiting for a kidney transplant in U. S. and among them so many even died waiting only. Today, there are 93,000 people on the U. S. kidney transplant list waiting for a surgery to happen. When there are kidneys in stock, then what exactly is the reason that hinders patients to get their treatment on time? Is it a way to keep the kidney transplant rate go higher? Most of the times the organs that are received from the donors are promising but then it all depends upon the age and health of the donors. And this is something that makes the organ unfeasible for transplant. But according to experts, if there is a system of allocating the right organ to the right recipient and during the right amount of time then at least half of these organs would be efficiently used and not discarded. The main culprit is the outdated computer matching program that has made the entire process inefficient, resulting into a medical rationing system. After nine years of fitful work, the governance committee that oversees kidney transplants in the United States proposed a series of tweaks on Friday aimed at making better use of the country’s desperately inadequate supply of deceased-donor organs. Central to the plan is a new index for better estimating the quality of the more than 14,000 kidneys recovered from dead donors each year. The top 20 percent of kidneys, as measured by the index, would be directed to those candidates expected to live the longest after a transplant — typically younger patients. Using computer simulations, the plan’s architects estimated the changes would produce an additional 8,380 years of life from one year of transplants. That is about half the number of years generated by a plan previously considered by the committee, which would have matched many kidneys to recipients by age. That plan was abandoned after federal officials warned last year that it would violate age discrimination laws.
New York Times has great article on this issue: Please Click Here
