Discussion board


Malvinder S. Parmar MD, FRCPC, FACP

Director of Nephrology, Coordinator, CME, Timmins & District Hospital
ON., Canada


El Nov 14, 2001 11:41 pm, Discussion on-line dijo:

[22:09] *** Malvinder (cor@tim-cable-lan19.vianet.on.ca) has joined #cin

[22:09] (Malvinder> Good evening, Ladies and Gentlemen.

[22:09] (MJesus> good night

[22:09] (gtorres> good night dr malvinder

[22:09] (Malvinder> Oh" Good night

[22:10] (SCigarran> Good night to everybody

[22:10] (pino> Good evening to Dr. Malvinder

[22:10] (SCigarran> special thanks to Dr Malvinder

[22:10] (Malvinder> Dr. MJ did you get the summary by email?

[22:11] (pino> good

[22:11] (pino> yes, we did

[22:11] (pino> in a few seconds

[22:11] (pino> we can start

[22:12] (pino> first we can read the brief summary you sent us

[22:12] (Malvinder> One line Introduction. I am a nephrologist and Internal Medicine specialist, practicing in a northern community in Canada.

[22:13] (MJesus> at Toronto ?

[22:13] (Malvinder> No, in Timmins, Ontario, About 788 Km North of Toronto.

[22:15] (SCigarran> Dr Malvinder at this time will be too cold

[22:15] (Malvinder> What is the plan now?

[22:15] (MJesus> too cold!

[22:15] (pino> and after we can start to do questions

[22:15] (Malvinder> Not yet, I think got used to cold weather.

[22:15] (SCigarran> ok!

[22:16] (MJesus> speaker could send to the channel your abstract , Malvider

[22:16] (Malvinder> yes

[22:17] (speaker> "Strategies to Retard Progession of Chronic Kidney Disease"

[22:17] (speaker> Summary:

[22:17] (speaker> The number of patients suffering from ESRD is continuously growing worldwide and mortality rate among patients with ESRD remains 10-20 times higher than general population.

[22:17] (speaker> ESRD is theTIP of the iceberg where chronic renal insufficiency, the predecessor of ESRD, is a significant and growing problem;

[22:18] (speaker> where extensive and complex set of physiologic consequences occur and progress to irreversible but preventable complications.

[22:18] (speaker> There is high prevalence of anemia, cardiovascular disease, bone disease and malnutrition in patients reaching ESRD and many of these conditions occur early in the course of CKD and are inter-related,

[22:18] (speaker> increasing the risk of morbidity and mortality during the course of disease progression.

[22:18] (speaker> Identifying and correcting these problems early during the course of kidney disease provides us clinicians with an opportunity to improve overall morbidity and mortality.

[22:18] (speaker> _

[22:18] (speaker> There is no fixed or widely accepted definition of CRI at present but an arbitrary staging process is proposed based on GFR.

[22:18] (speaker> Definitions and metabolic consequences of Incipient or early renal disease with Normal GFR; Early renal insufficiency;

[22:18] (speaker> CRI; Pre-ESRD; and ESRD are described in this review.

[22:18] (speaker> Once the process of renal insufficiency starts it progresses relentlessely is emphasied in the renal disease continuum.

[22:19] (speaker> Various risk factors that initiates or cause progression of kidney disease

[22:19] (speaker> are described with various common CV risk factors that if controlled early may improve overall mortality and morbidity related to CV disease and its complications

[22:19] (speaker> that is high in patients with ESRD and often the cause of death of these patients.

[22:19] (speaker> -

[22:19] (speaker> The important potentially reversible causes should be saught and treated at every stage of CKD if there is sudden, unexpected decline in renal function.

[22:19] (speaker> Goals and importance of effective glycemic control in diabetic pateints, blood pressure goals in patients with hypertension, diabetes, proteinuria and renal disease are discussed.

[22:19] (speaker> Roles of dietary protein restriction, effective treatment of dyslipidemia, phosphate control are discussed.

[22:19] (speaker> Anemia management and its role in progression of CV and renal disease is discussed and role of Erythropoietin in treatment of anemia, prevention of cardiovascular disease and possibly in prevention of progressive renal dysfunction is discussed in this review.

[22:20] (speaker> -

[22:20] (speaker> It is important to note that studies have not been performed specifically in CKD propulations and most of the studies are done either in ESRD population or in non-renal high-risk populations

[22:20] (speaker> but common sense guides us to effectively control these risk factors and various complications at an earlier stage of the disease process to improve the long-term outcome of these patients.

[22:20] (speaker> -

[22:20] (speaker> In summary, this review mainly presents the published data in a simple and concise format for use by practising clinicians - both nephrologists and non-nephrologists.

[22:20] (speaker> -

[22:20] (speaker> Thank you for your attention.
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[22:21] (Malvinder> Thank you all.

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[22:22] (gtorres> questions?

[22:22] (Malvinder> Now discussion points and questions

[22:23] (gtorres> Babel Fish Translation, In English:

[22:23] (gtorres> Dr to malvinder thinks that first desapeareds is the renal functional reserve?

[22:23] (Malvinder> This is a long review, I am not sure if all of you have time to review it before.

[22:23] (SCigarran> I will start with a controversy about protein restriction. Dr Malvinder what do yo think about low protein diets on patients with CrCl less than 30 ml/min

[22:25] (Malvinder> Dr. Scigarran: as you opened the line with controversy and as you various small studies showed the effectiveness of preotein restriction and

[22:26] (Malvinder> later, MDRD, study reanalysis also indicated that low protein diet was effective in retarding the progession but at the same time it is important to avoid Malnutrition.

[22:27] (Malvinder> We have some patient who are able to maintins low protein and phosphate intake and able to stay of dialysis for over a year.

[22:27] (javier> how to notice a physiologic GFR decrement from a shightly renal faillure in elderly people if they are under IECAS o ARA II treatment ?

[22:28] (Malvinder> These patients were almost ready to need dialysis before they were referred to us in the PRI clinic adn they got the PD catheter and we still haven't started them on dialysis.

[22:28] (SCigarran> Iam not so sure that protein restriction slow progression of CRI, because really there are not meta-analysis that probe it

[22:29] (SCigarran> In fact, MDRD study can not conclude that low protein diets are bennefficial.

[22:29] (Malvinder> I think in addition to protein restriction, comprehensive care, anemia treatment and phosphate control also played a significant role in preservation of renal function.

[22:30] (Malvinder> No initial MDRD data was not conclusive but when the data was re-analysed with actual protein intake then it was found that protein restriction had its benefits.

[22:30] (Malvinder> Refernce 50 and 52 in the paper by Levey et al.

[22:31] (Malvinder> I think there was another question but got missed in typing thediscussion about protein restriction.

[22:33] (Malvinder> The question was regarding physiologic GFR?

[22:34] (javier> how to notice a physiologic GFR decrement from a slightly renal failure in elderly people if they are under ACE-I o AIIA treatment ?

[22:34] (Malvinder> The main way to determine GFR is by Inulin clearance but this not practical all the time so its difficult to determine small decline in GFR especially in elderly patients.

[22:36] (Malvinder> Patients on ACE-I or AIIA may have some decline in GFR initially due to hemodynamic effects but usually these stablize with long term therapy and Imain way is to follow these patients clinically.

[22:36] (SCigarran> Dr Malvinder in your opinion what is more relevant protein restriction and consquently delay start dialysis or malnutrition?

[22:37] (Malvinder> In out practice mostly about 0.8 gm/kg although upto 0.6 mg.Kg is recommened in late stages of renal dysfunction.

[22:37] (SCigarran> In other word, NPNa about 0.8-1.2 gr/kg/d or 0.4-0.6 gr/kg/d

[22:38] (Malvinder> I don't have patient complying with strict restriction and I believe that some protein restriction than their usual intake does make a difference.

[22:38] (Malvinder> yes.

[22:38] (pino> Do you think that is possible to reach target blood pressure values of 125/75 in diabetic patients?

[22:39] (Malvinder> In about 70% of patients yes.

[22:39] (Malvinder> There are some very difficult to control patients as everyone has.

[22:40] (SCigarran> We observed in 103 pts that tricipital skinfold and mid arm circunference decrease as low protein is started with CRcl about 30 ml7min

[22:40] (pino> And what about patients compliance when they need many tablets to control their pressure or other medical problems?

[22:41] (SCigarran> Do you will initiate therapy in diabetics whom BP arise from 110/60 to 130/80 mmHg

[22:41] (Malvinder> Compliance, I believe is the problem and major problem in difficult to control HTN

[22:41] (Malvinder> If pateints have proteinuria or MAU yes, I go ahead with ACE-I

[22:43] (Malvinder> I also have been using combination of ACE-I and AIIA in some hypertensive diabetics to control either their BP or better control their protein excretion rate.

[22:43] (cin2001> Till what stage do you continue ACET

[22:43] * MJesus introduce Prof. J.Balasubramaniam as cin2001

[22:43] (pino> Has you notice any clinical diference between ACEs and ARA II?

[22:43] (Malvinder> I have continued patients on ACE-I till nd stage unless there is problem with hyperkalemia.

[22:44] (Malvinder> Wecome, Prof. balasubramaniam

[22:44] (cin2001> What about ARB?

[22:44] (Malvinder> Not to significant extent any difference between ACE-I and ARBs other that side effect profile, especially cough.

[22:45] (gtorres>do you think that oxidativew stress has some importance in the progression of the renal insufficiency?

[22:45] (Malvinder> Yes, patients who cannot tolerate ACE-I we use ARB as the recommended indication of these agents.

[22:45] (cin2001> Some claim combination- any advant?

[22:46] (Malvinder> There are some studies that have proposed that in anemic patients oxidative stress causes mesangial hyperthrophy and fibrosis, so there is evidence of this causing progression of CKD

[22:46] (Malvinder> Where the role of EPO, although only few small studies have shown, to retard this progression.

[22:47] (Malvinder> Combination of ACE-I and ARB may be useful in patients where either BP or protein excretion is not under effective control.

[22:48] (Malvinder> As you know that up to about 35-40% of angiotensin is produced intrarenally and also the non-ace pathways are important players in some patients where these combinations are helpful but clinically it is difficlut to determine who would responde.

[22:49] (cin2001> What about tissue ACEI ?

[22:50] (Malvinder> I use tissue ACE's when patients blood pressure are usually low 100-120 mmhg and they have proteinuria or patients have significant LV dysfunction and consequently have low BP.

[22:50] (Malvinder> This is my observation and not published report.

[22:50] (peterNoTa> buenas

[22:50] (pino> but, waht about potassium level whe we use ACEs + AIIA

[22:51] (Malvinder> I once had discussion with Dr. Moskovitz on this issue on nephrol.

[22:51] (Malvinder> In occasional patient I noted increase in serum potassium but is most did not find this problem.

[22:51] (cin2001> How do they chose drugs for large studies? When the outcome is positive(say ramipril), does it mean that other ACEI DONT WORK?

[22:52] (pino> do you think that there iare so many differences between ACEs drugs as Dr Moskowitz says?

[22:52] (Malvinder> I find that systemic ACE-I (Captopril, Enalapril and Lisinopril) to be more effective blood pressure lowering agents than tissue ACE-I.

[22:53] (Malvinder> There is mainly a class effect with ACE-I although most authors don't admit when they present studies.

[22:54] (Malvinder> Even if we look at the genesis of HOPE trial, it was based on the metanalysis of 9000 patients who were on other ACE-I before hope and that metanalysis showed the same results but only thing that HOPE was a prospective study and proved the efficacy and the dosage was determined.

[22:55] (Malvinder> I don't think there is major differences as proposed by Dr. Moskovitz.

[22:56] (cin2001> Regarding diet do you believe any advantage of veg diet?

[22:56] (Malvinder> When I was dicussing with him about my observations then he mentioned that he does not have experience with other ACE-I as in their hospital Quinapril is the only ACE-I obn the formulary and he has large experience with atht agent alone.

[22:56] (pino> do you thik that arterial stenosis can protect against crhonic renal failure?

[22:57] (Malvinder> Regarding diet, I think it is the total protein content and phosphate content that matters.

[22:57] (pino> or by the contrary it produces isquemic nephropahty

[22:58] (Malvinder> There was a paper reporting that the stenoed kidney is protected but the conseuqneces of stenosis, hypertension etc cause proble in the contralateral kidney, hence in practical sense, no it does not.

[22:59] (pino> thanks

[22:59] (Malvinder> Yes, it causes ischemic nephropathy on that side.

[22:59] (cin2001> I have problem here when advising protein dose to my dilysis patients who are mostly on inadequate dialysis due to econ reasons. Any suggestions?

[23:00] (Malvinder> May be someone else may have idea, but mainstay is to improve dialysis.

[23:01] (Malvinder> If they are not adequately dialysed then they will be anorexic because of poor dialysis.

[23:01] (pino> probaly to advcse to eat cheap proteins, for instance, those from legumes

[23:01] (SCigarran> I agree the mainstay is adjust the dialysis dose

[23:01] (Malvinder> Our main focus should be to improve overall quality.

[23:01] (cin2001> They often come for HD when they are symptomatic and not by schedule. I am in a dilemma as to low or high protein I know that there cant easy answers

[23:02] (Malvinder> I have one such native woman who is alcoholic and comes PRN for dialysis not on scheduled visits.

[23:03] (Malvinder> and she is doing reasonably well. I know that she is not following any dietary restrictions and she has been on HD for 3 years now. but can't do much than that.

[23:04] (SCigarran> Are she on HD if yes an alternative is transfer her to CAPD

[23:04] (cin2001> Has rhubarb been written off?

[23:04] (Malvinder> she would do CAPD as she is half of the time drunk and few times has been brought to the unit intoxicated.

[23:04] (cin2001> CAPD is costlier than HD in India

[23:05] (gtorres> the progression between a pielonefritis and one glomerulopatia is not equal. That factors influence?

[23:05] (Malvinder> What is about rhubarb?

[23:06] (cin2001> Rhubarb helping retardation of prog of CRF

[23:06] (SCigarran> cin2001, costlier means more expensive?

[23:06] (Malvinder> I am not sure, I definietly would apprecaite your response.

[23:07] (cin2001> Capd is expensive here

[23:07] (Malvinder> Tell cin 2001, about the rhubarb experience.

[23:08] (cin2001> There was a KI forum about the role of Rhubarb around 1992-93 I think

[23:08] (pino> We have not experience

[23:09] (Malvinder> But, haven't heard or read in recent literature.

[23:09] (Hteixeira> As far as I know, Rhubarb is contraindicated in renal insuficiency, as is starfruit, because of serious neurologic problems.

[23:09] (SCigarran> I would like know your experince on methods to evaluate renal function Are you using MDRD prediction GFR formula 7

[23:09] (cin2001> He had presented data from both experim animals and clinical studies. Ofcourse I dont rea about it now.

[23:10] (pino> sorry, it is very intersting, but we are on our last minutes

[23:10] (Malvinder> No, I still use old Cockfort-Gault method because of its eases.

[23:10] (pino> please, last questions

[23:11] (Malvinder> A difference of few ml/min does not make changes in therapy significantly.

[23:11] (SCigarran> and Kt/v weekly?

[23:11] (Hteixeira> Dr. Malvinder, would you indicate NSAI in order to diminish proteinuria, otherwise progressive, to slow progression of renal insuficiency?

[23:11] (Malvinder> Yes, we use Kt/V weekly

[23:12] (Malvinder> No I don't use NSAIDs unles proteinuria is severe and that too a last choice.

[23:12] (cin2001> Sorry I was a late entrant. It was a wonderful session. Good night

[23:12] (gtorres> thanks dr. malvinder

[23:12] (otamendi> At which LDL-cholesterol level do you start treatment with statines in CKD?

[23:13] (Malvinder> Thank you all for this active participation. Its been pleasure to be with you all today.

[23:13] (pino> webmaster says me we have only two minutes

[23:13] (Malvinder> I tend to bring LDL's to below 2.5 mmol/L

[23:13] (pino> thanks Dr Malvinder

[23:13] (SCigarran> Dr Malvinder was a great pleasure hve this disscission. Thanks a lot

[23:13] (Malvinder> Thank you all again and Good night.

[23:14] (pino> good evening for you

[23:14] (Malvinder> Happy Deepawali "Festival of Lights" to memebrs from India.

[23:14] (jczafra> good evening

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