1. Minimal versus Optimal Care Chronic Renal Failure Omar EL khashab Professor of Renal Medicine Cairo University

2. Minimal Versus Optimal Care 1- Prevention 2- Detection 3- Management 4- Regular Dialysis 5- Transplantation

3. Minimal Versus Optimal Care Prevention Magnitude of the Problem: 150 new case/million population. 25000 cases on regular hemodialysis. 5000 transplant cases. COST: 350 millions direct costs for Dx cases. 250 millions indirect costs for DX cases. 50 million direct transplantation costs. Huge costs for conservatively treated cases

4. Minimal Versus Optimal Care Prevention(Community level) Hypertension: Raising awareness of the disease and benefits of control. Decreasing salt content of processed foods. Concept of HTN clinics. Proper control of HTN, not necessarily using expensive drugs(control is more important than agent). Tight versus usual control is less important.

5. Minimal Versus Optimal Care Prevention (Community level) Diabetes: Raising awareness of the disease and benefit of control Concept of Diabetes clinics. Stressing the role of diet control in management. Adjusting HbA1c at 7 every 6 months check. Benefits of new expensive medications is not crucial

6. Minimal Versus Optimal Care Prevention(community level) Other Factors: NSAIDs restriction of use. Orthopedician orientation. Acrotoxin control. Obstructive Uropathy.

7. Minimal Versus Optimal Care Detection and Diagnosis Biochemistry: Creatinine, urea, urine analysis are needed. Others are needed only when clinical suspicion is high ( 24 hours urinary proteins, Blood sugar,C3&C4, Auto Abs, PEP etc.) Na, K, only in special circumstances. Frequency of investigations should in months not weeks.

8. Minimal Versus Optimal Care Detection and Diagnosis Radiological Abdominal ultrasound is essential. Plain UT, IVP in suspected obstruction. Isotopic studies not needed (all information can be deduced from US). Duplex renal vessels only when RAstenosis is suspected.

9. Minimal Versus Optimal Care Management Dietary control. BP Control. Ca,Phosphorous control Anemia correction CVS complication prevention

10. Minimal Versus Optimal Care Management Dietary Control Ideally a dietician is included in the team. Physician can take their role: Low protein diet Avoid high K foods Excess water (guided with simple scale) Decrease salt

11. Minimal versus Optimal Care Management BP control 130/80, 120/75 are optimal targets. At least 140/90 or below is needed. 24 hours regulation needed. long acting preparations, or 12 hours administration is practical, preferably of different classes. 24 hours monitoring is optimal but not essential.

12. Minimal versus Optimal Care Management BP control ACEi or ARBs (in diabetic nephropathy II) are optimal. But the main benefit comes from the control of BP with any agent. Slowing progression by ACEi comes mainly from BP control rather than specific agents, and their benefit concerns mainly early cases with gross proteinuria. In advanced diabetic cases ACEi proved to be cardioprotective.

14. Minimal Versus Optimal Care Management Calcium and Phosphorous control Prevent bone problems Prevent CVS problems Key is to normalize serum Phosphorus. Dietary control is mandatory. Bone biopsy not essential.

15. Minimal Versus Optimal Care Management Calcium and Phosphorus control Calcium carbonate is the standard If still hyperphosphatemic shift to Ca acetate. If hypercalcemia supervenes, use Sevalemer optimally. But Aluminum containing antacids can be used instead ( use short periods, safe in early cases). Ca, PO4 every 2 months and PTH 6 monthly is sufficient. Bisphosphonates and Calcitonin of no value.

16. Minimal Versus Optimal Care Management Control of Anemia Target HB >12 gm (optimal), can be reduced to 10 gm. Exclude blood loss. EPO use in special indication. Concomitant use of anabolic steroids, SC administration and proper diet can minimize the dose needed.Packed cell transfusion can be used if no EPO available.

17. Minimal Versus Optimal Care Management Reduction of CVS complications Unusual risk factors are operating. Control of BP, Diabetes CA,PO4 is essential. Statins are of very limited value. Antioxidants of no value ACEi in high risk cases are emerging.

18. Minimal Versus Optimal Care Unusual Cardiovascular risk factors in CRF: Anemia (major CVS risk factor, QOL ) High PO4, Ca&PO4 > 55, elevated PTH. Low Cholesterol, high LDL. Chronic inflammation syndrome. Low serum Albumin, high fibrinogen. Oxidative stress. ASDA. Low AGEs. Homocysteine. Folic acid deficiency.

19. Minimal Versus Optimal Care Regular Hemodialysis Make sure patient is ESRD( no reversible factors). Some cases need only twice /week at least early. Bicarbonate dialysis restricted to special indications. Routine monthly investigations restricted to HB, CA&PO4, K, Creatinine, SGPT. HCV, albumin, cholesterol Checked 3 monthly. HIV 6 monthly. Hemodiafiltration, Diasafe dialysis, use of special hemodialysers are of little value. RE_USE of dialysers can be safely applied.

20. Minimal Versus Optimal Care Transplantation Better quality of life,should be encouraged. Use of new agents( Tacrolimus, Sirolimus, Monoclonal Abs) only when indicated. MMF only when indicated or in the first year. Routine investigations restricted to the minimum