1. Diagnostic and Therapeutic Approach to Kidney Patient S. Ossareh- M.D. HKC-IUMS S. Ossareh- M.D. HKC-IUMS

2. Nephrotic Syndrome/GN Lab: –CBC, ESR –BUN, Cr, Na, K (daily?!!) –PPD –VDRL –Lipid profile –FBS? –Uric acid –Protein, Albumin –HBsAg, HCV Ab, HIV Ab –Immunologic: ANA, ANCA, C3, C4, CH50,antiGBM Ab? –Urinalysis, Urine sediment –24 hour urine collection for protein, creatinine –PTT, PT Sonography KUB Lab: –CBC, ESR –BUN, Cr, Na, K (daily?!!) –PPD –VDRL –Lipid profile –FBS? –Uric acid –Protein, Albumin –HBsAg, HCV Ab, HIV Ab –Immunologic: ANA, ANCA, C3, C4, CH50,antiGBM Ab? –Urinalysis, Urine sediment –24 hour urine collection for protein, creatinine –PTT, PT Sonography KUB

3. ESRD patients

4. Paraclinic LAB: –CBC,ESR –BUN, Cr (daily?!!) –Na, K (daily?!!) –Ca, P, ALP,PTH –Lipid profile –Fe, Ferritin,TIBC –Retic, Coombs,S/E, –HBsAg, HCV Ab, HIV Ab –Sonography X-Rays as needed LAB: –CBC,ESR –BUN, Cr (daily?!!) –Na, K (daily?!!) –Ca, P, ALP,PTH –Lipid profile –Fe, Ferritin,TIBC –Retic, Coombs,S/E, –HBsAg, HCV Ab, HIV Ab –Sonography X-Rays as needed

5. Erythropoetin (Eprex, PD Poetin, Epocin) Hb/Hct goal: –11/33% for women –12/36% for men & post-menopausal women Start Eprex with 50-100 unit/kg/wk Hb>13 → Reduce Eprex dose Hb> 13.5 → Stop Eprex for 1 month Hb/Hct goal: –11/33% for women –12/36% for men & post-menopausal women Start Eprex with 50-100 unit/kg/wk Hb>13 → Reduce Eprex dose Hb> 13.5 → Stop Eprex for 1 month

6. Iron supplement (Venofer, ferrous sulfate) Iron status goal: –Ferritin> 200 and Fe/TIBC> 20% Give IV Venofer 300 mg/wk till you reach the goal Then reduce Venofer dose to 100 mg/wk to keep iron profile within the expected range If ferritin > 500 → reduce Venofer dose If ferritin > 800 &/or Fe/TIBC> 50% → Stop Venofer Iron status goal: –Ferritin> 200 and Fe/TIBC> 20% Give IV Venofer 300 mg/wk till you reach the goal Then reduce Venofer dose to 100 mg/wk to keep iron profile within the expected range If ferritin > 500 → reduce Venofer dose If ferritin > 800 &/or Fe/TIBC> 50% → Stop Venofer

7. Calcium supplement (Calcium Carbonate, Ca-D) Goal: Keep Ca between 8.4 to 9.5 mg/dl Maximum maintenance dose of Ca: 2 grams of elemental Calcium Keep P between 4-5.5 mg/dl with 1.5-2 grams of elemental Calcium Carbonate P < 4 mg/dl → CaCO3 between meals Goal: Keep Ca between 8.4 to 9.5 mg/dl Maximum maintenance dose of Ca: 2 grams of elemental Calcium Keep P between 4-5.5 mg/dl with 1.5-2 grams of elemental Calcium Carbonate P < 4 mg/dl → CaCO3 between meals

8. Calcium supplement (Calcium Carbonate, Ca-D) P: 4-5.5 mg/dl → CaCO3 3 tabs/day (with meals) P:5.5-7 mg/dl → CaCO3 4-6 tabs/day for a limited period (with meals) P > 7 mg/dl or Ca  P >55 → Stop Calcium and use Al(OH)3 for a limited period (30 ml tid for 3-4 weeks) P: 4-5.5 mg/dl → CaCO3 3 tabs/day (with meals) P:5.5-7 mg/dl → CaCO3 4-6 tabs/day for a limited period (with meals) P > 7 mg/dl or Ca  P >55 → Stop Calcium and use Al(OH)3 for a limited period (30 ml tid for 3-4 weeks)

9. Rocaltrol (Calcitriol) If P < 5.5 mg/dl, and Ca < 9.5 and Ca  P <55 start Rocaltrol to keep PTH level between 150-300 pg/ml PTH: 300-600 → 2-6 pearls/qod PTH: 600-1000 → 4-16 pearls/qod PTH> 1000 → 12-28 pearls/qod If P < 5.5 mg/dl, and Ca < 9.5 and Ca  P <55 start Rocaltrol to keep PTH level between 150-300 pg/ml PTH: 300-600 → 2-6 pearls/qod PTH: 600-1000 → 4-16 pearls/qod PTH> 1000 → 12-28 pearls/qod

10. Vitamin Supplements Folic Acid: 5 mg Bid B-Complex: 1 tab/ day B6: 1 tab/day Folic Acid: 5 mg Bid B-Complex: 1 tab/ day B6: 1 tab/day