[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.
[22:20] (MJesus> plas plas plas plas plas plas plas plas plas
[22:20] (MJesus> plas plas plas plas plas plas plas plas plas
[22:20] (MJesus> plas plas plas plas plas plas plas plas plas
[22:20] (MJesus> plas plas plas plas plas plas plas plas plas
[22:21] (Malvinder> Thank you all.
[22:21] (SCigarran> plas plas plas plas plas plas plas plas
[22:21] (SCigarran> plas plas plas plas plas plas plas plas
[22:21] (SCigarran> plas plas plas plas plas plas plas plas
[22:21] (gtorres> plas plas plas plas plas plas plas plas plas
[22:21] (mjcoma> clap clap clap clap clap clap clap clap clap
[22:21] (mjcoma> clap clap clap clap clap clap clap clap clap
[22:21] (mjcoma> clap clap clap clap clap clap clap clap clap
[22:21] (mjcoma> clap clap clap clap clap clap clap clap clap
[22:22] (Pabli> plas plas plas plas plas ....
[22:22] (peter11> clap clap clap clap clap clap clap
[22:22] (peter11> clap clap clap clap clap clap clap
[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
