Transcript
Page 1: Chronic Kidney Disease (CKD)

CHRONIC KIDNEY DISEASEDr Beenish Sohail Bhutta

Page 2: Chronic Kidney Disease (CKD)

WHAT IS CKD ?

National Kidney Foundation (NKF) defines CKD as

evidence of renal damage (based on abnormal UA [proteinuria, hematuria] or

structural abnormalities (found with US) or

GFR < 60 mL/min for 3 or more months

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PATHOPHYSIOLOGY In CKD, reduced clearance of certain solutes

principally excreted by the kidney results in their retention in the body fluids.

CKD is rarely reversible and leads to progressive decline in renal function. Reduction in renal mass leads to hypertrophy of the remaining nephrons with hyperfiltration, and the GFR in these nephrons is transiently increased, placing a burden on remaining nephrons, leading to progressive glomerular sclerosis and interstitial fibrosis

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STAGING

Stage Description GFR

1 Kidney damage with normal or inc GFR

≥90

2 Kidney damage with mild reduction in GFR

60-89

3 Moderate dec in GFR 30-59

4 Sever dec in GFR 15-29

5 Kidney Failure <15 or dialysis

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EITIOLOGY Diabetic kidney disease Hypertension Vascular disease (renal artery stenosis,

vasculitidies, atheroemboli, renal vein thrombosis)

Glomerular Disease ( primary or secondary) Cystic kidney disease Urinary tract obstruction or dysfunction Recurrent kidney stone disease Congenital defects of kidney or bladder Unrecovered acute kidney injury

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PATIENT PRESENTS WITH..

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MAJOR CONSEQUENCES OF CKD Metabolic acidosis

Salt and water retention

Anemia

Uremia

Endocrine disorder

Disorder of mineral metabolism

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SIGNS OF METABOLIC ACIDOSIS IN STAGE 5 Protein energy malnutrition

Loss of lean body mass

Muscle weakness

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SIGNS OF SALT AND WATER RETENTION IN STAGE 5 Peripheral edema

Pulmonary edema

Hypertention

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SIGNS OF ANEMIA IN CKD Fatigue

Reduced exercise capacity

Impaired cognitive and immune function

Reduced quality of life

New onset heart failure or increased severity of heart failure

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SIGNS OF UREMIA Pericarditis

Encephalopathy

Perpheral neuropathy

Restless leg syndrome

GI symptoms: N V D , anorexia

Skin : dry skin, pruritis, echymosis

Fatigue, inc somnolence

Platelet dysfunction

Sexual dysfunction

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PHYSICAL SIGNS IN ADVANCED CKD

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LABS

Complete blood count (CBC) Basic metabolic panel Urinalysis (Patients with a P/C ratio above

200 mg/mg should undergo a full diagnostic evaluation. A value of greater than 300-350 mg/mg is within the nephrotic range.)

Serum albumin levels: Patients may have hypoalbuminemia due to urinary protein loss or malnutrition

Lipid profile: Patients with CKD have an increased risk of cardiovascular disease

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LABS

Evidence of renal bone disease can be derived from the following tests:

Serum phosphate

25-hydroxyvitamin D

Alkaline phosphatase

Intact parathyroid hormone (PTH) levels

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FURTHER EVALUATION Serum and urine protein electrophoresis: Screen for

multiple myeloma Antinuclear antibodies (ANA), double-stranded DNA antibody

levels: Screen for SLE Serum complement levels: Results may be depressed with

some glomerulonephritides Cytoplasmic and perinuclear pattern antineutrophil

cytoplasmic antibody (C-ANCA and P-ANCA) levels: Positive findings are helpful in the diagnosis of Wegener granulomatosis and polyarteritis nodosa; P-ANCA is also helpful in the diagnosis of microscopic polyangiitis

Anti–glomerular basement membrane (anti-GBM) antibodies: Presence is highly suggestive of underlying Goodpasture syndrome

Hepatitis B and C, human immunodeficiency virus (HIV), Venereal Disease Research Laboratory (VDRL) serology: Conditions associated with some glomerulonephritides

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IMAGING Renal ultrasonography: Useful to screen for hydronephrosis,

which may not be observed in early obstruction, or for involvement of the retroperitoneum with fibrosis, tumor, or diffuse adenopathy; small, echogenic kidneys are observed in advanced renal failure

Retrograde pyelography: Useful in cases with high suspicion for obstruction despite negative renal ultrasonograms, as well as for diagnosing renal stones

Computed tomography (CT) scanning: Useful to better define renal masses and cysts usually noted on ultrasonograms; also the most sensitive test for identifying renal stones

Magnetic resonance imaging (MRI): Useful in patients who require a CT scan but who cannot receive intravenous contrast; reliable in the diagnosis of renal vein thrombosis

Renal radionuclide scanning: Useful to screen for renal artery stenosis when performed with captopril administration; also quantitates the renal contribution to the GFR

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BIOPSY Biopsies are also indicated to guide

management in already-diagnosed conditions, such as lupus, in which the prognosis is highly dependent on the degree of kidney involvement. Biopsy is not usually indicated when renal ultrasonography reveals small, echogenic kidneys on ultrasonography, because this finding represents severe scarring and chronic, irreversible injury.

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TREATMENT

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HYPERTENTION HTN control with weight loss and tobacco cessation Salt intake reduced to 2g/day Initial Rx to include ACE inhibitor or angiotensin II receptor

blocker (ARB) Goal BP is <130/80 mm Hg; for those with proteinuria > 1-

2 g/d, goal is < 125/75 mm Hg When an ACE inhibitor (zestril 5-10mg HS) (ranitec

5-10mg, 20mg HS) or an Losartan (eziday 25-50mg HS) is initiated or uptitrated, patients should have serum creatinine and potassium checked within 5–14 days. Hyperkalemia or a rise in serum creatinine > 30% from baseline or dec of GFR <15% from baseline mandates reduction or cessation of the drug.

Second-line antihypertensive agents include calcium(HERBESSOR 30 mg OD, AMODIP 10mg OD) channel-blocking agents.

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HYPERKALEMIA

IV calcium gluconate 10 % in 10 ml N/S over 10-20 mins

Salbutamol (SALBO 5mg) nebulizer Low potassium diet 4 ampules of 25 % dextrose water with 12-14

units of insulin Lasix 40mg OD if systolic more than 90

mmHg Discontinue Aldactone Emergency dialysis in case of potentially

lethal hyperkalemia

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PULMONARY EDEMA Prop up and give high flow Oxygen with face

mask Lasix 120-250mg IV over 1 hour Hemodylisis or hemofiltration in

unresponsive cases CPAP Venesection (100-200ml)

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DISORDER OF BONE METABOLISM Dietary phosphorus restriction to 1000 mg/d . Oral phosphorus binders, such as calcium

carbonate(Qalsan D) (650 mg/tablet) or calcium acetate(LOPHOS) (667 mg/capsule), block absorption of dietary phosphorus and given in TDS or QID at the beginning of meals.

These should be titrated to a serum phosphorus of < 4.6 mg/dL in stage 3–4 of CKD (GFR of 15–59 mL/min) and

< 4.6–5.5 mg/dL in ESRD patients

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TREATMENT OF HYPOCALCEMIA Maximal elemental calcium doses of 1500 mg/d

(eg,nine tablets of calcium acetate),

doses should be decreased if serum calcium rises above 10 mg/dL

Typical calcitriol(BONE-ONE) dosing is 0.25 or 0.5 mcg orally daily or every other day initially. Cinacalcet is a calcimimetic agent that targets the calcium-sensing receptor on the chief cells of the parathyroid gland and suppresses PTH production.

Cinacalcet, 30–90 mg PO x OD, can be used if elevated serum phosphorus or calcium levels prohibit the use of vitamin D analogs

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MANAGEMENT OF ANEMIA Serum ferritin < 100–200 ng/mL or iron

saturation < 20% is suggestive of iron deficiency.

Iron therapy should be withheld if the serum ferritin is > 500–800 ng/mL, or Hb is 12 even if the iron saturation is < 20%.

Ferrous sulphate, gluconate or fumarate 325 mg from OD to TDS may be given,

Erythropoiten (Epokine, Heamex, 50IU/Kg once or twice a week)

Darbepoetin alfa ( Aranesp) is started at 0.45 mcg/kg and can be administered every 2–4 weeks.

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SIDE EFFECTS of ERYTHROPOETIN: Allergic reactions Hypertension Hyperviscosity Pure red cell aplasia

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TREATING COAGULOPATHIES Raising the Hb to 9–10 g/dL in anemic

patients can reduce bleeding time via increased blood viscosity

Desmopressin ( Minirin 25 mcg intravenously every 8–12 hours for two doses) is a short-lived but effective treatment for platelet dysfunction and it is often used in preparation for surgery.

Dialysis

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TREATING ACIDOSIS serum bicarbonate level should be

maintained at > 21 mEq/L

Administration of bicarb should begin with 20–30 mEq/d divided into two doses per day and titrated as needed

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DRUGS WHICH REQUIRE DOSE REDUCTION OR COMPLETE CESSATION Antivirals Benzodiazepines Colchicine Digoxin Exenatide Fenofibrate Gabapentin Insulin Lithium Metformin* Opioid analgesics Saxagliptin Sitagliptin Sotalol Spironolactone Sulphonylureas (all) Vildagliptin


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