dr sridhar ckd final

C.K.D

Chronic Kidney Chronic Kidney DiseaseDisease

Dr.G.SridharDr.G.Sridhar

MD,DM(Nephro)MD,DM(Nephro)

AWARE GLOBAL HOSPITALAWARE GLOBAL HOSPITAL

L.B.Nagar,Hyderabad.L.B.Nagar,Hyderabad.

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DefinitionDefinition• Kidney damage Kidney damage >> 3 months as defined 3 months as defined

by structural or functional abnormalities by structural or functional abnormalities of kidney, with or without GFR manifest of kidney, with or without GFR manifest by either.by either.

• GFR GFR << 60 ml / mt / 1.73 m2 for 60 ml / mt / 1.73 m2 for >> 3 3 months with or without kidney damagemonths with or without kidney damage

K Doqi Guideline 2002K Doqi Guideline 2002

C.K.DStaging of CKDStaging of CKD

NKF-DOQI CKD is divided in to 5 stages according to GFRNKF-DOQI CKD is divided in to 5 stages according to GFR StageStage DescriptionDescription GFRGFR ActionAction

(ml/min/1.73 m(ml/min/1.73 m22))

At riskAt risk >> 90 90 ScreeningScreening(with CKD risk factor)(with CKD risk factor) CKD risk reductionCKD risk reduction

11 Kidney damageKidney damage >> 90 90 Diagnosis & treatmentDiagnosis & treatmentwith N or GFRwith N or GFR Treatment Co-morbidityTreatment Co-morbidity

Slowing progressionSlowing progressionCVD risk reductionCVD risk reduction

22 Kidney damageKidney damage 60 - 8960 - 89 Estimate progressionEstimate progressionmild GFRmild GFR

33 Moderate GFRModerate GFR 30 - 5930 - 59 Evaluation & treatment ofEvaluation & treatment ofcomplicationscomplications

44 Severe GFRSevere GFR 15 - 2915 - 29 Prepare for RRTPrepare for RRT

55 Kidney failureKidney failure < 15< 15 ReplacementReplacement

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Chronic kidney diseaseChronic kidney disease

Patients with a GFR > 60 ml/min not considerd as Patients with a GFR > 60 ml/min not considerd as CKD unless evidence of kidney damage CKD unless evidence of kidney damage

• Proteinuria hematuria Proteinuria hematuria • Structure abnormalities (abnormal renal imaging)Structure abnormalities (abnormal renal imaging)• Genetic disease (APKD) Genetic disease (APKD) • Histological proven diseaseHistological proven disease

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GFRNormalMales110 –135ml/mt(Av.125ml/min/1.73m2)

Females90 -120ml/mt(Av.110ml/min/)

GFR decreases with age at 80 yrs80ml/min/1.73m2

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HOW TO CALCULATE e-GFR•1.Cockroft and Gault formula

Cr.Cl = (140 – age) x weight (kgs)S.creatinine X 72

• Creatinine Age Weight eGFR CKD •1. 1.5 50 50 Kg 69ml no ckd or ckd II•2. 1.5 50 40 Kg 39ml ckd III•3. 1.5 70 45 Kg 29 ml ckd IV.

•2./MDRD FORMULA2./MDRD FORMULA

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Common cause of ESRDCommon cause of ESRD

• Diabetes (43 %)Diabetes (43 %)

• Hypertension (25 %)Hypertension (25 %)

• Glomerulonephritis (21%)Glomerulonephritis (21%)

• Intersitial nephritis /pylonephritis (5 % )Intersitial nephritis /pylonephritis (5 % )

• Polycystic kidney and hereditary disease(7%)Polycystic kidney and hereditary disease(7%)

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Etiology of ESRD in IndiaEtiology of ESRD in India

Disease %Disease % Center ACenter A Center BCenter B Center CCenter C

Chronic glomerulonephritisChronic glomerulonephritis 28.628.6 36.6436.64 18.2018.20

Diabetic nephropathyDiabetic nephropathy 23.223.2 23.8423.84 26.7626.76

Chronic interstitial nephritisChronic interstitial nephritis 16.516.5 14.3514.35 27.0527.05

Hypertensive nephrosclerosisHypertensive nephrosclerosis 4.14.1 13.4713.47 10.0610.06

Obstructive nephropathyObstructive nephropathy 6.46.4 -- 1.221.22

ADPKDADPKD 2.02.0 3.533.53 2.072.07

UnknownUnknown 16.216.2 3.763.76 --

MiscellaneousMiscellaneous 3.03.0 4.34.3 --

Kher Neph. Forum KI July 2002Kher Neph. Forum KI July 2002

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Diagnosing CKDDiagnosing CKD

• Why to identify patient at CKDWhy to identify patient at CKD• Predisposes to increased cardio vascular risk .Predisposes to increased cardio vascular risk .• Some patient benefit from further evaluation Some patient benefit from further evaluation

(Biopsy)(Biopsy)• It is possible to slow progression to ESRD .It is possible to slow progression to ESRD .• Complications of CKD like anemia & bone Complications of CKD like anemia & bone

disease identified & treated early.disease identified & treated early.• Preparation for transplantation & dialysis .Preparation for transplantation & dialysis .

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WHY PROTEINURIA SO IMPORTANT ?WHY PROTEINURIA SO IMPORTANT ?

• Marker of chronic kidney damage Marker of chronic kidney damage

• Prognostic value in the progression of CKD Prognostic value in the progression of CKD

• It self causes progression of CKDIt self causes progression of CKD

• Good surrogate treatment target.Good surrogate treatment target.

• Independent CV risk factor Independent CV risk factor

C.K.DClinical PresentationClinical Presentation

GENERALGENERAL• DehydrationDehydration• Saline depletionSaline depletion• HyperkalemiaHyperkalemia• Metab. AcidosisMetab. Acidosis• Water Water

intoxicationintoxication• Susce. to Susce. to

infectioninfectionGIGI• AnorexiaAnorexia• HiccoughsHiccoughs• VomittingVomittingss• PolydipsiaPolydipsia

NERVOUSNERVOUS•TwitchingTwitching•ConvulsionConvulsionss•NeuropathNeuropathyy•ComaComa

HEMAT.HEMAT.• AnemiaAnemia• Pla.dysfnPla.dysfn

CVSCVS•HTNHTN•CADCAD•Pulm.edePulm.edemama•PericarditPericarditisis•ArrhythmiArrhythmiasasGENITOURINARYGENITOURINARY

•Oliguria/ Oliguria/ PolyuriaPolyuria•NocturiaNocturia•ImpotenceImpotence

SKELETALSKELETAL•Renal Renal osteodys.osteodys.•Metastatic Metastatic calcncalcn•DwarfismDwarfism•CrampsCramps•Loss of Loss of strengthstrength

SKINSKIN•PigmentatiPigmentationon•PruritusPruritus•FrostFrost•PurpuraPurpura

C.K.DWhen to referWhen to refer ? ?

• Screen patients at high risk:Screen patients at high risk:– Age >60Age >60– DiabetesDiabetes– HypertensionHypertension– Family history of renal diseaseFamily history of renal disease

• Refer to nephrologist if stable or rising Refer to nephrologist if stable or rising S.Creatinine >1.5 -female, >2.0 - S.Creatinine >1.5 -female, >2.0 -malemale

• Proteinuria > 1 gm/day even if GFR is normalProteinuria > 1 gm/day even if GFR is normal

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Benefits of early referralBenefits of early referral

• Those referred to nephrologists more than Those referred to nephrologists more than a year prior to dialysis have reduced a year prior to dialysis have reduced mortality in the first year of dialysismortality in the first year of dialysis

• Those with late referral more likely to be Those with late referral more likely to be sicker at the time of first dialysis more sicker at the time of first dialysis more likely to need emergency dialysislikely to need emergency dialysis

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Early referralEarly referral• Aim :Aim :

– To make early diagnosis if necessary renal biopsyTo make early diagnosis if necessary renal biopsy

– To identify and manage complicationsTo identify and manage complications

– To retard progression of diseaseTo retard progression of disease

– To reduce morbidity and mortalityTo reduce morbidity and mortality

– To prepare patient for maintenance dialysisTo prepare patient for maintenance dialysis

– To prepare for preemptive transplantationTo prepare for preemptive transplantation

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Does pre dialysis nephrology care influence Does pre dialysis nephrology care influence patient survival after initiation of dialysis ?patient survival after initiation of dialysis ?

• Early referral > 3 monthsEarly referral > 3 months• Late referral 1-3 monthsLate referral 1-3 months• Ultra late < 1 monthUltra late < 1 month• Study of 109321 pts Study of 109321 pts

- < 50 % have nephrology care in 6 months before - < 50 % have nephrology care in 6 months before initiation of dialysis initiation of dialysis • Better nephrology care 6 months before initiation of Better nephrology care 6 months before initiation of

dialysis reduces mortalitydialysis reduces mortality

*Kidney International March 2005

C.K.DRenal function preservation Renal function preservation - Primary health care Vs Nephrology - Primary health care Vs Nephrology

• Early referral of diabetic nephropathy ptsEarly referral of diabetic nephropathy pts

- Better renal function preservation- Better renal function preservation- Better BP control- Better BP control- Increased use of ACEi / ARBs / statins- Increased use of ACEi / ARBs / statins- Decreased use of NSAIDs- Decreased use of NSAIDs

**AJKD,AJKD,Jan Jan 20062006

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Reasons for non referralReasons for non referral

•UnavailabilityUnavailability•“ “ Holding back ” for non medical reasonsHolding back ” for non medical reasons•MisdiagnosisMisdiagnosis

- Persistent hematuria/proteinuria and - Persistent hematuria/proteinuria and pyuria always treated as UTIpyuria always treated as UTI

- Unreliability of serum creatinine as a - Unreliability of serum creatinine as a measure of renal function gives a false sense of measure of renal function gives a false sense of securitysecurity

- Serum creatinine is with in normal limits - Serum creatinine is with in normal limits despite significant loss of renal functions despite significant loss of renal functions

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PREVENTING PROGRESSION OF CKDPREVENTING PROGRESSION OF CKD • Factors influencing progression of CRFFactors influencing progression of CRF . .

• NONMODIFIABLENONMODIFIABLE• Underlying cause of CKD Underlying cause of CKD • RaceRace

• MODIFIABLEMODIFIABLE FACTORSFACTORS• Blood glucose controlBlood glucose control• Blood pressure Blood pressure • Level of proteinuriaLevel of proteinuria• PlusPlus• Nephrotoxic agents Nephrotoxic agents • Underlying disease acitivity Underlying disease acitivity • Further renal insults (obstruction , UTI hypovolemia )Further renal insults (obstruction , UTI hypovolemia )• Dislipdemia Dislipdemia • Hyperphosphatemia Hyperphosphatemia • Metabolic acidosisMetabolic acidosis• Anaemia smokingAnaemia smoking

C.K.DStaging of CKDStaging of CKD

NKF-DOQI CKD is divided in to 5 stages according to GFRNKF-DOQI CKD is divided in to 5 stages according to GFR StageStage DescriptionDescription GFRGFR ActionAction

(ml/min/1.73 m(ml/min/1.73 m22))

At riskAt risk >> 90 90 ScreeningScreening(with CKD risk factor)(with CKD risk factor) CKD risk reductionCKD risk reduction

11 Kidney damageKidney damage >> 90 90 Diagnosis & treatmentDiagnosis & treatmentwith N or GFRwith N or GFR Treatment Co-morbidityTreatment Co-morbidity

Slowing progressionSlowing progressionCVD risk reductionCVD risk reduction

22 Kidney damageKidney damage 60 - 8960 - 89 Estimate progressionEstimate progressionmild GFRmild GFR

33 Moderate GFRModerate GFR 30 - 5930 - 59 Evaluation & treatment ofEvaluation & treatment ofcomplicationscomplications

44 Severe GFRSevere GFR 15 - 2915 - 29 Prepare for RRTPrepare for RRT

55 Kidney failureKidney failure < 15< 15 ReplacementReplacement

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Conservative TreatmentConservative Treatment

Blood pressure targets in CKDBlood pressure targets in CKDo Without proteinuriaWithout proteinuria -Treat at 140/90-Treat at 140/90

--Target at 130/80Target at 130/80

o With proteinuriaWith proteinuria --Treat at 130/80Treat at 130/80

--Target 120/75Target 120/75o Diabetes mellitusDiabetes mellitus

-Target 120/75-Target 120/75

o What drug? Suggested batting orderWhat drug? Suggested batting order -ACEI -ACEI

-Loop diuretic-Loop diuretic

-Add ARB -Add ARB

-Calcium - channel blockers-Calcium - channel blockers

-B- Blockers-B- Blockers

-Centrally acting -Centrally acting alphaalpha blockers blockers

C.K.DManagement of CKDManagement of CKD

• DietDiet• Salt / fluid restrictionSalt / fluid restriction• RRxx of anaemia of anaemia• RRxx of HTN of HTN• RRxx of bone disease of bone disease• RRxx of infection of infection• RRxx of acidosis of acidosis• RRxx of hyperkalemia of hyperkalemia

ConservativeConservative ReplacemeReplacementnt

DialysiDialysiss

TransplantationTransplantation

HDHD

HomeHome

PDPD

InstituteInstitute

CAPDCAPD CCPDCCPD

CadaverCadaverLiveLive

LURDLURDLRDLRD

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Diet Diet

• ProteinProtein - 0.6 - 0.8 gm /Kg /day- 0.6 - 0.8 gm /Kg /day

- 14-20 gm EAA- 14-20 gm EAA

• CHOCHO - At least 100 gm- At least 100 gm

• FatFat - 15-20% of calories- 15-20% of calories

• CaloriesCalories - ~ 35 kcal / kg basal- ~ 35 kcal / kg basal

• Salt / HSalt / H22OO

• PotassiumPotassium

• VitaminsVitamins

• Trace-elementsTrace-elements

• FibreFibre

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HyperkalemiaHyperkalemia

• InsulinInsulin

• Soda bicarbSoda bicarb

• K- exchange resinsK- exchange resins

• Calcium GluconateCalcium Gluconate

• DialysisDialysis

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AcidosisAcidosis• Normal acid production Normal acid production -1-1mmol/kg/daymmol/kg/day

• Bicarb. replacement Bicarb. replacement - pH<7.3- pH<7.3

- S.bicarb. < - S.bicarb. < 1515mmol/Lmmol/L

Judicious use in oliguric patients (1mmol of HCOJudicious use in oliguric patients (1mmol of HCO33 givesgives

1mmol of Na+)1mmol of Na+)

• pH < 7.2 - dialysispH < 7.2 - dialysis

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AnemiaAnemia– < 12.0 gm% - Males / post menopausal< 12.0 gm% - Males / post menopausal

– < 11.0 gm % - Pre-menopausal< 11.0 gm % - Pre-menopausal

• Epo - supplement Epo (50-100 IU/kg/week)Epo - supplement Epo (50-100 IU/kg/week)

• Iron-def - Iron - supplement Iron-def - Iron - supplement

(Blood loss) (If S.Fe <100 mg/dl & TSAT <20%)(Blood loss) (If S.Fe <100 mg/dl & TSAT <20%)

• Blood - Tx ??Blood - Tx ??

• Vit - B12, Vit - CVit - B12, Vit - C

** Ramp - Renal anemia management Ramp - Renal anemia management programmeprogramme

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Renal osteodystrophyRenal osteodystrophy• HypocalcaemiaHypocalcaemia

– Ca supplements - Ca carbonateCa supplements - Ca carbonate

– Vit D analoguesVit D analogues

• HyperphosphatemiaHyperphosphatemia

– Aluminium hydroxideAluminium hydroxide

– Calcium based-carbonate acetateCalcium based-carbonate acetate

– Sevalamer HCLSevalamer HCL

– Lanthanum saltsLanthanum salts

• ParathyroidectomyParathyroidectomy

* * Prevent Ca x P product Prevent Ca x P product


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InfectionsInfections

• No drug absolutely contra-indicatedNo drug absolutely contra-indicated

• Dose - adjustment as per GFRDose - adjustment as per GFR

• Avoid combination of Nephrotoxic agentsAvoid combination of Nephrotoxic agents

• Close - monitoring of renal functionsClose - monitoring of renal functions

** Risk factors - Elderly, dehydration, pre-Risk factors - Elderly, dehydration, pre-existing renal diseaseexisting renal disease

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Reversible - FactorsReversible - Factors

Acute on Chronic Kidney Acute on Chronic Kidney DiseaseDisease

• Volume - depletionVolume - depletion

• Accelerated hypertensionAccelerated hypertension

• InfectionInfection

• ObstructionObstruction

• Drugs - ACE-I, Amino glycosides, Drugs - ACE-I, Amino glycosides, NSAIDS and Contrast drugsNSAIDS and Contrast drugs

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Prevention of complicationsPrevention of complications

• Early recognition and treatment of cardio vascular eventsEarly recognition and treatment of cardio vascular events

• Helping in planning Angiographic studies , avoid contrast Helping in planning Angiographic studies , avoid contrast nephrotoxicitynephrotoxicity

• Judicious use of antibioticsJudicious use of antibiotics

• Avoiding NSAIDs and nephrotoxic drugsAvoiding NSAIDs and nephrotoxic drugs

• Plan nutrition Plan nutrition

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Renal Replacement TherapyDialysis

– Home

Peritoneal dialysis (CAPD)

–Institutional

Hemodialysis

Transplantation

–Kidney Tx

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Hemodialysis Access – when ?Hemodialysis Access – when ?

• Educate patients to “Educate patients to “Save Their Veins”Save Their Veins”

• If GFR is 25 ml/mt and in Diabetics < 30-40 ml/mtIf GFR is 25 ml/mt and in Diabetics < 30-40 ml/mt

• AV fistula to be created 6 months to 1 year prior to dialysis AV fistula to be created 6 months to 1 year prior to dialysis to allow for maturation time.to allow for maturation time.

• Avoid temporary hemodialysis catheter whenever possibleAvoid temporary hemodialysis catheter whenever possible

• Placement of CAPD catheter to be planned 6 – 8 weeks Placement of CAPD catheter to be planned 6 – 8 weeks prior to commencement of dialysisprior to commencement of dialysis

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DialysisDialysis

Absolute IndicationsAbsolute Indications

• Severe azotemiaSevere azotemia

• Acute LVFAcute LVF

• PericarditisPericarditis

• HyperkalaemiaHyperkalaemia

• Metabolic acidosisMetabolic acidosis

• Uraemic Uraemic encephalopathyencephalopathy

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Renal TransplantationRenal Transplantation

• Live - relatedLive - related• Live - unrelatedLive - unrelated• CadaverCadaver

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ConclusionsConclusions

• CKD on the rise - especially in youngCKD on the rise - especially in young• Monitoring of “at - risk” groupMonitoring of “at - risk” group• Measures to retard progressionMeasures to retard progression• Identify & treat reversible factorsIdentify & treat reversible factors

““As RRT is beyond reach of many ”As RRT is beyond reach of many ”

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Start early Start early

&&

Reach safelyReach safely

(To ESRD)(To ESRD)

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““Better to beBetter to be

late on late on

earth earth (to nephrologist)(to nephrologist)

than early tothan early to

heaven heaven ””

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Thank youThank you

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Any Questions?

dr sridhar ckd final

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