kuliah ckd 2015


Chronic Kidney Chronic Kidney DiseaseDisease

A. A. Gede Budhitresna,MD,PhD,Int-CE,FINASIMA. A. Gede Budhitresna,MD,PhD,Int-CE,FINASIMSCHOOL OF MEDICINE UNIVERSITY OF SCHOOL OF MEDICINE UNIVERSITY OF

WARMADEWAWARMADEWA20152015


Chronic Kidney DiseaseChronic Kidney Disease►A 54 year old woman is evaluated for a Cr A 54 year old woman is evaluated for a Cr

of 1.3; 18 months ago it was 0.9. She has of 1.3; 18 months ago it was 0.9. She has a 5 year history of DM 2, dyslipidemia a 5 year history of DM 2, dyslipidemia and HTN well controlled with lisinopril, and HTN well controlled with lisinopril, HCTZ, and atenelol. She is also on HCTZ, and atenelol. She is also on glipizide and simvastatin. Hemoglobin is glipizide and simvastatin. Hemoglobin is normal. What is the most appropriate for normal. What is the most appropriate for this patient?this patient?• 24 hour collection for proteinuria24 hour collection for proteinuria• Kidney USGKidney USG• Measurement of Urine micro albuminMeasurement of Urine micro albumin• SPEPSPEP• Measurement of HbA1CMeasurement of HbA1C


In the United States, there is a rising incidence In the United States, there is a rising incidence and prevalence of Kidney Disease.and prevalence of Kidney Disease.

Nearly 350,000 of these are on dialysis.Nearly 350,000 of these are on dialysis. Also, there is an increasing prevalence of Also, there is an increasing prevalence of

earlier stages of chronic kidney disease which earlier stages of chronic kidney disease which unfortunately is “under-diagnosed” and unfortunately is “under-diagnosed” and “under-treated” in the United States.“under-treated” in the United States.

In 2000, the In 2000, the National Kidney Foundation National Kidney Foundation (NKF) Kidney Disease Outcomes Quality (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI) Initiative (K/DOQI) Advisory Board approved Advisory Board approved development of clinical practice guidelines to development of clinical practice guidelines to define chronic kidney disease and to classify define chronic kidney disease and to classify stages in the progression of chronic kidney stages in the progression of chronic kidney disease. disease.

Chronic Kidney DiseaseChronic Kidney Disease


CKD – Risk FactorsCKD – Risk Factors

Diabetes MellitusDiabetes Mellitus HypertensionHypertension Cardiovascular Cardiovascular

DiseaseDisease ObesityObesity Metabolic Metabolic

SyndromeSyndrome Age and RaceAge and Race Acute Kidney InjuryAcute Kidney Injury MalignancyMalignancy

Family history of Family history of CKDCKD

Kidney StonesKidney Stones Infections like Infections like

Hep C and HIVHep C and HIV Autoimmune Autoimmune

diseasesdiseases Nephrotoxics Nephrotoxics

like NSAIDSlike NSAIDS


Diseases of the KidneyDiseases of the Kidney

• DiabetesDiabetes• HypertensionHypertension• AtherosclerosisAtherosclerosis• Glomerular diseasesGlomerular diseases• ToxinsToxins

• GentamicinGentamicin• NSAIDSNSAIDS• Compound analgesicsCompound analgesics

• Inherited diseasesInherited diseases• Tubular disordersTubular disorders

All global renal diseases affect

glomerular filtration rate (GFR)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.K/DOQI (USA)

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/Gif_File/kck_t10.gif


Causes of End Stage Renal Disease

0%10%20%30%40%50%60%70%80%90%

100%

%

OtherInterstit NCystic KDGNBPDiabetes

USRDS Annual Data Report


CKD - CausesCKD - Causes►DiabeticDiabetic►Non DiabeticNon Diabetic

• GlomerularGlomerular► Nephritic: PIGN, IgA, MPGNNephritic: PIGN, IgA, MPGN► Nephrotic: FSGS, Membranous, AmyloidosisNephrotic: FSGS, Membranous, Amyloidosis

• Tubulointerstitial: Analgesic, Reflux, Ch. ObsTubulointerstitial: Analgesic, Reflux, Ch. Obs• Vascular: Vasculitis, HTN, RASVascular: Vasculitis, HTN, RAS• Cystic: ADPKDCystic: ADPKD• CKD in transplantationCKD in transplantation


Increased Mortality in Patients With Increased Mortality in Patients With Diabetes Diabetes

and CKD: 2-Year Clinical Outcomesand CKD: 2-Year Clinical Outcomes

CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension, obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms.DM = diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Statistical Classification of Diseases, 9th Revision, Clinical Modification.Collins et al. Kidney Int. 2003;64(suppl 87):S24-S31.

+ DM, - CKD

- DM,+CKD

+ DM,+ CKD

Medical Cohort

Patie

nts

(%)

0

20

40

60

80

100

84.067.6 61.6

No Events

29.515.7

32.3

DeathESRD, CKD Stage 5

0.3

2.9 6.1

© 2005 The Johns Hopkins University School of Medicine.

Q050240

M9_1803_Sec I

L. Blonde

slide 9 How was this study done? How many people included; what levels of CKD


Chronic Kidney Disease Chronic Kidney Disease (CKD)(CKD)

• Involves progressive, irreversible Involves progressive, irreversible loss of kidney functionloss of kidney function

• Defined as either presence of Defined as either presence of • Kidney damageKidney damage

• Pathological abnormalities Pathological abnormalities • Glomerular filtration rate (GFR) Glomerular filtration rate (GFR)

• <60 ml/min for 3 months or longer<60 ml/min for 3 months or longer


Gangguan Fungsi GinjalGangguan Fungsi Ginjal• KlinisKlinis

Tanda, gejala, pemeriksaan fisik.Tanda, gejala, pemeriksaan fisik.• LaboratorisLaboratoris

Ureum ↑, kreatitin ↑, asam urat ↑Ureum ↑, kreatitin ↑, asam urat ↑• Tes klirens kreatinin (TKK)Tes klirens kreatinin (TKK)

• Rumus Cockrof-GaultRumus Cockrof-Gault

Kreatinin urin(mg/dL) x vol.urin(mL/24 jamKreatinin urin(mg/dL) x vol.urin(mL/24 jamKreatinin serum(mg/dL) x 1440Kreatinin serum(mg/dL) x 1440

LFG LFG = = (140-umur) x BB (Kg)(140-umur) x BB (Kg)72 x kreatinin serum 72 x kreatinin serum

(mg/dL(mg/dLWanita = 0,85 x priaWanita = 0,85 x pria


Estimate of GFR

• Measured GFRMeasured GFR• Serum creatinineSerum creatinine• Creatinine clearanceCreatinine clearance• Formulae based on serum creatinineFormulae based on serum creatinine

• Cockcroft and GaultCockcroft and Gault• MDRDMDRD

• OtherOther• Eg Cystatin CEg Cystatin C

All based on measurements of serum creatinine


Kriteria CKDKriteria CKD•Kerusakan ginjal > 3 bln, Kerusakan ginjal > 3 bln,

struktural atau fungsional dengan struktural atau fungsional dengan atau tanpa penurunan LFGatau tanpa penurunan LFG• Kelainan patologi atauKelainan patologi atau• Tanda kerusakan ginjal dalam darah Tanda kerusakan ginjal dalam darah

ataupun urine atau pada ataupun urine atau pada pemeriksaan pencitraanpemeriksaan pencitraan

•LFG < 60mL/m/1,73m2, > 3blnLFG < 60mL/m/1,73m2, > 3bln


Pathophysiology Of CKDPathophysiology Of CKD

• Repeated injury to kidneyRepeated injury to kidney


Gejala CKDGejala CKD• Nafsu makan hilang / kurangNafsu makan hilang / kurang• Nausea Nausea vomiting vomiting• Gatal-gatalGatal-gatal• Gangguan miksi, poli/oliguria, Gangguan miksi, poli/oliguria,

nokturia, dllnokturia, dll• Gejala-gejala anemiaGejala-gejala anemia• InsomniaInsomnia• GelisahGelisah• Gangguan mental / kesadaran Gangguan mental / kesadaran

comacoma


►Abnormal Sodium-Water metabolismAbnormal Sodium-Water metabolism• Edema, HypertensionEdema, Hypertension

►Abnormal Acid-base abnormalitiesAbnormal Acid-base abnormalities• Metabolic Acidosis due to uremia or RTAMetabolic Acidosis due to uremia or RTA

►Abnormal hematopoesisAbnormal hematopoesis• Anemia of CKDAnemia of CKD

►Cardiovascular AbnormalitiesCardiovascular Abnormalities• LVH, CAD, Diastolic DysfunctionLVH, CAD, Diastolic Dysfunction

►Abnormal Calcium-Phosphorus metabolismAbnormal Calcium-Phosphorus metabolism• Hyperphosphatemia, pruritus, arthralgiaHyperphosphatemia, pruritus, arthralgia• HyperparathyroidismHyperparathyroidism• Renal OsteodystrophyRenal Osteodystrophy

CKD - ManifestationsCKD - Manifestations


Manifestations of Chronic Manifestations of Chronic UremiaUremia


Chronic Kidney DiseaseChronic Kidney DiseaseClinical ManifestationsClinical Manifestations

•UremiaUremia• Syndrome that incorporates Syndrome that incorporates

all signs and symptoms seen all signs and symptoms seen in various systems in various systems throughout the body throughout the body



Urinary systemUrinary system•PolyuriaPolyuria

• Results from inability of Results from inability of kidneys to concentrate urine kidneys to concentrate urine

• Occurs most often at nightOccurs most often at night• Specific gravity fixed around Specific gravity fixed around

1.0101.010



Urinary systemUrinary system•Oliguria Oliguria

• Occurs as CKD worsensOccurs as CKD worsens•Anuria Anuria

• Urine output <40 ml per 24 Urine output <40 ml per 24 hourshours



Metabolic disturbancesMetabolic disturbances• Waste product accumulationWaste product accumulation

• As GFR As GFR ↓↓, BUN , BUN ↑↑ and serum and serum creatinine levels creatinine levels ↑↑• BUN BUN ↑↑

• Not only by kidney failure but by protein Not only by kidney failure but by protein intake, fever, corticosteroids, and intake, fever, corticosteroids, and catabolismcatabolism

• N/V, lethargy, fatigue, impaired thought N/V, lethargy, fatigue, impaired thought processes, and headaches occurprocesses, and headaches occur



Electrolyte/acid–base imbalancesElectrolyte/acid–base imbalances• PotassiumPotassium

• HyperkalemiaHyperkalemia• Most serious electrolyte disorder in Most serious electrolyte disorder in

kidney diseasekidney disease• Fatal dysrhythmiasFatal dysrhythmias



Electrolyte/acid–base imbalancesElectrolyte/acid–base imbalances• SodiumSodium

• May be normal or lowMay be normal or low• Because of impaired excretion, Because of impaired excretion,

sodium is retained sodium is retained • Water is retained Water is retained

• EdemaEdema• HypertensionHypertension• CHFCHF



Electrolyte/acid–base imbalancesElectrolyte/acid–base imbalances• Calcium and phosphate alterations Calcium and phosphate alterations • Magnesium alterationsMagnesium alterations• Metabolic acidosisMetabolic acidosis

• Results from Results from • Inability of kidneys to excrete acid load Inability of kidneys to excrete acid load

(primary ammonia)(primary ammonia)



Hematologic systemHematologic system•AnemiaAnemia

• Due to ↓Due to ↓ production of production of erythropoietinerythropoietin• From From ↓↓ of functioning renal of functioning renal tubular cellstubular cells

•Bleeding tendenciesBleeding tendencies• Defect in platelet functionDefect in platelet function



Hematologic systemHematologic system• InfectionInfection

• Changes in leukocyte Changes in leukocyte functionfunction

• Altered immune response Altered immune response and functionand function

• Diminished inflammatory Diminished inflammatory responseresponse



Cardiovascular systemCardiovascular system• HypertensionHypertension• Heart failureHeart failure• Left ventricular hypertrophyLeft ventricular hypertrophy• Peripheral edemaPeripheral edema• DysrhythmiasDysrhythmias• Uremic pericarditis Uremic pericarditis



Respiratory systemRespiratory system• Kussmaul respiration-Why?Kussmaul respiration-Why?• Dyspnea-Why?Dyspnea-Why?• Pulmonary edema-Why?Pulmonary edema-Why?• Uremic pleuritis-Why?Uremic pleuritis-Why?• Pleural effusionPleural effusion• Predisposition to respiratory infectionsPredisposition to respiratory infections• Depressed cough reflexDepressed cough reflex• ““Uremic lung”Uremic lung”



Gastrointestinal systemGastrointestinal system• Every part of GI is affectedEvery part of GI is affected

• Due to excessive ureaDue to excessive urea• Mucosal ulcerationsMucosal ulcerations• StomatitisStomatitis• Uremic fetor (urinous odor of the Uremic fetor (urinous odor of the

breath)breath)• GI bleedingGI bleeding• AnorexiaAnorexia• N/V N/V



Neurologic systemNeurologic system• Expected as renal failure progressesExpected as renal failure progresses

• Attributed to Attributed to • Increased nitrogenous waste productsIncreased nitrogenous waste products• Electrolyte imbalancesElectrolyte imbalances• Metabolic acidosisMetabolic acidosis• Demyelination of nerve fibers Demyelination of nerve fibers

• Altered mental abilityAltered mental ability• Seizures and ComaSeizures and Coma• Dialysis encephalopathyDialysis encephalopathy• Peripheral neuropathyPeripheral neuropathy



Neurologic systemNeurologic system• Restless leg syndromeRestless leg syndrome• Muscle twitchingMuscle twitching• IrritabilityIrritability• Decreased ability to concentrateDecreased ability to concentrate



Musculoskeletal systemMusculoskeletal system• Renal osteodystrophyRenal osteodystrophy

• Syndrome of skeletal changesSyndrome of skeletal changes• Result of alterations in calcium and Result of alterations in calcium and

phosphate metabolismphosphate metabolism• Weaken bones, Weaken bones, increase fracture riskincrease fracture risk

• Two types associated with ESRD:Two types associated with ESRD:• OsteomalaciaOsteomalacia• Osteitis fibrosa Osteitis fibrosa


Feedback Loops in SHPTFeedback Loops in SHPT(Secondary hyperparathyroidism)(Secondary hyperparathyroidism)

Ca = calcium; CVD = cardiovascular disease; P = phosphorus.Courtesy of Kevin Martin, MB, BCh.

PTH

Bone DiseaseFracturesBone pain

Marrow fibrosisErythropoietin resistance

Serum P1,25D

Calcitriol

Renal Failure

PTH

Systemic ToxicityCVD

HypertensionInflammationCalcification

Immunological

25D

Ca++

Decreased Vitamin D Receptors and Ca-Sensing Receptors



Renal OsteodystrophyRenal Osteodystrophy



Integumentary systemIntegumentary system• Most noticeable changeMost noticeable change

• Yellow-gray discoloration of the skinYellow-gray discoloration of the skin• Due to absorption/retention of urinary Due to absorption/retention of urinary

pigmentspigments

• PruritusPruritus• Uremic frostUremic frost• Dry, pale skin Dry, pale skin



Integumentary systemIntegumentary system• Dry, brittle hairDry, brittle hair• Thin nailsThin nails• PetechiaePetechiae• Ecchymoses Ecchymoses



Reproductive systemReproductive system• InfertilityInfertility

• Experienced by both sexesExperienced by both sexes• Decreased libidoDecreased libido• Low sperm countsLow sperm counts• Sexual dysfunctionSexual dysfunction


CKD - ManagementCKD - Management

Diagnostic work up to decide underlying Diagnostic work up to decide underlying etiologyetiology

Treatment of Hypertension and DyslipidemiaTreatment of Hypertension and Dyslipidemia Treatment of AnemiaTreatment of Anemia Treatment of HyperphosphatemiaTreatment of Hyperphosphatemia Avoidance of Dehydration & Nephrotoxic Avoidance of Dehydration & Nephrotoxic

agentsagents Proper Dosing of DrugsProper Dosing of Drugs Preparation for Renal Replacement TherapyPreparation for Renal Replacement Therapy


►Serum electrolytesSerum electrolytes►Urine spot protein analysis (24 hour no Urine spot protein analysis (24 hour no

longer recommended).longer recommended).►ANA, C3, C4ANA, C3, C4►Kidney UltrasoundKidney Ultrasound►Urine sediment analysisUrine sediment analysis►BiopsyBiopsy

• Evidence of glomerular disease without Evidence of glomerular disease without diabetesdiabetes

• Sudden onset of nephrotic syndrome or Sudden onset of nephrotic syndrome or glomerular hematuriaglomerular hematuria

CKD - EvaluationCKD - Evaluation



►Diagnostic work up to decide underlying Diagnostic work up to decide underlying etiologyetiology

►Treatment of Hypertension and Dyslipidemia Treatment of Hypertension and Dyslipidemia ►Treatment of AnemiaTreatment of Anemia►Treatment of HyperphosphatemiaTreatment of Hyperphosphatemia►Avoidance of Dehydration & Nephrotoxic Avoidance of Dehydration & Nephrotoxic

agentsagents►Proper Dosing of DrugsProper Dosing of Drugs►Preparation for Renal Replacement TherapyPreparation for Renal Replacement Therapy


CKD - HypertensionCKD - Hypertension►Anti-Hypertensive AgentsAnti-Hypertensive Agents

• Single most important measure could be Single most important measure could be adequate BP control adequate BP control

• Target BP <130/80 with minimal proteinuria and Target BP <130/80 with minimal proteinuria and BP<125/75 with significant proteinuria (>1g).BP<125/75 with significant proteinuria (>1g).

• ACEIs and ARBs ACEIs and ARBs have been demonstrated to have been demonstrated to slow both diabetic and non-diabetic renal disease slow both diabetic and non-diabetic renal disease in both experimental and human studies.in both experimental and human studies.

• Decrease the sodium intake to 2.5 g /dayDecrease the sodium intake to 2.5 g /day• Usually requires more than 2 medications.Usually requires more than 2 medications.• Diuretics enhance the antihypertensive and Diuretics enhance the antihypertensive and

antiproteinuric effects of other agents.. antiproteinuric effects of other agents..


Recommendations for BP and Recommendations for BP and RAS Management in CKDRAS Management in CKD

BP = blood pressure; RAS = renin angiotensin system; CCB = calcium channel blocker; BB = -blocker; JNC 7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.ADA. Diabetes Care. 2005;28(suppl 1); Chobanian et al. JAMA. 2003;289:2560-2572; Kidney Disease Outcomes Quality Initiatives (K/DOQI). Am J Kidney Dis. 2004;43(5 suppl 1):S1-S290.

PatientGroup

Goal BP(mm Hg) First Line Adjunctive

+ Diabetes <130/80 ACE-I or ARB Diuretics then CCB or BB

Diabetes + Proteinuria <130/80 ACE-I or ARB Diuretics then CCB or BB

Diabetes Proteinuria <130/80

No specific preference: Diuretics then ACE-I, ARB, CCB, or BB

EXPECT TO NEED TO USE 3+ AGENTS TO ACHIEVE GOALSRecommendations largely consistent across JNC 7, ADA, and K/DOQI

Q050240

M60_1803_Sec II


Relationship Between Achieved Relationship Between Achieved BP BP

and GFRand GFR

-14-12-10-8-6-4-20

95 98 101 104 107 110 113 116 119

eGFR

(mL/

min

/1.7

3 m2 ) p

er y

MAP = Mean Arterial Pressure*

r = 0.69P<0.05

UntreatedHypertension

130/80 140/90

*MAP = [SBP + (2 × DBP)]/3 mm Hg.Summary of 9 studies used in figure.Parving et al. 1989; Viberti et al. 1993; Klahr et al. 1993; Hebert et al. 1994; Lebovitz et al. 1994; Moschio et al. 1996; Bakris et al. 1996; Bakris et al. 1997; GISEN Group. 1997.Bakris et al. Am J Kidney Dis. 2000;36:646-661.



Chronic Kidney DiseaseChronic Kidney DiseaseCollaborative CareCollaborative Care

Drug therapyDrug therapy• Hypertension (cont’d)Hypertension (cont’d)

• Antihypertensive drugsAntihypertensive drugs• DiureticsDiuretics• ββ-Adrenergic blockers-Adrenergic blockers• Calcium channel blockersCalcium channel blockers• Angiotensin-converting enzyme (ACE) Angiotensin-converting enzyme (ACE)

inhibitorsinhibitors• Angiotensin receptor blocker (ARB)Angiotensin receptor blocker (ARB)


CKD - DyslipidemiaCKD - Dyslipidemia►Dyslipidemia and Cardiovascular Dyslipidemia and Cardiovascular

morbidity morbidity • Several studies like the 4D study showed no Several studies like the 4D study showed no

benefit of statins in dialysis patients.benefit of statins in dialysis patients.• However, post hoc analysis of this data However, post hoc analysis of this data

does suggest that the management of does suggest that the management of dyslipidemia in CKD 2 – 4 improves cardiac dyslipidemia in CKD 2 – 4 improves cardiac mortality and morbidity.mortality and morbidity.

• Dyslipidemia is frequently seen in Dyslipidemia is frequently seen in glomerular disease with proteinuria glomerular disease with proteinuria (nephrotic syndrome) and its control (nephrotic syndrome) and its control reduces atherosclerosis related morbidity reduces atherosclerosis related morbidity and mortality.and mortality.




►Treatment of Hypertension and DyslipidemiaTreatment of Hypertension and Dyslipidemia►Treatment of AnemiaTreatment of Anemia►Treatment of HyperphosphatemiaTreatment of Hyperphosphatemia►Avoidance of Dehydration & Nephrotoxic Avoidance of Dehydration & Nephrotoxic



CKD - AnemiaCKD - Anemia

Decreased quality Decreased quality of life with anemia.of life with anemia.

Diagnosis of Diagnosis of exclusion.exclusion.

Mostly apparent in Mostly apparent in the stage 4 and 5 of the stage 4 and 5 of CKD.CKD.

Due to decrease in Due to decrease in EPO production in EPO production in the kidney.the kidney.



Drug therapyDrug therapy• AnemiaAnemia

• ErythropoietinErythropoietin• Epoetin alfa (Epogen, Procrit)Epoetin alfa (Epogen, Procrit)• Administered IV or subcutaneouslyAdministered IV or subcutaneously• Increased hemoglobin and hematocrit in Increased hemoglobin and hematocrit in

2 to 3 weeks2 to 3 weeks• Side effect: HypertensionSide effect: Hypertension



Drug therapyDrug therapy• Anemia (cont’d)Anemia (cont’d)

• Iron supplementsIron supplements• If plasma ferritin If plasma ferritin <100 ng/ml<100 ng/ml• Side effect: Gastric irritation, Side effect: Gastric irritation,

constipationconstipation• May make stool dark in colorMay make stool dark in color



Drug therapyDrug therapy• Anemia (cont’d)Anemia (cont’d)

• Folic acid supplementsFolic acid supplements• Needed for RBC formation Needed for RBC formation • Removed by dialysisRemoved by dialysis

• Avoid blood transfusionsAvoid blood transfusions


CKD - HyperphosphatemiaCKD - Hyperphosphatemia►Control of HyperphosphatemiaControl of Hyperphosphatemia

• Due to decreased excretion in urine.Due to decreased excretion in urine.• Control of hyperphosphatemia by dietary measures Control of hyperphosphatemia by dietary measures

slow progression in experimental models of CKD.slow progression in experimental models of CKD.• Hyperphosphatemia leads to pruritus, calcification Hyperphosphatemia leads to pruritus, calcification

in synovial membranes, blood vessels and even in synovial membranes, blood vessels and even cardiac valves.cardiac valves.

• Therapy includes Phosphorus restriction to Therapy includes Phosphorus restriction to 800mg/day and use of phosphrous binders with 800mg/day and use of phosphrous binders with food.food.► Calcium Carbonate (TUMS), Ca-acetate (PHOSLO)Calcium Carbonate (TUMS), Ca-acetate (PHOSLO)► LanthanumLanthanum► RenagelRenagel


CKD – Bone and Mineral diseaseCKD – Bone and Mineral disease

►Hyperparathyroidism:Hyperparathyroidism:• High phosphorus and low Vitamin D High phosphorus and low Vitamin D

causing low calcium.causing low calcium.• Monitor Intact PTH levels and keep Monitor Intact PTH levels and keep

between 100 and 500.between 100 and 500.• Maintain Phosphorus and Calcium Maintain Phosphorus and Calcium

within normal ranges.within normal ranges.• Vitamin D analog paricalcitol.Vitamin D analog paricalcitol.• Calcimimetic agents like cinacalcet.Calcimimetic agents like cinacalcet.



Drug therapyDrug therapy• Renal osteodystrophyRenal osteodystrophy

• Phosphate intake restricted to Phosphate intake restricted to <1000 mg/day<1000 mg/day

• Phosphate bindersPhosphate binders• Calcium carbonate (Tums)Calcium carbonate (Tums)

• Bind phosphate in bowel and excretedBind phosphate in bowel and excreted• Sevelamer hydrochloride (Renagel)Sevelamer hydrochloride (Renagel)

• Lowers cholesterol and LDLsLowers cholesterol and LDLs



Drug therapyDrug therapy• Renal osteodystrophy (cont’d)Renal osteodystrophy (cont’d)

• Phosphate binders (cont’d)Phosphate binders (cont’d)• Should be administered with each mealShould be administered with each meal• Side effect: ConstipationSide effect: Constipation

• Supplementing vitamin DSupplementing vitamin D• Calcitriol (Rocaltrol)Calcitriol (Rocaltrol)• Serum phosphate level must be lowered before Serum phosphate level must be lowered before

administering calcium or vitamin Dadministering calcium or vitamin D


CKD - ManagementCKD - Management►Diagnostic work up to decide underlying Diagnostic work up to decide underlying

etiologyetiology►Treatment of Hypertension and Treatment of Hypertension and

DyslipidemiaDyslipidemia►Treatment of AnemiaTreatment of Anemia►Treatment of HyperphosphatemiaTreatment of Hyperphosphatemia►Avoidance of Dehydration & Nephrotoxic Avoidance of Dehydration & Nephrotoxic



CKD - NephrotoxicsCKD - Nephrotoxics►Avoidance of Dehydration/Nephrotoxic AgentsAvoidance of Dehydration/Nephrotoxic Agents

• Drugs such as Aminoglycosides, NSAIDsDrugs such as Aminoglycosides, NSAIDs• Avoiding exposure to Radio contrast agents.Avoiding exposure to Radio contrast agents.• In presence of dehydration, even in absence of In presence of dehydration, even in absence of

renovascular disease, ACEIs or ARBs can renovascular disease, ACEIs or ARBs can aggravate renal dysfunctionaggravate renal dysfunction

• Dehydration is frequent in tubulo-interstitial Dehydration is frequent in tubulo-interstitial disorders where urinary concentration is disorders where urinary concentration is impaired. impaired.

• Proper Dosing of Drugs eg. AllopurinolProper Dosing of Drugs eg. Allopurinol

►00



Drug therapyDrug therapy• HyperkalemiaHyperkalemia

• IV insulin and glucoseIV insulin and glucose

• IV 10% calcium gluconateIV 10% calcium gluconate• Raises threshold for excitationRaises threshold for excitation

• Sodium bicarbonateSodium bicarbonate• Shift potassium into cellsShift potassium into cells• Correct acidosisCorrect acidosis



Drug therapyDrug therapy• Hyperkalemia (cont’d)Hyperkalemia (cont’d)

• Sodium polystyrene sulfonate Sodium polystyrene sulfonate (Kayexalate)(Kayexalate)

• Cation-exchange resin Cation-exchange resin • Resin in bowel exchanges potassium for Resin in bowel exchanges potassium for

sodiumsodium• Evacuates potassium-rich stool from bodyEvacuates potassium-rich stool from body• Educate patient that diarrhea may occur due Educate patient that diarrhea may occur due

to laxative in preparationto laxative in preparation



Nutritional therapyNutritional therapy• Protein restrictionProtein restriction

• 0.6 to 0.8 g/kg body weight/day0.6 to 0.8 g/kg body weight/day• Water restriction Water restriction

• Intake depends on daily urine outputIntake depends on daily urine output



Nutritional therapyNutritional therapy• Sodium restrictionSodium restriction

• Diets vary from 2 to 4 g depending on Diets vary from 2 to 4 g depending on degree of edema and hypertensiondegree of edema and hypertension

• Sodium and salt should not be equated Sodium and salt should not be equated • Patient should be instructed to avoid Patient should be instructed to avoid

high-sodium foodshigh-sodium foods• Salt substitutes should not be used because Salt substitutes should not be used because

they contain potassium chloridethey contain potassium chloride


Chronic KidneyChronic Kidney DiseaseDiseaseCollaborative CareCollaborative Care

Nutritional therapyNutritional therapy• Potassium restrictionPotassium restriction

• 2 to 4 g2 to 4 g• High-potassium foods should be High-potassium foods should be

avoidedavoided• OrangesOranges• BananasBananas• TomatoesTomatoes• Green vegetablesGreen vegetables



• Phosphate restrictionPhosphate restriction• 1000 mg/day1000 mg/day• Foods high in phosphateFoods high in phosphate

• Dairy products Dairy products • Most foods high in phosphate are also Most foods high in phosphate are also

high in calciumhigh in calcium


CKD – Medication DosingCKD – Medication Dosing►Proper Dosing of DrugsProper Dosing of Drugs

• Uremia affects GI absorption; eg Iron.Uremia affects GI absorption; eg Iron.• Impaired plasma protein binding of drugs; eg Impaired plasma protein binding of drugs; eg

Dilantin.Dilantin.• Increased volume of distribution; Increased volume of distribution; • Excretion of many drugs depends upon the Excretion of many drugs depends upon the

kidney;kidney;► Some drugs used in normal dose will lead to Some drugs used in normal dose will lead to

nephrotoxic effectsnephrotoxic effects eg. Allopurinoleg. Allopurinol► Other drugs when used in normal dose will lead to Other drugs when used in normal dose will lead to

other toxic effects eg. Vancomycin.other toxic effects eg. Vancomycin.►Dose Reduction or Interval ExtensionDose Reduction or Interval Extension


CKD - RRTCKD - RRT►Preparation for Renal Preparation for Renal

Replacement TherapyReplacement Therapy• Education for Options of Dialysis & Renal Education for Options of Dialysis & Renal

Transplantation for Renal ReplacementTransplantation for Renal Replacement• Hemodialysis Vs Peritoneal DialysisHemodialysis Vs Peritoneal Dialysis• Avoidance of Veni-puncture & insertion of Avoidance of Veni-puncture & insertion of

catheters in peripheral veins once GFR < catheters in peripheral veins once GFR < 60mls.60mls.

• Timely placement of vascular access or Timely placement of vascular access or PD catheter.PD catheter.


CKD - RRTCKD - RRT►Indications (Absolute):Indications (Absolute):

• Uncontrolled hyperkalemia and acidosisUncontrolled hyperkalemia and acidosis• Uncontrollable hypervolemia (pulmonary edema)Uncontrollable hypervolemia (pulmonary edema)• PericarditisPericarditis• AMS and somnolence (advanced AMS and somnolence (advanced

encephalopathy)encephalopathy)• Bleeding diathesisBleeding diathesis

►Indications (Relative):Indications (Relative):• Nausea, vomiting and poor nutritionNausea, vomiting and poor nutrition• Metabolic acidosisMetabolic acidosis• Lethargy and MalaiseLethargy and Malaise• Worsening kidney function <10 ml or <15 ml in Worsening kidney function <10 ml or <15 ml in

diabeticsdiabetics


Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation

• Health promotionHealth promotion• Identify individuals at risk for CKDIdentify individuals at risk for CKD

• History of renal diseaseHistory of renal disease• HypertensionHypertension• Diabetes mellitusDiabetes mellitus• Repeated urinary tract infectionRepeated urinary tract infection

• Regular checkups and changes in Regular checkups and changes in urinary appearance, frequency and urinary appearance, frequency and volume should be reportedvolume should be reported


CKD - SummaryCKD - Summary In creasing prevalence of CKD in the In creasing prevalence of CKD in the

population.population. Early detection and prevention of Early detection and prevention of

progression. progression. Early involvement of nephrologists in the Early involvement of nephrologists in the

care (when GFR<30).care (when GFR<30). Treatment of Manifestations and Treatment of Manifestations and

complications.complications. Renal Replacement TherapyRenal Replacement Therapy

Timely referral for AccessTimely referral for Access Timely Transplant Work up.Timely Transplant Work up.


CKDCKDdeathdeath

Stages in Progression of Chronic Stages in Progression of Chronic Kidney Disease and Therapeutic Kidney Disease and Therapeutic

StrategiesStrategies

ComplicationsComplications

Screening Screening for CKDfor CKD

risk factorsrisk factors

CKD riskCKD riskreduction;reduction;

Screening forScreening forCKDCKD

DiagnosisDiagnosis& treatment;& treatment;

Treat Treat comorbidcomorbid

conditions;conditions;Slow Slow

progressionprogression

EstimateEstimateprogression;progression;

TreatTreatcomplications;complications;

Prepare forPrepare forreplacementreplacement

ReplacementReplacementby dialysisby dialysis

& transplant& transplant

NormalNormal IncreasedIncreasedriskrisk

KidneyKidneyfailurefailureDamageDamage GFRGFR


The Story of Mr. George LopezThe Story of Mr. George Lopez

• 45 yr HM with Diabetes for 10 yrs, 45 yr HM with Diabetes for 10 yrs, “reasonably well controlled” “reasonably well controlled”

• PMH: PMH: • Hypertension for 7 yrs..well Hypertension for 7 yrs..well

controlledcontrolled• BMI of 30BMI of 30• DyslipidemiaDyslipidemia

• Fam Hx: Diabetes; Fam Hx: Diabetes; • Soc Hx: Sedentary; non smoker; Soc Hx: Sedentary; non smoker;

ComedianComedian• ExamExam

• 139/85 – Mild Obesity, rest fairly 139/85 – Mild Obesity, rest fairly normalnormal

• LabsLabs• BUN 28, Creatinine 1.8, Urine BUN 28, Creatinine 1.8, Urine

protein (dipstick) 2+protein (dipstick) 2+


MDRD GFR for Mr LopezMDRD GFR for Mr Lopez

• Diabetic, Hypertension, Metabolic Diabetic, Hypertension, Metabolic Syndrome XSyndrome X

• Stage 3 CKDStage 3 CKD• GFR = 44 ml/min/1.73 mGFR = 44 ml/min/1.73 m22


Chronic Kidney DiseaseChronic Kidney Disease►A 70 yr old woman comes for F/U of recently A 70 yr old woman comes for F/U of recently

diagnosed CKD and HTN. She is asymptomatic. Her diagnosed CKD and HTN. She is asymptomatic. Her only medications is Lisinopril which has been titrated only medications is Lisinopril which has been titrated to its maximum dose in the last 3 months. She is to its maximum dose in the last 3 months. She is compliant and uses salt restriction. BP is 160/90. exam compliant and uses salt restriction. BP is 160/90. exam is normal except for trace pedal edema. Cr is 1.3, K is is normal except for trace pedal edema. Cr is 1.3, K is 5 and Urine Prot is 2.1 gm. Which of the following is 5 and Urine Prot is 2.1 gm. Which of the following is the most appropriate treatment for this patient?the most appropriate treatment for this patient?• ChlorthalidoneChlorthalidone• LosartanLosartan• MetoprololMetoprolol• MinoxidilMinoxidil• AmlodipineAmlodipine


In God we In God we trust,everything else trust,everything else should be based on should be based on evidence evidence (Claude Organ)(Claude Organ)

Copy right: [email protected]

kuliah ckd 2015

Documents