CHRONIC KIDENY DISEASE ......CKD ........DR ASEM MOH.ABOU ISSA.....NEPHROLOGIST PART 1

Chronic kidney Disease

CKD

BY DR

ASEM MOH. ABO EISSA

NEPHROLOGIST

National Kidney Foundation (NKF) defines

CKD as evidence of

renal damage

based on abnormal UA

proteinuria

> 300 mg/24 h

hematuria

structural abnormalities found with US

Or GFR < 60 mL/min

for 3 months or more

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 months or more

What is the definition of CKD?

Abnormal

Kidney structure

or Kidney function

for

> 3 months

CKD ClassificationWhat is GFR?

Glomerular Filtration

TubularReabsorption

Tubular Secretion

Excretion

GFR: The quantity of glomerular

filtrate formed in all nephrons of both kidneys /

min.

Chronic Kidney Disease

Five stages of CKD

Causes of CKD

DM

Hypertension

CVD

Chronic glomerulonephritis

Chronic pyelonephritis

Renal stones

Polycystic Kideny

Obstructive Uropathy

Neurogenic Bladder

Analgesic Nephropathy

Common Causes of CKD

CVD and its related risk factors

(e.g. obesity, smoking)

Chronic glomerulonephritis

Chronic pyelonephritis

Renal stones & Obstructive uropathy

APKDAKI

Analgesics abuse

DMHypertension

In CKD

reduced clearance of certain solutes excreted by the kidney results in their retention in the body fluids

. The solutes are end products of the metabolism of substances of exogenous origin (eg, food) or endogenous origin (eg, catabolism of tissue)

CKD

is rarely reversible and leads to progressive decline in renal function

Symptoms develop slowly and are nonspecific

Pts may remain asymptomatic until renal failure is far-advanced (GFR < 10-15 ml/min)

Manifestations include

fatigue, malaise, weakness, pruritis anorexia, n/v, metallic taste and hiccuph are common

Neurologic problems include

irritability, difficult concentration, insomnia, and forgetfulness

Menstrual irregularities,

infertility,

and loss of libido

are also common

a chronically ill-appearing pt

Look for possible underlying

cause (DM, lupus)

HTN is common

Skin may be yellow, with evidence of easy bruising

Uremic fetor

may be present

Lab :

elevations of BUN and serum creatinine

GFR…once < 60, refer to Nephrologist

Persistent proteinuria is suggestive of CKD, regardless of GFR level

anemia,

metabolic acidosis,

Hyperphosphatemia

, hypocalcemia,

Imaging

Finding of small hyperechogenic kidneys (<10 cm) by US

Radiological evidence of

renal osteodystrophy =BMD

( Bone Mineral Disease )

Check phalanges of hands

Complications of uraemia

HyperkalemiaAcid-base disordersCardiovascular HematologicNeurologicDisorders of mineral metabolismEndocrinal disorders

Hyperkalemia

Potassium balance usually remains intact until GFR < 10-20 mL/min

R\ of acute hyperkalemia involves cardiac monitoring, IV calcium chloride or gluconate, insulin with glucose, bicarbonate and dialysis.

Acid-base disorders

Damaged kidneys are unable to excrete the acid generated by metabolism of dietary proteins. The resultant metabolic acidosis is primarily due to loss of renal mass

R/

Maintain serum bicarb level at > 21 mEq/LAlkali supplements include sodium bicarbonate, calcium bicarbonate, and sodium citrate & dialysis

Cardiovascular complications

Hypertension

HTN is most common complication of ESRD

HTN control with weight loss and tobacco cessationSalt intake reduced to 2g/dayInitial treatment include ACE inhibitors or angiotensin II receptor blockers (ARBS)If serum potassium and GFR permit (recheck 1 wk)Goal BP is <130/80 mm Hg; for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg

Pericarditis may develop with uremia

believed to be due to retention of metabolic toxins

Chest pain and fever. May have and friction rub on exam

Pericarditis is an absolute indication for initiation of hemodialysis

CONGESTIVE HEART FAILURE

high cardiac output

extracellular fluid overload

shunting of blood through AV fistula

anemia

HTN

increased rate of atherosclerosis.

All of this contributes to LVH

and dilation present in 75% of pts starting dialysis

loop diuretics, ACE inhibitors, and regulation of salt and water

Hematologic complicationsAnemia

Normochromic, normocyticDue to decreased erythropoiesis and RBC survival

Many pts are also iron deficient

Recombinant erythropoietin (epoetin alfa) used in pts whose hematocrits are < 33%

Iron supplement

Hematologic complications

Coagulopathy

platelet dysfunction

Platelets show abnormal adhesiveness and aggregation

Pts may present with petechiae, purpura, and increased bleeding during surgery

Dialysis improves bleeding time but doesn’t normalize it

Neurologic complications

Symptoms begin

with diff. concentration

and can progress to

lethargy

confusion, and coma

Peripheral Neuropathy

Earlier initiation of dialysis may prevent peripheral neuropathies

Disorders of bone & mineral metabolism

BMD

Disorders of calcium, phosphorus, and bone are referred to as renal osteodystrophy or bone mineral disease.

Osteitis fibrosa cystica – the bony changes of secondary hyperparathyroidism…

Radiographically, lesions most prominent in phalanges and lateral ends of clavicles

May also have osteomalacia or adynamic bone disease

All of the above may cause bon ache proximal muscle weakness, and spontaneous bone fractures

R / may consist of dietary phosphorus restriction,

oral phosphorus-binding agents such as calcium carbonate or Renogel, and vitamin D

Hyperparathyroidism treated with calcitriol or cinacalcit ( mimpara )

lateral radiograph of the leg in a child with chronic renal failure reveals anterior bowing of the distal tibia.

the hip in a dialysis patient reveals erosion of a large portion of the medial femoral neck and trochanteric region from amyloid deposition (arrowheads) with a pathologic fracture in the basocervical portion of the femoral neck (arrow).

Anteroposterior radiograph of the forefoot in a patient with chronic renal failure reveals diffuse osteosclerosis.

radiograph of the hand in a dialysis patient reveals multifocal, large, amorphous calcific deposits (calcinosis) around the hand and wrist (arrows).

Endocrine

Circulating insulin levels are higher because of decreased renal insulin clearance

Glucose intolerance can occur in chronic renal failure when GFR is < 10-20 mL/min. This is mainly due to peripheral insulin resistance

Decreased libido and impotence are common. Men have decreased testosterone; women are often anovulatory

Treatment (Dialysis)

When conservative management of ESRD is inadequate, hemodialysis, peritoneal dialysis, and kidney transplantation are alternatives

Dialysis should be started when pt has GFR of 10 mL/min or serum creatinine of 8 mg/dL

Diabetics should start when GFR reaches 15 mL/min or serum creatinine is 6 mg/dL

Treatment (Dialysis)Other absolute indications for dialysis include

Uremic symptoms such as pericarditis, encephalopathy, or coagulopathy

Fluid overload unresponsive to diuresisRefractory hyperkalemia…>7

Severe metabolic acidosis (pH < 7.20)Neurologic symptoms such as seizures or neuropathy

Hemodialysis

Vascular access accomplished by an a/v fistula (preferred) or prosthetic graft

Infection, thrombosis, and aneurysm formation are complications

seen more often in grafts than fistulas.

Staphylococcus aureus is most common infecting agent

Pts typically require hemodialysis 3x/wk…sessions last 3-5 hrs each

Peritoneal dialysis

The peritoneal membrane is the “dialyzer”Most common type is continuous ambulatory peritoneal dialysis (CAPD)

Pts exchange dialysate 4-6 times/day

Continuous cyclic peritoneal dialysis (CCPD) utilizes a cycler machine to automatically perform exchanges at nightMost common complication = peritonitis

Most common pathogen = S aureus

Most common type is continuous ambulatory peritoneal dialysis (CAPD)Pts exchange dialysate 4-6 times per day

Continuous cyclic peritoneal dialysis (CCPD) utilizes a cycler machine to automatically perform exchanges at night

Kidney transplantation

1st - Dr Hamburger in 1952

Up to 50% of all pts with ESRD are suitable for transplant. Age becoming less of a barrier

In general, not placed on list until GFR <15

Living donor is best option

Two-thirds of kidney transplants come from deceased donors

Average wait for cadaveric transplant is 2-4 yrs; becoming longer as more pts go on the list while donor pool does not expand

One yr survival rate is approx. 98%