Chronic Kidney Disease And Its Affect on Mineral

& Bone DisorderDr. Salman Imtiaz

MRCP (UK), FCPS (Nephrology)Assistant Professor

Department of Nephrology The Kidney Center PGTI,

Karachi.

Function Of A Normal Kidney

1) Filtration.2) Fluid and electrolyte balance.3) Homeostasis.4) Erythropoietin synthesis.5) Active vitamin D6) Rennin.

How Chronic Kidney Disease AppearSign & Symptoms

1) Anorexia.2) Nausea.3) Vomiting.4) Lethargy.5) Increased Blood Pressure.6) Proteinuria.7) Malnutrition.8) Anemia9) Renal osteodystrophy.

Why Kidney FailsEtiologies of chronic Kidney Dysfunction

• In developed countries.1) Old age.2) Diabetes.3) Hypertension.4) Obesity. and5) Cardiovascular disease ˡ• In developing countries.( In addition to above)1) Glomerular. and2) Tubulointerstitial diseases. 3) Kidney Stone disease². ˡ United States Renal Data System.

2010 Annual Data Report:² thelancet.com Vol 379 January 14, 2012

How Kidney FailsInitiation and Progression Of CKD

Comprehensive clinical nephrology John Feehally.—4th ed.2010

GFR (Glomerular Filtration Rate)

• It is the rate by which kidney filter the blood

• Normal GFR is 180 liter /day or 125ml/min

Stages Of CKDCKD STAGE DEFINATIONSTAGE 1 Normal or increase GFR

STAGE 2 Moderate decrease in GFR(80-60ml/min/1.73m²

STAGE 33a3b

GFR(59-30ml/min/1.73m²)GFR(59-45ml/min/1.73m²)GFR(44-30ml/min/1.73m²)

STAGE 4 GFR 29-15ml/min/1.73m²

STAGE 5 GFR ˂ 15 ml/min/1.73m²

Stages Of CKD

www.thelancet.com Vol 379 January 14, 2012

Determination of CKD stages

Comprehensive clinical nephrology John Feehally.—4th ed.2010

Cockcroft-Gault FormulaeGFR (estimated GFR)

Ccr (ml/min) =

(140 – age) × weight__________________

72 × Scr(mg/dl)

Bone Mineral Disorder

Comprehensive clinical nephrology John Feehally.—4th ed.2010

�GFR

�PO4

�1,25 DHCC

�Ca

�PTH

Effect Of CKD On Body

• Increase phosphorus.• Reduce Calcium.• Increase Parathyroid hormone level.• Reduce Vitamin Dз

Definition of CKD-MBD

A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following:– Abnormalities of calcium, phosphorus, PTH, or vitamin D

metabolism

– Abnormalities in bone turnover, mineralization, volume, linear growth, or strength

– Vascular or other soft tissue calcification

Moe et al Kidney International June 2006

Calcium And Phosphorus Metabolism In Renal Failure

GFR

Pi Serum Levels

Bone Disease and soft tissue

calcificationCa and Pi released Bone Turn over

Vitamin D Activation

Ca serum Levels

PTH Stimulation

Comprehensive clinical nephrology John Feehally.—4th ed.2010

0

5

10

15

20

25

30

35

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

Year of ESRD Incidence or Transplantation

21.5

19.8

4.12.0

1999 annual report of the US Renal Data System

Dea

ths/

100

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ears

Dialysis All ESRD Cadaveric Transplant Living Related Transplant

Adjusted 1st Year Patient Death Rates by Treatment Modality and Year of Incidence, 1986-96

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25–34 45–54 65–74 ≥8535–44 55–64 75–84

Age (years)

Cardiovascular Mortality in the General Population and in Dialysis Patients

General populationMale Female

BlackWhite

Dialysis populationMale Female

BlackWhite

Comprehensive clinical nephrology John Feehally.—4th ed.2010

Clinical case 1

• 43 years old lady, she diagnosed to have DM for 15 years and CKD for five years and hemodialysis was started one year before. she admitted with drowsiness and pain in her right hand. She had

• S.Calcium 8.8 mg/dl• S.Phosphorus 7.5 mg/dl• S.iPTH 440μg/ml

CASE 2

• S.Calcium 5.5mg/dl• S.Phosphorus 8.5mg/dl• S.iPTH 1500 μg/ml

• S.Calcium 9.3mg/dl• S.Phosphorus 3.2mg/dl• S.iPTH 5 μg/ml

• S.Calcium 10.5mg/dl• S.Phosphorus 8.8mg/dl• S.iPTH 2500 μg/ml

• S.Calcium 8.0mg/dl• S.Phosphorus 4.2mg/dl• S.iPTH 355 μg/ml

THANK YOU