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7/30/2019 ChronicKidneyDisease IX semseter MBBS
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Chronic Kidney Disease
Robin Maskey, MD
Department of Internal Medicine
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A. Definitions
o Azotemia - elevated blood urea nitrogen (BUN>28mg/dL) and creatinine (Cr>1.5mg/dL)
o Uremia - azotemia with symptoms or signs ofrenal failure
o End Stage Renal Disease (ESRD) - uremiarequiring transplantation or dialysis
o Chronic Kidney Disease (CKD) - irreversiblekidney dysfunction with azotemia >3 months
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o Creatinine Clearance (CCr) - the rate offiltration of creatinine by the kidney (GFR
marker)
o Glomerular Filtration Rate (GFR) - the totalrate of filtration of blood by the kidney
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Prevalence
1 in 5 diabetics
1 in 6 hypertensives
1 in 5 of all elderly > 80 without
HTN and DM
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Common Underlying Causes ofCRF
Diabetes: most common cause ESRD (risk13x )
CRF associated HTN causes - 23% ESRD
Glomerulonephritis accounts for ~10% Polycystic Kidney Disease - about 5%
Rapidly progressive glomerulonephritis(vasculitis) - about 2%
Renal (glomerular) deposition diseases Renal Vascular Disease - renal artery
stenosis, atherosclerotic vs. fibromuscular
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Non-DM Causes of CKD
Glomerular
Lupus or vasculitis
Hepatitis or HIV
Endocarditis Amyloidosis
Medications
Lithium
Ratio of protein:creatinine is high
Tubulointerstitial
Myeloma
Pyleonephritis
Obstruction BPH
Tumor
Chronic reflux
Sarcoidosis
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Non-DM Causes of CKD
Cystic and otherhereditary renaldiseases
Transplant
Chronic rejection
Medications
Chronic disease
Vascular
Hypertension
Renal artery
stenosis Renal vasculitis
Sickle cell
HUS
Low-flow states
Cirrosis, CHF, etc.
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Clinical Approach
History
Symptoms and Signs
Examination Investigations
Renal Biopsy
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History
Duration of symptoms
Drug h/o
Past medical and surgical h/o Family h/o
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Symptoms &SignsOrgansystem
Symptoms Signs
General Fatigue, weakness Sallow appearing
Skin Pruritus, easy brusisability Pallor,edema,ecchymoses
ENT Metallic taste, epistaxis Urinous breath
Eye Pale conjunctiva
Pulmonary Dyspnea Rales,Pl.effussion
CvS Dyspnea onexertion,pericarditis
HTN,cardiomegaly,frictionrub
GIT Anorexia,hiccupsRenal Nocturia,impotence
Neuromuscular
Restless legs,numbness
Neuro Irritability,libido Stupor,asterixis
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Examination
Short stature
Pallor/hyperpigmenation/brown
nails/scratch marks Signs of fluid oerload
Pericardial rub
Flow murmur According to etiology-
DM,PD,SLEetc.
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Investigations Urinalysis, microscopic exam, quantitation of
protein in urine (protein:creatinine ratio)
Calcium, phosphate, uric acid, magnesiumand albumin
Calculation of creatinine clearance andprotein losses
Complete blood count
Consider complement levels, proteinelectrophoresis, antinuclear antibodies, ANCA
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NOMORE
24-HOURURINES!Spot
urinesareadequate
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Methods of Estimating GFR
Inulin/iothalamateclearance GOLD
STANDARD
Creatinine Clearance (24 h urine) Equations base on serum creatinine
Cockroft-Gault formula
140-age/72 xcreatnine in males or
Same X0.84 in females
MDRD
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Radiographic Evaluation
Renal Ultrasound - evaluate for obstruction,stones, tumor, kideny size, chronic change
Duplex ultrasound or angiography
Spiral CT scan to evaluate renal arterystenosis
MRA preferred over contrast agents
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Complications
Anemia
Bone disease
Skin disease GIT complications
Metabolic complications
Endocrinological Muscular
CNS
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Anemia
Erythropoietin defieciency
Bone marrow toxins/fibrosis
Iron,folate and B12 deficiency RBC destruction and blood loss
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Bone disease
Renal osteodystrophy
Hyperparathyriodism
Osteomalacia Osteoporosis
Osteosclerosis
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Skin disease
Uremic pruritis
Eczematous leisons
Cutanea tarda
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GIT complications
GERD
Peptic ulcer
Acute pancreatitis Constipation in CAPD patients
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Metabolic
Gout
Insulin resistance
Lipid abnormalities Hypoglycemia
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Endocrine
Hyperprolactionemia
Abnormal thyriod hormones
LH / testosterone Abnormal GH
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CNS
Uremic encephalopathy
Dialysis dementia-alumunium
toxicity Seizures
Restless leg symdrome
Carpel tunnel syndrome Polyneuropathy
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Cardiac
Myocardial infacrtion
Accelerated HTN
Cardiac faliure Coronary calcification
Systolic and diastolic dysfunction
Uremic pericarditis Dialysis pericarditis
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Goals of Care
1. Slow decline in renal function
2. Prevent cardiovascular disease
3. Detect and manage complications Anemia
Hyperparathyroidism
Bone disease
Electrolyte abnormalities
Vascular complications
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To slow decline
Low salt diet (for HTN)
Low protein diet in CKD 4 & 5 Nutrition consult!
Avoid nephrotoxic agents Contrast dye, NSAIDs, gentamicin
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To slow decline
Diabetes control HA1c ~ 7.0 7.5
Metformin?
Glipizide v. Glyburide
Insulin
Blood pressure control - < 130/80
ACE-I or ARB
Diuretics thiazide for GFR > 30
- furosemide for GFR < 30
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To slow decline
Prescribe an
ACE-I or ARB
for proteinuria + CKD
even in the ABSENCE of
diabetes
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Goals of Care
1. Slow decline in renal function
2. Prevent cardiovascular disease
3. Detect and manage complications Anemia
Hyperparathyroidism
Bone disease
Electrolyte abnormalities
Vascular complications
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Prevent CV disease
Most common cause of death is CV diseaseand not renal failure.
Smoking cessation
Diabetes and Blood pressure control
Lipids No evidence that tx affects renal fxn
Guidelines: ATP3 -> LDL goal < 100
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Renal replacement therapy
Hemodialysis
Peritoneal dialysis
CAPD Renal transplantation
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Indications of HD
H-Severe Hyperkalemia
U-Uremia - azotemia with symptoms and/or
signs
M-Metabolic acidosis
P- Volume Overload - usually with congestiveheart failure (pulmonary edema)
Periccariditis
S- serum creatnine >6 mg/dl1/17/2013 34
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When to refer
Proteinuria > 3.5 gm in 24 hours
Nephritis
Hematuria, proteinuria and HTN Diabetes & CKD but no retinopathy
GFR decline of 50% in one year
Stage 3 or 4 CKD
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Chronic Hemodialysis Medications
Anti-hypertensives - labetolol, CCB, ACEinhibitors
Eythropoietin - for anemia in ~80%dialysis pts
Vitamin D Analogs - calcitriol given oral
Calcium carbonate or acetate tophosphate and PTH
RenaGel, a non-adsorbed phosphate
binder, is being developed forhyperphosphatemia
DDAVP may be effective for patients withsymptomatic platelet problems
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Key Points
Think about CKD and screen
Creatinine AND urine protein
Calculate the GFR!
Look for reversible cause if no DM
Get to know the KDOQI guidelines &think about the complications
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Thank you
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