chronic kidney disease/dialysis
Post on 04-Jan-2016
61 Views
Preview:
DESCRIPTION
TRANSCRIPT
Chronic Kidney Chronic Kidney Disease/DialysisDisease/Dialysis
Belinda Jim, MDBelinda Jim, MD
January 15, 2009January 15, 2009
DefinitionDefinition NKF’s (National Kidney Foundation’s) NKF’s (National Kidney Foundation’s)
K/DOQI (Kidney Disease Outcomes Quality K/DOQI (Kidney Disease Outcomes Quality Initiative) Work Group criteria for CKD Initiative) Work Group criteria for CKD are:are:
Kidney damage for >3months, with or Kidney damage for >3months, with or without decreased GFR manifest by without decreased GFR manifest by either:either:
Pathological abnormalities orPathological abnormalities or Markers of kidney damage, including Markers of kidney damage, including
abnormalities in the composition of abnormalities in the composition of the blood or urine, or abnormalities the blood or urine, or abnormalities in the imaging tests.in the imaging tests.
OROR GFR < 60ml/min/1.73m2 for >3monthsGFR < 60ml/min/1.73m2 for >3months
Causes of ESRDCauses of ESRD
Regardless of acute or chronic, Regardless of acute or chronic, should calculate renal function by should calculate renal function by eGFReGFR
Used to evaluate extent of Used to evaluate extent of impairment, follow course of disease impairment, follow course of disease and response to therapyand response to therapy
Dose adjustmentsDose adjustments
Equations to Estimate Equations to Estimate GFRGFR
Gold Standard – inulin clearance, I-iothalmate, Gold Standard – inulin clearance, I-iothalmate, Tc-DTPA clearance. These tests are not uniform.Tc-DTPA clearance. These tests are not uniform.
Cockcroft-Gault equation-Cockcroft-Gault equation- (140-age) x wt/ 72 x SCr. (x 0.85 for women).(140-age) x wt/ 72 x SCr. (x 0.85 for women).
MDRD (Modification of Diet in Renal Disease) – MDRD (Modification of Diet in Renal Disease) – Abbreviated versionAbbreviated version 186 x SCr. To power of -0.203 (x 0.742 if 186 x SCr. To power of -0.203 (x 0.742 if
female) and (x1.210 if black).female) and (x1.210 if black). 24 hr. Urine for Cr.Cl –24 hr. Urine for Cr.Cl –
GFR = UCr.V/PCr x 0.70 (to convert to GFR = UCr.V/PCr x 0.70 (to convert to ml/min)ml/min)
CKD Staging and CKD Staging and PrevalencePrevalence
CKD CKD StageStage
GFRGFR(mL/min/1.73 m(mL/min/1.73 m22))
Number Number of of
IndividuaIndividualsls
1190 and evidence of 90 and evidence of kidney damagekidney damage 5.6 million5.6 million
2260-89 and evidence of 60-89 and evidence of kidney damagekidney damage 5.7 million 5.7 million
33 30-5930-59 7.4 million7.4 million
44 15-2915-29 300,000300,000
55 <15 or dialysis<15 or dialysis 431,284431,284Coresh et al , J Am Soc Nephrol, 2005; 16: 180-188Coresh et al , J Am Soc Nephrol, 2005; 16: 180-188Data supplied by USRDS 2004 Annual Data Report.Data supplied by USRDS 2004 Annual Data Report.
Natural History of Renal Natural History of Renal DiseaseDisease
Initial injury may vary in pathogenesisInitial injury may vary in pathogenesis Kidney adapts by increasing filtration rate in Kidney adapts by increasing filtration rate in
remaining normal nephronsremaining normal nephronsadaptive adaptive hyperfiltrationhyperfiltration
Long-term damage, manifested by proteinuria Long-term damage, manifested by proteinuria and progressive renal insufficiency and progressive renal insufficiency
Gradual decline usually asymptomaticGradual decline usually asymptomatic No exact correlation between level of BUN No exact correlation between level of BUN
and symptomsand symptoms Uremic symptoms: anorexia, nausea, Uremic symptoms: anorexia, nausea,
vomiting, fatigue, hiccups, pruritisvomiting, fatigue, hiccups, pruritis
General ManagementGeneral Management
Treatment of reversible causesTreatment of reversible causes Decreased renal perfusionDecreased renal perfusion Administration of nephrotoxic drugsAdministration of nephrotoxic drugs Urinary tract obstructionUrinary tract obstruction
Prevention or slow the progression Prevention or slow the progression Treatment of complications Treatment of complications Identification and adequate Identification and adequate
preparation of renal replacement preparation of renal replacement therapy (RRT)therapy (RRT)
Factors Affecting Factors Affecting Progression of CKDProgression of CKD
Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Age – incidence climbs after 65Age – incidence climbs after 65 Gender – more common in males Gender – more common in males
with a faster rate of decline.with a faster rate of decline. Race – incidence higher in AA and Race – incidence higher in AA and
Hispanics.Hispanics. Genetics – diabetic and non-diabetic Genetics – diabetic and non-diabetic
nephropathies cluster in families.nephropathies cluster in families.
Modifiable Risk Factors Modifiable Risk Factors
Proteinuria – aim for <500mg/24hr.Proteinuria – aim for <500mg/24hr. Hypertension – aim for <130/80 or Hypertension – aim for <130/80 or
MAP <90 with ACE I/ARB.MAP <90 with ACE I/ARB. Glycemic control – Evidence is Glycemic control – Evidence is
conflicting in progression of CKD.conflicting in progression of CKD. Dyslipidemia – elevated levels Dyslipidemia – elevated levels
associated with more rapid decline – associated with more rapid decline – esp in DN.esp in DN.
Obesity - linked to faster rate of Obesity - linked to faster rate of progression in CKD.progression in CKD.
Hyperuricemia – May cause renal Hyperuricemia – May cause renal injury and HTN through stimulationinjury and HTN through stimulation of of renin-angiotensin systemrenin-angiotensin system..
Treatment of Treatment of ComplicationsComplications
Volume overloadVolume overload HyperkalemiaHyperkalemia Metabolic acidosisMetabolic acidosis HyperphosphatemiaHyperphosphatemia AnemiaAnemia HyperparathyroidismHyperparathyroidism Bone diseaseBone disease Uremic symptomsUremic symptoms
Volume OverloadVolume Overload
Sodium and intravascular volume Sodium and intravascular volume balance usually maintained until balance usually maintained until GFR falls below 10 to 15 ml/minGFR falls below 10 to 15 ml/min
Mild to moderate CKD less able to Mild to moderate CKD less able to respond to rapid infusions of sodium, respond to rapid infusions of sodium, prone to overloadprone to overload
Respond to combination of dietary Respond to combination of dietary sodium restriction and diuretic sodium restriction and diuretic therapytherapy
HyperkalemiaHyperkalemia Problem with Problem with
AldosteroneAldosterone Distal flow in kidney (eGFR<10 -15ml/min).Distal flow in kidney (eGFR<10 -15ml/min).
Patient is either:Patient is either: Oliguric.Oliguric. Has high K diet.Has high K diet. Has increased tissue breakdown.Has increased tissue breakdown. Has Hypoaldosteronism (eg. ACE Has Hypoaldosteronism (eg. ACE
Inhibitors, type IV RTA).Inhibitors, type IV RTA). Treatment consists of low K diet Treatment consists of low K diet
(2gm/day), diuretics and kayexalate.(2gm/day), diuretics and kayexalate.
Ion transport in collecting tubule cell
Metabolic AcidosisMetabolic Acidosis
Increasing tendency to retain HIncreasing tendency to retain H++
Decreased HCO3Decreased HCO3--, usually between 12-, usually between 12-20meq/L20meq/L
Bone buffering of excess HBone buffering of excess H++ ions associated ions associated with release of Cawith release of Ca2+2+ and Phos from bone and Phos from bone
Uremic acidosis increase skeletal muscle Uremic acidosis increase skeletal muscle breakdown and diminish albumin synthesisbreakdown and diminish albumin synthesis loss of lean muscle mass and fatigueloss of lean muscle mass and fatigue
Sodium bicarbonate or sodium citrate to Sodium bicarbonate or sodium citrate to keep HCOkeep HCO33 above 22meq/L above 22meq/L
Secondary Secondary HyperparathyroidismHyperparathyroidism
Treatment of Secondary Treatment of Secondary HyperparathyroidismHyperparathyroidism
Phosphate binders:Phosphate binders: Low Phos diet (<800 mg/day)Low Phos diet (<800 mg/day) Ca based:Ca based:
CaCO3CaCO3 Ca acetateCa acetate
Non absorbable agent:Non absorbable agent: Sevelamer Hydrochloride (Renagel)Sevelamer Hydrochloride (Renagel) Sevelamer Carbonate (Renvela)Sevelamer Carbonate (Renvela) Lanthanum carbonate (Fosrenol)Lanthanum carbonate (Fosrenol)
Aluminum binders.Aluminum binders. Vitamin D analogs:Vitamin D analogs:
Calcitriol (Rocaltrol)Calcitriol (Rocaltrol) Paricalcitol (Zemplar)Paricalcitol (Zemplar) Doxercalciferol (Hectoral)Doxercalciferol (Hectoral)
Calcimimetic: Cinacalcet (Sensipar)Calcimimetic: Cinacalcet (Sensipar)
Renal OsteodystrophyRenal Osteodystrophy
Types of Bone DiseaseTypes of Bone Disease Osteitis fibrosaOsteitis fibrosa OsteomalaciaOsteomalacia Adynamic bone diseaseAdynamic bone disease
Target PTHTarget PTH Stage 3 (GFR 30-59): 35-70 pg/mLStage 3 (GFR 30-59): 35-70 pg/mL Stage 4 (GFR 15 to 29): 70-110 pg/mLStage 4 (GFR 15 to 29): 70-110 pg/mL Stage 5 (GFR less than 15): 150-300 Stage 5 (GFR less than 15): 150-300
pg/mLpg/mL
Metastatic CalcificationMetastatic Calcification
HypertensionHypertension
Mostly volume mediatedMostly volume mediated Start with ACEI/ARB and diureticStart with ACEI/ARB and diuretic Thiazides become ineffective when Thiazides become ineffective when
GFR falls below 20GFR falls below 20 Goal is less than 130/80, but even Goal is less than 130/80, but even
lower systolic with urine prot/creat lower systolic with urine prot/creat >1>1
Anemia in CKDAnemia in CKD The primary cause of anemia in
patients with CKD is insufficient production of erythropoietin (EPO) by the diseased kidneys.
Other causes include: Iron deficiency. Secondary hyperparathyroidism. Decreased RBC lifespan. Folate deficiency.
K/DOQI Guidelines for Anemia K/DOQI Guidelines for Anemia in CKDin CKD
Target Hgb between 11-12 g/dLTarget Hgb between 11-12 g/dL Anemia work-up when
Hgb <11g/dL (Hct is <33 percent) in pre-menopausal females and pre-pubertal patients.
Hgb <12g/dL (Hct is <37 percent) in adult males and post-menopausal females.
Use of erythropoietic agents Use of erythropoietic agents (Epo,Procrit,Aranesp)(Epo,Procrit,Aranesp)
DyslipidemiaDyslipidemia Primary finding in CKD is Primary finding in CKD is
hypertriglyceridemiahypertriglyceridemia
Goal of LDL in CKD in similar to CHD Goal of LDL in CKD in similar to CHD – LDL <100, but there is not much – LDL <100, but there is not much evidence whether this is beneficial.evidence whether this is beneficial.
One large study in CKD Stage V One large study in CKD Stage V showed a negative association with showed a negative association with very low cholesterol levelsvery low cholesterol levels
Preparation for Renal Preparation for Renal Replacement TherapyReplacement Therapy
Refer to nephrology when GFR < 60Refer to nephrology when GFR < 60 Early education of CKDEarly education of CKD Choice of renal replacement therapyChoice of renal replacement therapy
In-center hemodialysisIn-center hemodialysis Peritoneal dialysisPeritoneal dialysis Home hemodialysisHome hemodialysis
Access placementAccess placement Referral to vascular surgery of AVF placement Referral to vascular surgery of AVF placement
if patient choses HD and advising patient to if patient choses HD and advising patient to save non-dominant arm from venopuctures save non-dominant arm from venopuctures and heplocks.and heplocks.
What is Dialysis?What is Dialysis?
Initiation of Emergent Initiation of Emergent DialysisDialysis
• Uremic syndromeUremic syndrome• Refractory volume overloadRefractory volume overload• Uncontrollable hyperkalemiaUncontrollable hyperkalemia• Severe metabolic acidosisSevere metabolic acidosis• Steady worsening of renal Steady worsening of renal
function, with BUN exceeding 70-function, with BUN exceeding 70-100 mg/dL or creatinine clearance 100 mg/dL or creatinine clearance of less than 15-20 ml/min/1.73 m2of less than 15-20 ml/min/1.73 m2
DiffusionDiffusion Transport process by which a solute Transport process by which a solute
passively passively diffusesdiffuses down its concentration down its concentration gradient from one fluid compartment into gradient from one fluid compartment into the otherthe other
Dialysis MembraneDialysis Membrane
Contents of Dialysate Contents of Dialysate SolutionSolution
Ultrafiltration (UF)Ultrafiltration (UF) Fluid removal occurs via hydrostatic Fluid removal occurs via hydrostatic
pressure gradient across membrane pressure gradient across membrane generated by dialysis machinegenerated by dialysis machine
Peritoneal Dialysis (PD)Peritoneal Dialysis (PD) Uses peritoneal Uses peritoneal
membrane to membrane to transport solutes and transport solutes and water across two water across two compartmentscompartments
One compartment is One compartment is blood in the blood in the peritoneal capillaries, peritoneal capillaries, second compartment second compartment is dialysate solution is dialysate solution in peritoneal cavityin peritoneal cavity
Continuous Renal Continuous Renal Replacement Therapies Replacement Therapies
(CRRTs)(CRRTs) Slower rate of solute or fluid Slower rate of solute or fluid
removal per unit of timeremoval per unit of time Slower blood flow rate for the Slower blood flow rate for the
hemodynamically unstable patienthemodynamically unstable patient Better tolerated than conventional Better tolerated than conventional
therapytherapy
ComplicationsComplications
HypotensionHypotension InfectionInfection Catheter DysfunctionCatheter Dysfunction
HypotensionHypotension Common CausesCommon Causes
Fluctuations in UF rateFluctuations in UF rate
High UF rate High UF rate
Target dry weight set too lowTarget dry weight set too low
Dialysis solution too warmDialysis solution too warm
Food ingestionFood ingestion
Autonomic neuropathyAutonomic neuropathy
Antihypertensive medicationsAntihypertensive medications
Hypotension-CardiacHypotension-Cardiac
Diastolic dysfunction due to LVH, Diastolic dysfunction due to LVH, ischemic heart diseaseischemic heart disease
Failure to increase cardiac rateFailure to increase cardiac rate Inability to increase cardiac output Inability to increase cardiac output
for other reasonsfor other reasons
HypotensionHypotension
Less common reasonsLess common reasons Pericardial tamponadePericardial tamponade Myocardial infarctionMyocardial infarction Arrhythmia Arrhythmia Occult hemorrhageOccult hemorrhage Dialyzer reactionDialyzer reaction HemolysisHemolysis Air embolismAir embolism
Dialysis Catheter Dialysis Catheter InfectionsInfections
Localized exit site infectionLocalized exit site infection Erythema and/or crust, no purulent discharge, Erythema and/or crust, no purulent discharge,
treat with antibiotics for up to 2 weekstreat with antibiotics for up to 2 weeks Tunnel InfectionTunnel Infection
Purulent exudate present, and pain/warmth Purulent exudate present, and pain/warmth along the tunnel, removal of catheter with along the tunnel, removal of catheter with antibiotic administration for 3 weeksantibiotic administration for 3 weeks
Systemic InfectionSystemic Infection Fever, leukocytosis, may have no overt signs Fever, leukocytosis, may have no overt signs
of catheter infectionof catheter infection
Microbiology Microbiology
Staph species (40-81%)Staph species (40-81%) Enterococci, gram neg organisms, Enterococci, gram neg organisms,
fungal organismsfungal organisms Empiric treatment with Vancomycin Empiric treatment with Vancomycin
and Gentamicinand Gentamicin Treat with Nafcillin if MSSA!Treat with Nafcillin if MSSA!
Complications of Catheter Complications of Catheter InfectionInfection
EndocarditisEndocarditis OsteomyelitisOsteomyelitis ThrombophlebitisThrombophlebitis Spinal epidural abscessSpinal epidural abscess
Catheter DysfunctionCatheter Dysfunction
Early Early less than 5 daysless than 5 days Due to malposition or to intracatheter Due to malposition or to intracatheter
thrombosisthrombosis Fibrin sleeves and mural thrombiFibrin sleeves and mural thrombi
TreatmentTreatment Catheter exchange Catheter exchange TPATPA
Catheter DysfunctionCatheter Dysfunction
Late (more than 5 days)Late (more than 5 days) More likely due to intracatheter More likely due to intracatheter
thrombosis than malpositionthrombosis than malposition TreatmentTreatment
TPATPA Catheter exchangeCatheter exchange
Vascular AccessVascular Access
Permanent catheterPermanent catheter AV graftAV graft AV fistulaAV fistula
Permanent CatheterPermanent Catheter
Cuffed venous catheters an Cuffed venous catheters an alternative form of long-term accessalternative form of long-term access
High rate of complicationsHigh rate of complications ThrombosisThrombosis InfectionInfection
Inadequate blood flowInadequate blood flow
AV GraftAV Graft
AdvantagesAdvantages• AV connection made using a tube graft AV connection made using a tube graft
from synthetic materialfrom synthetic material• Maturation requires 2-3 weeks for Maturation requires 2-3 weeks for
adhesion of subcutaneous tunnel and adhesion of subcutaneous tunnel and graftgraft
DisadvantagesDisadvantages• Higher rates of infectionHigher rates of infection• Higher rates of thrombosisHigher rates of thrombosis• Shorter lifespanShorter lifespan
AV fistulaAV fistulaAdvantagesAdvantages• Subcutaneous anastomosis of artery to Subcutaneous anastomosis of artery to
adjacent veinadjacent vein• Safest longest lasting permanent accessSafest longest lasting permanent access• Excellent patencyExcellent patency• Lower morbidityLower morbidity• Lower complicationLower complication
DisadvantagesDisadvantages• Long maturation timeLong maturation time• Failure to mature in some patientsFailure to mature in some patients• May not be feasible in patients with May not be feasible in patients with
vascular diseasevascular disease
top related