chronickidneydisease ix semseter mbbs

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

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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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chronickidneydisease ix semseter mbbs

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