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Chronic kidney Disease
CKD
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BY DR
ASEM MOH. ABO EISSA
NEPHROLOGIST
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National Kidney Foundation (NKF) defines
CKD as evidence of
renal damage
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based on abnormal UA
proteinuria
> 300 mg/24 h
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hematuria
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structural abnormalities found with US
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Or GFR < 60 mL/min
for 3 months or more
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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
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What is the definition of CKD?
Abnormal
Kidney structure
or Kidney function
for
> 3 months
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CKD ClassificationWhat is GFR?
Glomerular Filtration
TubularReabsorption
Tubular Secretion
Excretion
GFR: The quantity of glomerular
filtrate formed in all nephrons of both kidneys /
min.
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Chronic Kidney Disease
Five stages of CKD
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Causes of CKD
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DM
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Hypertension
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CVD
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Chronic glomerulonephritis
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Chronic pyelonephritis
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Renal stones
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Polycystic Kideny
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Obstructive Uropathy
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Neurogenic Bladder
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Analgesic Nephropathy
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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
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In CKD
reduced clearance of certain solutes excreted by the kidney results in their retention in the body fluids
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. The solutes are end products of the metabolism of substances of exogenous origin (eg, food) or endogenous origin (eg, catabolism of tissue)
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CKD
is rarely reversible and leads to progressive decline in renal function
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Symptoms develop slowly and are nonspecific
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Pts may remain asymptomatic until renal failure is far-advanced (GFR < 10-15 ml/min)
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Manifestations include
fatigue, malaise, weakness, pruritis anorexia, n/v, metallic taste and hiccuph are common
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Neurologic problems include
irritability, difficult concentration, insomnia, and forgetfulness
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Menstrual irregularities,
infertility,
and loss of libido
are also common
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a chronically ill-appearing pt
Look for possible underlying
cause (DM, lupus)
HTN is common
Skin may be yellow, with evidence of easy bruising
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Uremic fetor
may be present
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Lab :
elevations of BUN and serum creatinine
GFR…once < 60, refer to Nephrologist
Persistent proteinuria is suggestive of CKD, regardless of GFR level
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anemia,
metabolic acidosis,
Hyperphosphatemia
, hypocalcemia,
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Imaging
Finding of small hyperechogenic kidneys (<10 cm) by US
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Radiological evidence of
renal osteodystrophy =BMD
( Bone Mineral Disease )
Check phalanges of hands
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Complications of uraemia
HyperkalemiaAcid-base disordersCardiovascular HematologicNeurologicDisorders of mineral metabolismEndocrinal disorders
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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 )
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lateral radiograph of the leg in a child with chronic renal failure reveals anterior bowing of the distal tibia.
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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).
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Anteroposterior radiograph of the forefoot in a patient with chronic renal failure reveals diffuse osteosclerosis.
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radiograph of the hand in a dialysis patient reveals multifocal, large, amorphous calcific deposits (calcinosis) around the hand and wrist (arrows).
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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
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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
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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
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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
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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
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Most common type is continuous ambulatory peritoneal dialysis (CAPD)Pts exchange dialysate 4-6 times per day
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Continuous cyclic peritoneal dialysis (CCPD) utilizes a cycler machine to automatically perform exchanges at night
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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%
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