CHRONIC kidney disease   UREMIC SYNDROME
Chronic kidney diseasez CHRONIC IRREVERSIBLE and  PROGRESSIVE LOSS OF RENAL  FUNCTION.z REDUCED NUMBER OF  FUNCTIONING NEP...
C k dz Results in :  y Retention  y Altered hormonal function  y Deficiency state
CLINICAL EXPRESSIONz   Fatigue.z   Anorexia, nausea, vomitingz   Water and salt retention. Edemaz   Hypertensionz   Thirst...
RetentionSMALL MOLECULESz Water.z Sodium, potassiumz Hydrogen ions.z Creatinine, urea.z Phosphate.z Oxalatez Calciumz Alum...
UREMIC TOXINSMiddle molecules: 300- 12000Dz   PTHz   Beta 2 microglobulinz   Homocysteinez   Guanidinz   Guanidin succinic...
Parathyroid hormone(MW 9000)z   HTNz   CARDIOMYOPATYz   OSTEODYSTROPHYz   ANEMIA, PLT.z   DISLIPIDEMIAz   IMMUNE DEFFICIEN...
PTHz Glucose intolerancez T cell dysfunctionz Prognostic factor
BETA 2 MICROGLOBULINz   Histocompatibility complexz   DIALYSIS MEMBRANESz   Bonez   Jointz   Tendon (Carpal Tunnel)z   DIA...
HOMOCYSTEINEz Cardiovascular morbidityz Progression of renal diseasez Renovascular HTN
Uremic toxinsz Guanidinz Guanidin succinic acidz Phenol
Deficiencyz Malnutritionz Loss - Nephrotic Syndrome          Hemodialysis         Peritoneal Dialysis
deficiencyz   Albumin- Prognostic factorz   Vitaminsz   Ironz   Amino acids
Hormonal disturbancesz PTHz INSULINz RENINz PROLACTINz ENDOTHELINz SEX HORMONS: Amenorrhea               Azoospermiaz GROW...
Systemic damagez   HYPERTENSIONz   Prevalence 70%z   Cytosolic calciumz   Water and Sodiumz   Reninz   Endothelinz   Ather...
ACIDOSISz CATABOLIC STATEz FATIGUE
Cardiovascularz   ACCELERATED ATHEROSCLEROSISz   Hypertensionz   Hyperlipidemiaz   Vascular calcification - Calciphilaxisz...
Cardiovascularz Incidence - 400 % higher then normalz First cause of death in ESRD (60%)z IHD: 50% (prevalence)
Myocardiumz Systolic function - decreased                     (cytosolic calcium)z Diastolic function - decreased         ...
MYOCARDIUMz Cardiomyopaty -v Concentric - HTNv Dilated - Volume overload - Anemia.
Coronaryz   Hypertensionz   Hyperlipidemiaz   Hyperhomocysteinemiaz   Calcification
PERICARDIUMUremic Pericarditisz   Under dialysis (50%)z   Viral (50%)z   Cause of deathz   Differential diagnosisz   Treat...
Cardiac valvesz Dilated cardiomyopathyz Calcificationz SBE
NEUROLOGIC DISORDERSMENTAL: y   FATIGUE y   DEPRESSION y   MEMORY y   DECISION y   CONCENTRATION
Neurologic involvementz UREMIC NEUROPATHYz UREMIC MYOPATHYz UREMIC ENCEPHALOPATHY
PERIPHERAL NEUROPATYz   POLYNEUROPATHYz   DISTAL > PROXIMALz   SYMETRICz   SENSORIAL >MOTOR
DISEQULIBRIUMSYNDROMEz HYPEROSMOLAR STATE (HYPERGLICEMIA , HYPERNATREMIA)z IDIOPATHIC OSMOLSz AMINO ACID, URIC ACID, SORBI...
ENCEPHALOPATHYz DIALYSIS DEMENTIAz ALUMINUM
ANEMIAz   DECREASED EPOz   BLOOD LOSSz   DEFICIENCY(IRON,PROT,VIT)z   SHORT SURVIVAL (Intrinsic-Extrinsic)
Immune systemz   DISTURBED PHAGOCYTOSIS (TB)z   DIALYSIS LEUCOPENIAz   ANTIBODY PRODUCTIONz   CELLULAR IMMUNITY (TB + Tumo...
Coagulationz THROMBASTHENIA(PTH)z CHRONIC HEPARIN TREATMENTz HYPERCOAGULABILITY
SKINz DRY SKINz PRURITUSz UREMIC FETORz UREMIC FROSTz Ca, PO3H-, PTH, INDOL
UREMIC ENCEPHALOPATYz Early : EEG changesz Advance : Confusion, Convulsion, Coma  and Deathz Disequlibrium
Renal Osteodystrophy      DECREASED PHOSPHATE EXCRETION        Decreased 1 alpha hydroxylase         Decreased Ca absorpti...
1- Alpha hydroxylase deficiencyz Acidosisz Secondary hyperparathyroidism.z Skeletal resistance to PTH
ACIDOSISz Bone bufferingz Bone resorption
Amyloidz Beta2 microglobulinz Bone fracture
Osteodystrophyz   Aluminumz   Immobilizationz   Heparinz   Malnutritionz   Drugsz   Osteoporosis
RENAL OSTEODYSTROPHYz   Osteitis fibrosa cystica (HIGH)z   Osteomalacia (low)z   Aluminnum (low)z   Adynamic bone disease ...
RENAL OSTEODYSTROPHYz Hemodialysis - High turn over  (Osteoclasts)z Peritoneal Dialysis - Low turn over
TREATMENTz   Accepted level of PTHz   Phosphate : diet, chelation ,dialysis perscriptionz   Calcium : dialysate, intakez  ...
Natural History of           CKDz   NORMAL: From 40 years of agez   1 ml/yearz   ACTIVE RENAL DISEASEz   KIDNEY DONORz   N...
PATOPHYSIOLOGYz Over work of the remaining nephronsz Hyperfiltrationz Afferent arteriole vasodilation (DM,  Protein intake...
Hyperfiltrationz Increased filtration pressurez Increased mechanical stretch and strainz Activation of AT2, TGFz Increased...
TREATMENTz   Blood pressurez   Proteinuriaz   Protein intakez   Glycemiaz   Dietary Naz   Hyperlipidemiaz   Smokingz   Hom...
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Icm crf 235

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  • can get utimate dx by doing renal biopsy\n- not simple- is last stage of investigation\n\n\n
  • chronic renal failure:\n- defined mainly by irreversibility of the disease\n- can never cure- and have normal renal fnxn\n- is a progressive disease\n- progression depend on several causes:\n- HTN \n- diabetes\n- primary renal disease\n- coexistence of other diseases \n- diabetes- most common dx of renal disease- which brings pts to end stage disease\n- bc of the great prevalence of diabetics in the pop\n- used to not accept daibetics for dialysis, and now its the main cause for dialysis in the western world (bc in africa- malaria is more common than diabetics)\n\n-reduced number of functioning nephrons\n- but blood supply to kidney is the same- same blood, less nephrons\n- so each nephron now has work to do now\n- each nephron filtrates more: hyperfiltration\n\nhyperfiltration- not only a mechanical problem- but also some physiology/pharmacological changes in the kidney\n\n- each mm higher causes damage to the cap membrane epithelium\n-diff btw blood pressure and intraglomerular pressure\n- glomer cap pressure- is not not always the systemic pressure: ACEI- reduce bp - reduce glomer pressure than other drugs\n- aff arterioles, in situation of hyperfiltration: dilate more than the efferent- this is good thing\n\n
  • result in renal function:\n- retention: \n- main fnxn of kidney is exretion of water, and salt, and urea, metabolites, toxins, ammonia, aids...\n- so retention of these things\n- altered hormonal fnxn\n- PTH\n- erythropoietin\n- vit D\n- deficiency state\n- \n\n\n- decrease in GFR (more than 30% decrease) one of first things that happen in normal way: retention of K\n\nretention: \n- k (advanced state of renal failure)\n- first stage- dont see hyperkalemia- only seen in the pre-dialysis situation-- EXCEPT in situation of drugs (k sparing diuretics, ACEI, ARBS, NSAIDS, Spironolactone, diet, )\n- nephrologists dont like spironolactone- bc scared of the hyperkalemia, but cardiologists like it\n\n
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  • Icm crf 235

    1. 1. CHRONIC kidney disease UREMIC SYNDROME
    2. 2. Chronic kidney diseasez CHRONIC IRREVERSIBLE and PROGRESSIVE LOSS OF RENAL FUNCTION.z REDUCED NUMBER OF FUNCTIONING NEPHRONS.z Hyperfiltration of the remaining nephrons
    3. 3. C k dz Results in : y Retention y Altered hormonal function y Deficiency state
    4. 4. CLINICAL EXPRESSIONz Fatigue.z Anorexia, nausea, vomitingz Water and salt retention. Edemaz Hypertensionz Thirst dehydrationz Organ related symptoms.z Pruritusz Mental and cognitive disorders
    5. 5. RetentionSMALL MOLECULESz Water.z Sodium, potassiumz Hydrogen ions.z Creatinine, urea.z Phosphate.z Oxalatez Calciumz Aluminum
    6. 6. UREMIC TOXINSMiddle molecules: 300- 12000Dz PTHz Beta 2 microglobulinz Homocysteinez Guanidinz Guanidin succinic acidz Phenolz (( phosphate ))
    7. 7. Parathyroid hormone(MW 9000)z HTNz CARDIOMYOPATYz OSTEODYSTROPHYz ANEMIA, PLT.z DISLIPIDEMIAz IMMUNE DEFFICIENCYz ENCEPHALOPATY
    8. 8. PTHz Glucose intolerancez T cell dysfunctionz Prognostic factor
    9. 9. BETA 2 MICROGLOBULINz Histocompatibility complexz DIALYSIS MEMBRANESz Bonez Jointz Tendon (Carpal Tunnel)z DIALYSIS CLEARANCE (P A N )
    10. 10. HOMOCYSTEINEz Cardiovascular morbidityz Progression of renal diseasez Renovascular HTN
    11. 11. Uremic toxinsz Guanidinz Guanidin succinic acidz Phenol
    12. 12. Deficiencyz Malnutritionz Loss - Nephrotic Syndrome Hemodialysis Peritoneal Dialysis
    13. 13. deficiencyz Albumin- Prognostic factorz Vitaminsz Ironz Amino acids
    14. 14. Hormonal disturbancesz PTHz INSULINz RENINz PROLACTINz ENDOTHELINz SEX HORMONS: Amenorrhea Azoospermiaz GROWTH HORMON
    15. 15. Systemic damagez HYPERTENSIONz Prevalence 70%z Cytosolic calciumz Water and Sodiumz Reninz Endothelinz Atherosclerosis,z Physical inactivity
    16. 16. ACIDOSISz CATABOLIC STATEz FATIGUE
    17. 17. Cardiovascularz ACCELERATED ATHEROSCLEROSISz Hypertensionz Hyperlipidemiaz Vascular calcification - Calciphilaxisz Hyperhomocysteinemia
    18. 18. Cardiovascularz Incidence - 400 % higher then normalz First cause of death in ESRD (60%)z IHD: 50% (prevalence)
    19. 19. Myocardiumz Systolic function - decreased (cytosolic calcium)z Diastolic function - decreased (interstitial precipitation)z Decreased ability of volume handling
    20. 20. MYOCARDIUMz Cardiomyopaty -v Concentric - HTNv Dilated - Volume overload - Anemia.
    21. 21. Coronaryz Hypertensionz Hyperlipidemiaz Hyperhomocysteinemiaz Calcification
    22. 22. PERICARDIUMUremic Pericarditisz Under dialysis (50%)z Viral (50%)z Cause of deathz Differential diagnosisz Treatment
    23. 23. Cardiac valvesz Dilated cardiomyopathyz Calcificationz SBE
    24. 24. NEUROLOGIC DISORDERSMENTAL: y FATIGUE y DEPRESSION y MEMORY y DECISION y CONCENTRATION
    25. 25. Neurologic involvementz UREMIC NEUROPATHYz UREMIC MYOPATHYz UREMIC ENCEPHALOPATHY
    26. 26. PERIPHERAL NEUROPATYz POLYNEUROPATHYz DISTAL > PROXIMALz SYMETRICz SENSORIAL >MOTOR
    27. 27. DISEQULIBRIUMSYNDROMEz HYPEROSMOLAR STATE (HYPERGLICEMIA , HYPERNATREMIA)z IDIOPATHIC OSMOLSz AMINO ACID, URIC ACID, SORBITOL,z PHOSPHOCREATINEz BRAIN EDEMA - HERNIATION
    28. 28. ENCEPHALOPATHYz DIALYSIS DEMENTIAz ALUMINUM
    29. 29. ANEMIAz DECREASED EPOz BLOOD LOSSz DEFICIENCY(IRON,PROT,VIT)z SHORT SURVIVAL (Intrinsic-Extrinsic)
    30. 30. Immune systemz DISTURBED PHAGOCYTOSIS (TB)z DIALYSIS LEUCOPENIAz ANTIBODY PRODUCTIONz CELLULAR IMMUNITY (TB + Tumor)z PTH, PHENOL, INDOLz Chronic Infection (Bioincompatibility)
    31. 31. Coagulationz THROMBASTHENIA(PTH)z CHRONIC HEPARIN TREATMENTz HYPERCOAGULABILITY
    32. 32. SKINz DRY SKINz PRURITUSz UREMIC FETORz UREMIC FROSTz Ca, PO3H-, PTH, INDOL
    33. 33. UREMIC ENCEPHALOPATYz Early : EEG changesz Advance : Confusion, Convulsion, Coma and Deathz Disequlibrium
    34. 34. Renal Osteodystrophy DECREASED PHOSPHATE EXCRETION Decreased 1 alpha hydroxylase Decreased Ca absorption Ca x P increased PTH stimulation Decreased PTH inhibition
    35. 35. 1- Alpha hydroxylase deficiencyz Acidosisz Secondary hyperparathyroidism.z Skeletal resistance to PTH
    36. 36. ACIDOSISz Bone bufferingz Bone resorption
    37. 37. Amyloidz Beta2 microglobulinz Bone fracture
    38. 38. Osteodystrophyz Aluminumz Immobilizationz Heparinz Malnutritionz Drugsz Osteoporosis
    39. 39. RENAL OSTEODYSTROPHYz Osteitis fibrosa cystica (HIGH)z Osteomalacia (low)z Aluminnum (low)z Adynamic bone disease (low)z Mixedz Amyloid
    40. 40. RENAL OSTEODYSTROPHYz Hemodialysis - High turn over (Osteoclasts)z Peritoneal Dialysis - Low turn over
    41. 41. TREATMENTz Accepted level of PTHz Phosphate : diet, chelation ,dialysis perscriptionz Calcium : dialysate, intakez Vitamin Dz Pulse therapyz PTXz Desferioxaminz Nutrition
    42. 42. Natural History of CKDz NORMAL: From 40 years of agez 1 ml/yearz ACTIVE RENAL DISEASEz KIDNEY DONORz NEPHRECTOMY 3/4
    43. 43. PATOPHYSIOLOGYz Over work of the remaining nephronsz Hyperfiltrationz Afferent arteriole vasodilation (DM, Protein intake)z Efferent arteriole vasoconstriction (angiotensin )
    44. 44. Hyperfiltrationz Increased filtration pressurez Increased mechanical stretch and strainz Activation of AT2, TGFz Increased synthesis of collagenz Glomerulosclerosis and fibrosisz Increased tubular flow, reabsorption and and solute precipitationz Interstitial fibrosis
    45. 45. TREATMENTz Blood pressurez Proteinuriaz Protein intakez Glycemiaz Dietary Naz Hyperlipidemiaz Smokingz Homocysteinemia

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