What is CKD ?• Also known as Chronic Renal Failure.• It is defined by either a pathologic abnormality of the kidney, such as hematuria and/or proteinuria, or reduction of GFR of <60 mL/minute/1.37 m^2 for >3 months duration. Proteinuria and/or GFR < 60 Hematuria For 3 Months
StagesStage 1 disease is defined by a normal GFR (greater than 90 mL/min per1.73 m2) and persistent albuminuriaStage 2 disease is a GFR between 60 to 89 mL/min per 1.73 m2 andpersistent albuminuriaStage 3 disease is a GFR between 30 and 59 mL/min per 1.73 m2Stage 4 disease is a GFR between 15 and 29 mL/min per 1.73 m2 Stage 5disease is a GFR of less than 15 mL/min per 1.73 m2 or end-stage renaldisease
Epidemiology• Common condition• Often unrecognized until advanced stages.• It is estimated that 10% of the adult population world wide will have CKD• Incidence is raising• Due to different factors (aging population, increased incidence of DM & HTN, Increased incidence of glomerular diseases …….)
Epidemiology • conclude that prevalence of CKD in the young Saudi population is around 5.7% • Only 7.1% of the CKD patients were aware of their CKD status • 32.1% were told that they had protein or blood in their urine and 10.7% had known kidney stones in the past.
By the end of 2008, therewere 10,203 patients onhemodialysis
Meet Our Patient:• Mr. Saeed M. M.• 73 Years old Aging process causes decline in• Saudi GFR. Typically 1 per year after the• Male age of 50• From Abha• Admitted Feb 26th 2012. Men are at higher risk than women.• Through OPD The mechanism Is unknown but it is though to be related to sex hormones• Hx was taken from his son and is reliable.• C/C • Itching and bruising for 1 month • Swelling of face and limbs for 2 weeks
HPI• Mr. Saeed is known Diabetic for 30 years Diabetes is the most common cause. on insulin and Hypertensive for 3 years It is estimated that 30% of diabetics• He is known to have kidney disease since will have CKD within 5 to 10 years 3 years and following up of Diagnosis• Came to Nephrology clinic for regular follow up complaining of itching all over his body for 1 month. Second Most common cause of• This itching started gradually and is CKD. Accounts for 1 third of continuous and moderate with no rashes or patients undergoing renal fever. replacement therapy• It was associated with easy bruising on minimal trauma over his limbs. Thought to be due to accumulation• he has Hx of recurrent melena for the past of toxic waste products in the 3 months circulation such as urea• Pt has also edema around his eye developed 1 month gradually with Nitrogen retention that causes puffiness of the face and abdominal impaired prothrombin consumption, distention defect in platelet factor and abnormal platelet aggregation
Cont• Mr. Saeed also has chronic intermittent productive cough for 3 years and it progressed in severity in the last year, clear to greenish yellow sputum of moderate amount not associated with fever or hemoptysis. Associated with pulmonary edema due to• He also has dyspnea grade 2, no reduced urine output orthopnea no PND.• He also has vomiting for the past 3 weeks, of food content after taking breakfast. No hematemesis.• He also has anorexia and weight loss of 7 Kg over the last year Thought to be due to accumulation of• he also has dysuria, frequency (10 toxic waste products in the circulation times/day), nocturia such as urea• No hematuria, flank pain or obstructive Lower urinary tract Important to exclude obstructive symptoms. nephropathy
• Patient is known to have kidney To confirm the chronicity. Sometimes you disease since 3 years ago have to look for previous investigations• Admitted 3 years ago with LL and follow up notes. edema, ascites and treated for proteinuria• Discharged after 45 days• On follow up with nephrologist• Was found to have very high creatinine in the last follow up Incidental discovery is common• Was admitted for management of his problem
Systemic enquiryGeneral GI• Fatigue • Anorexia• Dizziness • Wt loss• No loss of consciousness • Melena • Abdominal distentionCVS • Morning vomiting • No jaundice• Dyspnea • No pain• No chest pain • No dysphagia• Cough• No PND Nervous• No orthopnea • Headache• No palpitations • No confusion or LOC• No cyanosis • No weakness• No claudication • Other unremarkable
Respiratory• Productive cough Skin• Dyspnea• No chest pain • Easy bruising• No hemoptysis• No other symptoms • ItchingMSK • no rash• Knee pain• Lower back pain • No eruptions• No joint swelling of redness• No limitation of movement • No ulcers
Drug Hx Insulin Mixed 20 a.m. 30 p.m. Captopril 25 mg BID Aspirin 81 mg OD Simvastatin 40 mg OD Phenytoin (Discontinued)
Past Surgical Hx Little toe Hernia Cataract amputation repair – 20 surgery – 2 – 15 years years ago years ago ago
Allergy Hx• -ve People with close family member with the disease are at higher risk themselves of developing CKD. The mechanism isTransfusion Hx thought to be due in part to genetic• -ve susceptibility to certain diseases such as DM, HTN, PKD, Alport syndrome.Family Hx• His brother had renal transplantation• History of chronic diseases, DM, HTN, IHD in first degree relatives• No Hx of malignancySocial• Married Smoking has been associated as a risk factor for• 40 pack-years Ex-smoker the development and progression of the disease.• Lives in Abha Likely because of accelerated atherosclerosis and• Illiterate vascular disease as well as exacerbating underlying HTN
On ExaminationGeneral• Patient looks not well, not comfortable, lying on his side and tachypnic• He is drowsy, not alert, not dehydrated, connected to IV line.Vitals• Pulse: 94 BPM regular, average volume, no special character, no radio-radial or radio-femoral delay.• BP: 130/85 mmHg• RR: 35 per minute – Shallow and Indicating metabolic acidosis fast pattern• O2 Saturation: 96% in room air
Hands Brown line of at least 1mm wide at distal• Clubbing in the nails end of nail may be present in some patients• Pallor in the palmar creases• Scratch marks over both arms As result of pruritus Due to deposition of• 3 echymotic patches around calcium or phosphate in the skin or the elbow and the site of IV stimulation of nerve endings due to some cannula- 1-3 cm in diameter retained toxins• Fine white scales over both arms Due to precipitation of high concentration of urea in the sweat• No astrexis• No liver disease stigmata• No A/V fistula For dialysis
H&N• Periorbital edema• Pallor• No Jaundice Anemia• No parotid swelling• No uremic fetor Smell from mouth due to breakdown of• No oral ulcer urea to ammonia• Bad dental hygiene• JVP is raised (4+5 cm)• No lymph node enlargement May be present due to dryness• No bruit over the carotids• no spider angiomata• Trachea is centralFundoscopy To look for retinal changes of DM and• Not done HTN
Chest• Inspection • No chest deformity or scars • Equal bilateral chest movement • No visible veins • Apex beat is not visible• Palpation • Normal bilateral chest expansion • Normal tactile fremitus • No heaves • No thrills • Apex beat is palpable in the 5th IC space 3 cm lateral to the mid- clavicular line.• Auscultation • Normal bilateral air entry • Coarse bilateral basal crepitation • Normal S1 + S2 + 0 Due to pulmonary edema • No added sounds, No murmurs • No pericardial Rub
Abdomen• Inspection • Distended flanks • Hernial repair scar • No visible veins • Normal umbilicus• Palpation • Soft, lax • No masses or tenderness • Kidneys are not palpable • No hepatomegaly (liver span= 12 cm) You may find enlarged kidneys or mass or • No splenomegaly polycystic kidney• Percussion • Ascites elicited by shifting dullness • No fluid thrill • No organomegaly• Auscultation • Normal bowel sounds • No renal artery bruits
Back• No renal angle tenderness• Sacral edemaLL• Amputated Rt little toe• Wasting of muscles in both limbs Indicator for poor control of DM• Bilateral pitting edema• Loss of hair distally• Scaling of the skin• No temperature difference• Dorsalis pedis pulsation is not palpable Peripheral vasculopathy due to DM• Posterior tibial pulsation is not palpable• Popliteal artery pulsation is palpable in both legs
Motor and sensory examination Right Left UL LL UL LLPower 3 5 4 5Tone + N + NLight touch N N N NPosition N N N NCoordination N N N NReflexes are ++ in right knee and Biceps. Others Normal
Urea & Creatinine High >1.1 mg/dl in men >1.2 mg/dl in women• Estimating Creatinine Clearance (ml/min)• Cockcroft and Gault equation:• CrCl = (140 - age) x IBW / (Scr x 72) (x 0.85 for females)• In our patient = 7.24 mL/min• Which Stage ??
Electrolytes• Hyponatremia is common• Potassium is normal until end stage• Calcium is low• Phosphate is high
ABG PH: 7.31 pCO2: 34 mmHg pO2: 85 mmHg HCO3: 18 mEq/literMetabolic acidosis because kidney is unable to regulate acid base balance
Urinalysis • Screening test to determine for pathologic markers of kidney damage excreted in the urine • Microalbuminurea is a risk factor for development of progressive CKD and CAD associated with DM and HTN . Indicated in patient with DM .
Other Investigations• Chest X-ray • pulmonary edema• ECG May show abnormalities associated with electrolyte • Normal disturbance in CKD• Renal Ultrasound • Small kidneys, No obstruction, No stones• Others • ?????????
Management• Drugs: • Replacement therapy • Iron 200 mg PO BID • Folic acid 5 mg PO OD • CaCO3 • 1-alpha What if the patient has • Hypertensive drug Hyperkalemia ?? • Captopril 50 mg PO BID • Pantazole 40 mg PO OD
Management• Education about hemodialysis• Referal for Radiology for Permacath insertion• Preparation for hemodialysis
Hemodialysis• method for extracorporeal removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies (the other two being renal transplant; peritoneal dialysis).