knowledge of kidney and its function

1. Information
about kidney and it’s
problems
Dr Lalit Agarwal
Consultant Nephrologist
Woodlands Hospital

2. The Urinary System

3. The Urinary System

4. Structure of the Kidney

5. A Typical Nephron
Each kidney contains about 1 million nephrons

6. A Renal Corpuscle

7. Renal Corpuscles

8. FUNCTION OF KIDNEYS
• Produce urine by filtering blood and excretes waste products
• Balance fluid content in the body.
• Adjust levels of minerals and other chemicals to keep the body
working properly.
• Produce the enzyme Renin that helps control Blood Pressure.
• Produce hormone Erythropoietin to help make Red Blood
Cells.
• Activate Vitamin D to maintain healthy bone.

9. Types of kidney disease
•Acute kidney Injury (AKI)
or acute rise in creatine
•Chronic kidney Disease (CKD)
or chronic rise in creatine
• AKI on CKD
•Kidney Failure or CKD Stage 5

10. What is AKI?
An abrupt (within 7 days) &
sustained (>6 hours)
decrease in renal function/GFR
(usually reversible)
resulting in accumulation of
waste products.

11. Key causes of AKI
• Prerenal AKI
Functional or minimal cellular damage with
treatment rapid recovery
• Intrinsic AKI
Glomerular, Tubular , Interestitial and
Vascular
• Postrenal AKI

12. OR ACUTE KIDNEY INJURY

13. Definition of AKI - KDIGO
• Increase in S.cr by ≥ 0.3 mg/dl within 48
hrs or
• Increase in S.cr to ≥ 1.5 times of baseline,
which is known or presumed to have
occurred within prior 7 days or
• Urine volume < 0.5 ml/kg/hr for 6 hours.
ADQI(RIFLE) -- AKIN-- KDIGO GROUP

14. Staging of AKI(KDIGO)
Stage Serum Creatinine Urine output
1 1.5-1.9 times baseline within 1 wk or
≥ 0.3 mg/dl increase within 48 hrs
<0.5ml/kg/h for
6-12 hrs
2 2.0-2.9 times baseline <0.5ml/kg/h for
≥ 12 hrs
3 3.0 times baseline or
increase in serum creat to ≥ 4.0 mg/dl or
initiation of RRT or
in patients < 18 yrs, decrease in eGFR to
<35ml/min per 1.73 m²)
<0.3ml/kg/h for
≥ 24 hrs or
Anuria for ≥ 12
hrs

16. MAJOR COMPLICATIONS OF AKI
• Volume overload
• Hyperkalemia
• Metabolic acidosis
• Hypocalcemia
• Hyperphosphatemia
• Hyperuricemia and hypermagnesemia
• Signs of uremia

17. Distinguishing AKI from CKD
• Review h/o kidney disease and old
records
• Ultrasonography
• Anemia (GFR < 30ml/min , absence of
anemia suggests AKI( exception
HUS/TTP)

18. Prevention of AKI
• Identify patients at increased risks
advanced age,low eGFR,proteinuria,low
albumin, DM,previous AKI,
• Avoidance of renal insults
Volume depletion, nephrotoxic drugs
(NSAIDS, ACEI/ARB, contrast,TLS,
amphotericin, aminoglycosides etc.)
• Prophylactic treatments
Good hydration,?NAC,IV Sodabicarbonate

19. TREATMENT OF AKI
• Determine cause of AKI with special
attention to reversible causes
• Stage severity of AKI according to
creatinine and urine output
• Manage as per AKI stage and specific
cause
• Management of complications of AKI

20. RRT in AKI-1
• Conservative vs RRT?
• When to start RRT?
• Early vs late?
• What modality (IHD vs CRRT) of RRT to
use
• What dose of RRT to give?

21. RRT in AKI-2
• What type of temporary dialysis access to
use?
• What type of dialysis membranes to use?
• What choice of anticoagulation?
• When to stop RRT in AKI? ( CRRT to IHD,
recovery of kidney function)

22. Initiation of RRT in AKI
• Extremely variable on clinical situation,
empirical and if no improvement to
medical/supportive interventions.
• RRT indicated in severe (stage 3) kidney
injury.
• Absolute/urgent (objective) and
relative/elective (subjective) indications
• ICU:(early/low threshold to start in MOF)
• Renal ward:(single organ AKI)

23. Modality of dialysis in ITU
• IHD (rapid removal of solute & water)
• SLED
• Hemofiltration
• Hemodiafiltration
• UF (Aquapharesis)
• Approx. 10% pts with AKI cannot be treated with
IHD because of hemodynamic instability
• SLED and CRRT meta-analysis: no difference in
outcome (Zhang et al AJKD Aug 2015)

24. Outcomes of AKI
• Recovery
• Predialysis-CKD
• ESRD (10-30%)
• Death

25. 25
SIRS inducing MODS
Sepsis , Trauma ,Major Surgery
Pancreatitis, CPB .
Host Defenses
Tissue damage and hypotension
Cellular activation & release of IM

26. CKD usually means
fewer functioning
nephrons

27. CKD is reduced kidney function
and/or kidney damage
• Chronic kidney disease
– Kidney function
• Glomerular filtration rate (GFR)< 60mL/min/1.73m2 for
≥ 3 with or without kidney damage
– Kidney damage
• ≥ 3 months with or without decreased GFR, manifested
by either
– Pathological abnormalities
– Markers of kidney damage, e.g., albuminuria
– Urine albumin-to-creatinine ratio (UACR)> 30mg/g
This definition does not account for age related GFR
decline

28. Causes of CKD
• Diabetes - rapid loss of renal function
• Hypertension - both cause and effect
• Glomerulonephritis
• Cystic Disease
• Drug toxicity
• Interstitial disease
• Chronic infections

29. Zone of “Compensation”
(Adequate Renal Reserve)
Cr
K
Na
Normal Range
Serum
creatinine
G F R percent of Normal
Renal
Failure
0 25% 50% 75% 100%
1.4mg/dl
4 Sr. Cr 1.4 mg/dl
Sr. creatinine > 1.4
indicates G F R is
down by 50 %
Relationship between serum creatinine and GFR

30. Creatinine as a marker of KIDNEY FUNCTION(GFR)
Formula based GFR measurements
• MDRD formula (6 variable)
• Modified MDRD formula (4 variable)
• CKD-EPI formula
• Cystatin C (independent of muscle mass)
• Cockcroft -Gault formula
• Creatinine clearance test (measured GFR)

31. Creatinine GFR
1 100
2 50
3 25
4 12.5
5 6.125
6 3.06125
GFR which is related directly to urine creatinine excretion and
inversely to plasma creatinine. on the basis of this
relationship GFR will fall in roughly inverse proportion or
reciprocal to the rise in plasma creatinine. Creatinine is used
as a surrogate to eGFR. Direct GFR measurement is not
feasible.
Rough GFR

32. Note: further refined by KDIGO 2012 CKD work group

33. Albuminuria categories
Category
AER
(mg/24hr)
ACR
(Approximate equivalent)
(mg/mmol) (mg/g)
Terms
A1 < 30 < 3 < 30
Normal to mildly
increased
A2 30 - 300 3 - 30 30 - 300
Moderately
increased
A3 > 300 > 30 > 300
Severely
increased
No longer uses prefixes “normo”, “micro”, or “macro” when referring to
albuminuria because these terms are antiquated, non-descriptive
definations

34. Classification of CKD
• It is recommended that CKD be classified
by:
– Cause
– GFR category
– Albuminuria category
• This is collectively referred to as “CGA
staging”
• Represents a revision of the previous
KDOQI CKD guidelines, which included
staging only by level of GFR

35. Each kidney has about 1 million nephrons;
slow loss may not be noticeable
• We have a large physiological reserve
• Slow, progressive loss of functioning
nephrons may not be noticeable
• The person with CKD may not feel
different up to ckd stage 4

36. Early referral to nephrologist
• Identify reversible/treatable factors
• Avoid nephrotoxic drugs
• Retardation of progression of renal
disease
• Prevent cardiovascular mortality
• Better planning of RRT

37. Early Treatment Makes a Difference
Slow CKD progression

38. Optimal Care in CKD-prevent CVD
The incidence rate of new ESRD declined for the first
time in 2011 after been stable since 2000.(USRDS 2013)
Timely initiation
of dialysis/Txp
Timely access
placement
Informed choice
of RRT
Education
Modification of
comorbidity
Preparation for
RRT
Early detection
Protein restriction
Blood sugar control
BP control
ACE inhibitors/ARB
Secondary
hyperparathyroidism
Anemia
Malnutrition
Interventions that
delay progression
Management of
complications
Retinopathy
(diabetics)
Neuropathy
(diabetics)
Vascular disease
Cardiac disease
Acidosis/
dyslipidemia

39. Kidney Failure is an eGFR < 15
• Kidneys cannot maintain homeostasis
• Kidney failure is associated with fluid,
electrolytes and hormonal imbalances and
metabolic abnormalities
• ESRD means the patient is on dialysis or
has a kidney transplant

40. Symptoms of kidney failure that can be caused by a build-
up of wastes in the body include:
• A metallic taste in the mouth or ammonia breath
• Nausea and vomiting
• Loss of appetite
• Difficulty in concentrating
• Itchiness (pruritis)
• Weight Loss
Symptoms of kidney failure that can be caused by a build-
up of fluid in the body include:
• Swelling in the face, feet or hands
• Shortness of breath (from fluid in the lungs)
SYMPTOMS OF KIDNEY FAILURE

41. Symptoms of kidney failure that can be caused by
damage to the kidneys include:
• Making more or less urine than usual
• Urine that is foamy or bubbly (may be seen when protein is in
the urine)
• Blood in the urine (typically only seen through a microscope)
Symptoms of kidney failure that can be caused by anemia (a
shortage of red blood cells) include:
• Fatigue
• Weakness
• Feeling cold all the time
• Shortness of breath
• Mental confusion

43. CKD
ESRD
GLOBAL CKD-ESRD: Prevalence/Incidence
500 MILLION ADULTS WITH CKD
2.5 MILLION
Many CKD patients die
prematurely from CVD

44. CKD
ESRD
CKD-ESRD: INDIA Prevalence/Incidence
17% of ADULTS WITH CKD
25,000/yr get RRT
Many CKD patients die
prematurely from CVD
IN INDIA ONLY 25,000 (10% NEW ESRD GET RRT) AND 90% (2,50,000) UNABLE TO
AFFORD RRT AND SIMPLY DIE.
50,000 patients undergoing regular MHD in 5500 machines in 800 dialysis centers
5000 patients on PD and 5000 transplant done annually.
In India dialysis population is growing at a rate of 10%

45. 46
What are CKD patients Dying From?
Stroke Myocardial
Infarction
Heart
Failure
Sudden
Death

46. TREATMENT OPTIONS
INTRODUCTION
It is not the end of the world for a person with
impaired,non-functional kidneys.
"QUALITY OF LIFE" can be improved by proper
and timely medical intervention.

47. The four options for treating
kidney failure
• Renal replacement therapy (RRT)
1. Hemodialysis
- In-centre or home
2. Peritoneal dialysis
3. Kidney transplantation
• Conservative management
4. Active medical management without RRT

48. Indications to begin dialysis
depend on objective and subjective criteria
• Absolute indications :
• Traditional indications/uremic symptoms
• Relative indications:
• anorexic, sleepiness, loss of energy,
malnutrition, decrease in cognition
• Diabetics need to initiate dialysis earlier
than non diabetics.

49. Main Goals of Dialysis
• Remove
– Fluid
– Waste Products
• Urea
• Creatinine
• Potassium
• Phosphorous
• Sodium
• Maintain
– Fluid
– Electrolyte
– Acid-base balance
BENEFITS OF DIALYSIS
improve quality and
quantity of life

50. HEMODIALYSIS

51. DIALYSER

53. Vascular access
Temporary Permanent
Femoral
cannulation
Central
Venous
Cannulation
AV Fistula AV Graft
Permanent
Venous
Catheter
Internal Jugular Subclavian

54. Arteriovenous Fistula/Graft

55. Central Venous Catheter

56. Peritoneal
Dialysis

57. International Variation in PD

58. Peritoneal Dialysis
• Blood is cleaned inside the
body, through the Peritoneum
• The peritoneum allows waste
products to pass through it .
• Dialysis Fluid pass through
Tenckhoff Catheter.

59. The two aspects of peritoneal
transport
1. Solute clearance.
• Diffusive
• Convective.
2. Fluid removal
(Ultrafiltration)

60. Getting Ready for PD

61. Peritoneal Dialysis Options
CAPD
–Continuous
–Ambulatory
–Peritoneal
–Dialysis
APD
–Automated
–Peritoneal
–Dialysis

62. Chronic Peritoneal Dialysis:
Continuous
Ambulatory PD
Automated PD
• 2.0-2.5 L dwells
• 4-8 hours
• 4 times/day
• 3-10 dwells nightly
• CCPD:Continuous
Cycling PD– 1 dwell
during the day
• NIPD:Nocturnal
Intermittment PD- dry
during day

63. CAPD
• Perform 4-5 exchanges
per day
– Treatment can be done
almost anywhere
– No machine needed
– Exchange takes about 30
to 40 minutes
– Ultra BagTM

64. Fluid Bags- contain fluid Blue Clamps-Control Flow
Transfer Set-barrier to infection
Minicap-prevent germs entry
CAPD Components

65. Peritoneal dialysis: There are three phases of PD
Fill- New Fluid enters the peritoneal cavity
Dwell-The fluid stays inside your body for
4-6 hours.
Drain-The fluid plus waste is drained out and
replaced with new fluid.
Drain
How does PD work?

66. Automated Peritoneal
Dialysis
CCPD
• Dialysate solution
is changed by a
machine, at night.
• 8-12 liters over 8-
10 hours
• Leave 1-2 liters to
dwell during the
day.

68. Complications of PD
• Infectious
• Non-infectious

69. Infectious complications
• Exit – site infection
• Tunnel infection
• Peritonitis: remains significant cause of
– Hospitalization
– PD failure
– Damage to peritoneal membrane
– Morbidity and mortality

71. A Normal Exit Site

73. The Problem with
ONE GERM
is that
it becomes a lot of germs!!

74. A
single germ
can turn
into over
a million
in just
5 hours!!
In 15 minutes 1 germ divides into 2
In 30 minutes 2 germs divide into 4
In 45 minutes 4 germs divide into 8
In 60 minutes 8 germs divide into 16
In 75 minutes 16 germs divide into 32
In 90 minutes 32 germs divide into 64
In 105 minutes 64 germs divide into 128
In 120 minutes 128 germs divide into 256
In 135 minutes 256 germs divide into 512
In 150 minutes 512 germs divide into 1024
In 165 minutes 1024 germs divide into 2048
In 180 minutes 2048 germs divide into 4096
In 195 minutes 4096 germs divide into 8192
In 210 minutes 8192 germs divide into 16384
In 225 minutes 16384 germs divide into 32768
In 240 minutes 32768 germs divide into 65536
In 255 minutes 65536 germs divide into 131072
In 270 minutes 131072 germs divide into 262144
In 285 minutes 262144 germs divide into 524288
In 300 minutes 524,288 germ divides into 1,048,576!!

75. Non-infectious complications
Non infectious
complications
Catheter related Catheter unrelated
•Outflow failure
•Pericatheter leak
•Abdominal wall herniation
•Catheter cuff extrusion
•Intestinal perforation
GERD Hemoperitoneum
Back/abdominal pain UF failure
Abdominal wall herniation Peritoneal sclerosis
Pleural effusion Metabolic

77. Acute peritoneal dialysis

80. KIDNEY
TRANSPLANTATION

81. Benefits of Transplantion
 Improve life expectancy
 Cardio-vascular benefits
 Improve Quality-of-life
 Socio-economic benefits

82. The Transplantation Process
 Pre-transplant evaluation
 Legal compliance
 The operation
 Immunosuppression
 Complications
 Short and long term follow up

83. Kidney Donor
Living related.
Living unrelated (altruistic).
Deceased/Cadaveric (Brain-dead).
Beating and non-beating heart.

86. The Final Look

87. Surgical Complications
 Vascular Complications: arterial, venous
 Ureteric complications : urine leak/obstruction
 Perigraft Fluid Collections:
Seroma & Hematoma
Abscess
Urinoma
Lymphocele
 Wound infection
 Delayed graft function

88. Medical Complications
 Acute rejection
- Acute cellular rejection
- Antibody-mediated rejection-C4d
 NODAT/PTDM
 Infectious complications
- Cytomegalovirus
- BK virus
- Post op infections
 Malignancy-PTLD and Skin Carcinoma
common
 Chronic allograft dysfunction(r/o reversible
factors)

89. India – Legal Aspects
Transplantation of Human Organs Act,
1994
Aims
• Regulate removal, storage and
transplantation of human organs for
therapeutic purposes
• To prevent commercial dealings in
organs
• Recognise Brain Death

90. WHAT IS REJECTION?
• Rejection is a normal reaction of the body to a foreign object.
When a new kidney is placed in a person's body, the body sees
the transplanted organ as a threat and tries to attack it
What is done to prevent rejection?
Medications is given for the rest of the life to fight rejection.
The anti-rejection medications most commonly used includes:

91. Immunosuppressive Medications
 Induction:
–Corticosteroids
–Anti-thymocyte globulin (ATG)
–IL-2 receptor antagonists - Basiliximab
 Maintenance:
–Corticosteroids
–Calcineurin inhibitors (CNIs)
–mTOR inhibitors
–Antimetabolites

92. Immunosuppressive Medications
• Treatment of rejection (Rescue) :
– Corticosteroids
– Anti-thymocyte globulin
– Intravenous Immunoglobulin (IVIG)
– Rituximab
– Plasmapheresis

93. T-10
Risks and possible side
effects
Lowered resistance to illness
• Immunosuppressive
medications lower your
resistance to infection
• To stay healthy, you must
protect yourself from coming
in contact with infections
• Take the correct dosage of
medication and see your
doctor regularly

96. In conclusion, renal transplantation should be
recommended as the preferred mode of RRT for
most patients with ESRD in whom surgery and
subsequent immuno-suppression is safe and
feasible.

97. Chronic Allograft Dysfunction:
Why Do Grafts Fail?
• Chronic low-grade immune injury
• Long-standing hypertension
• Recurrent disease (diabetic nephropathy
or glomerulonephritis)
• Repeated episodes of acute rejection
• Donor disease
• Calcineurin inhibitor nephrotoxicity

98. USRDS 1999.
Expected
Years
Remaining*
0
35
10
20
30
Prostate
Ca
21.6
13
8
4.5
2.5
* Based on adult, age 59 years
Survival in ESRD

99. Kidney Disease Cycle
Dialysis
At-risk  Chronic  Kidney Failure 
Kidney Disease (Stage 5)
(Stage 1 – 4)
Transplant

100. Continuum of kidney disease
care
• Prevent kidney disease (awareness of
risk)
• Identify kidney disease (awareness of
diagnosis)
• Manage kidney disease (knowledge to
achieve management goals)
• Renal replacement or conservative care
for renal failure

101. Any Questions?