The document provides information on acute kidney injury (AKI) and chronic kidney disease (CKD) in Nepal. It discusses the epidemiology, causes, clinical features, diagnosis and management of AKI and CKD. It also presents data on the prevalence and outcomes of patients with AKI and CKD from two hospitals in Nepal. The economic burden of dialysis and the increasing availability of treatment options over time are also reviewed.
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Final presentation on Acute kidney injury AKI and Chronic kidney disease CKD in TUTH emergency department
1. Approach to AKI and CKD
Presentation by:
Junior intern Group B1
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2. Epidemiology
AKI
• Approximately 7% of all hospitalized patients and 20% of acutely ill patients develop AKI
• In uncomplicated AKI; mortality is low even when RRT is required
• In AKI associated with sepsis and multi-organ failure, mortality is 50-70%
CKD
• Prevalence of CKD stages 3-5 in many countries is around 5-7%
• More prevalent in people aged 65 years and older
• Substantially higher in the patients with HTN, DM and vascular diseases
Source: Davidson’s Principles and Practice of medicine 2
3. CKD in context of Nepal
• 3rd most prevalent disease among chronic disease: COPD (11.7%) > DM (8.5%)> CKD
(6%) among studied population
• Prevalence of CKD above 60 years and above: 11.5%
• Males (6.5%) > Females (5.7%)
Source: Population based prevalence of selected NCDs in Nepal 2019 (NHRC)
Social security/Bipanna Nagarik Aushadi Upachar Programme
• MoH began offering free lifetime hemodialysis in 2016
• In FY 2075/76; 5297 kidney patients (9.93% among those who were included in the
social security scheme for various diseases) were benefitted from the impoverished
citizens service scheme
Source: DoHS Annual Health Report 2075/76
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4. • 1st Hemodialysis in Nepal: Bir Hospital (1987)
• In 2016:
42 HD Centres existed (223% increase since 2010)
Serving 1975 ESRD patients (303% increase since 2010)
36 nephrologists (200% increase since 2010) and 12 were trained in transplantation
Economic Aspect
• Annual cost of approx. US $2300 per dialysis patient
• Free dialysis could potentially cost the government US $6.7 million per year, suggesting
that 2.1% of annual health budget would be allocated to 0.01% of the population
• 50% of Hemodialysis center In Nepal cover only 14.5% of Nepal population as most of
them are centralized in and around valley
Source: TUTH 38th souvenir/Deputy Nursing controller: Gyanu Gurung
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5. Timeline of events in TUTH….
1992: Nephrology service
1996/97 (2053 B.S): 1st HD service with 2 HD machines
2008: initiation of living donor kidney transplantation services
2009: Department of nephrology was convened
2076:
11,104 HD; 289 jugular insertion; 320 femoral insertion; 52 plasmapheresis; 69
kidney transplant and 8 permanent catheter insertion was performed
Separate team for renal replacement
Services
Currently; 8 functioning dialysis machines in dialysis unit and 1 in ICU
Till March 2020, over 650 living kidney transplant has been done including that of PM of
Nepal
Source: TUTH 38th souvenir/Deputy Nursing controller: Gyanu Gurung
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6. 6
mangsir 25-poush25 poush 25-magh25
CKD 2.93% 2.41%
AKI 1.17% 0.96%
75
68
30 27
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
percentage
months
Percentage of CKD/AKI patients among total emergency
admission
CKD AKI
14. AKI: Definition
AKI is defined as –
Increase in Serum Cr by 0.3 mg/dl within 48 hours
OR
Increase in Serum Cr to 1.5 times of baseline, which is known or
presumed to have occurred within the prior 7 days
OR
Urine volume <0.5 ml/kg/h for 6 hours.
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18. Clinical Features
• Asymptomatic
• elevations in the plasma creatinine
• abnormalities on urinalysis
• Signs and symptoms resulting from loss of kidney function:
• decreased or no urine output, flank pain, edema, hypertension, or discolored
urine
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19. Clinical Features
• Symptoms and/or signs of renal failure:
• weakness and
• easy fatiguability (from anemia),
• anorexia,
• vomiting, mental status changes or
• Seizures
• edema
• Systemic symptoms and findings:
• fever
• arthralgias,
• pulmonary lesions
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20. Diagnosis
• Detailed history
• Blood urea nitrogen and serum creatinine
• CBC, peripheral smear, and serology
• Urinalysis
• Urine electrolytes
• Ultrasonography, CT
• Serology: ANA,ANCA, Anti DNA, HBV, HCV, Anti GBM, cryoglobulin, CK, urinary
Myoglobulin
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22. Treatment
• Optimization of hemodynamic and volume status
• Avoidance of further renal insults
• Optimization of nutrition
• If necessary, institution of renal replacement therapy
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23. Indication for RRT
1) Symptoms of uremia ( encephalopathy)
2) Uremic pericarditis
3) Refractory volume over load
4) Refractory hyperkalemia
5) Refractory metabolic acidosis
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24. CKD: Definition(criteria)
• Kidney damage for >= 3 months, as defined by structural or functional
abnormalities of the kidney, with or without decreased GFR, manifest
by either:
• Pathological abnormalities or
• Markers of kidney damage, including abnormalities in the composition of
blood and urine, or abnormalities in the imaging tests
• GFR <60 ml/min/1.73m2 for >=3 months, with or without kidney
damage
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25. Staging
Stage Description GFR (ml/min/1.73m2)
I Kidney damage with normal or increased
GFR
>=90
II Kidney damage with mild decrease in GFR 60-89
III Kidney damage with moderate decrease in
GFR
30-59
IV Kidney damage with severe decrease in GFR 15-29
V Kidney failure <15 (or dialysis)
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27. Clinical features
• Most asymptomatic till GFR falls below 30 ml/min
• Nocturia- early symptom (but non-specific)
• GFR < 20 ml/min- affect almost all systems
• Tiredness, breathlessness- anemia, fluid overload
• Pruritus, anorexia, weight loss, nausea, vomiting and hiccups
• Advanced renal failure- kussmaul breathing(metabolic acidosis),
muscular twitching, drowsiness and coma
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29. Management
• Aims of management in CKD are
• To monitor renal function
• To prevent or slow further renal damage
• To limit complications of renal failure
• To treat risk factors for cardiovascular diseases
• To prepare for RRT, if appropriate
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30. Management
Conservative
Slowing the Progession
Limiting the adverse
effects
Preparing for Renal
Replacement Therapy
Definitive
RENAL REPLACEMENT
THERAPY (RRT)
• Dialysis:
• Hemodialysis
• Peritoneal Dialysis
• Renal Transplantation
• Live
• Cadaveric
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31. Limiting the adverse effects of CKD
• Anemia
• Fluid and electrolyte balance
• Acidosis
• Cardiovascular disease and lipids
• Renal Osteodystrophy
• Infection
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32. Anaemia
Defined as Hemoglobin < 13.5 g/dl in males
< 12 g/dl in females
Normocytic normochromic anaemia – as early as in Stage III CKD or
universally by Stage IV CKD
Primary cause : insufficient production of Erythropoetin
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33. Other factors causing anemia
Iron deficiency/Folate and Vit B12 deficiency
Chronic inflammation (ACD)
Hyperparathyroidism / bone marrow fibrosis
Decreased erythropoeisis
Decreased RBC survival
Increased blood loss
Occult gastrointestinal bleeding
Platelet dysfunction
Blood loss during hemodialysis
Blood sampling
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34. Anemia - goals
Target Hb : not more than 11.5g/dl
Target Iron status : TSAT : lower limit > = 20
Check Hb monthly while on ESAs (Erythropoeisis stimulating agents)
Iron studies monthly when started on ESA
On stable ESA Therapy : Iron studies can be done 3 monthly
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35. Anemia – treatment options
Oral iron
IV Iron Dextran
IV Iron Sucrose
IV Sodium Ferric Gluconate Complex
Folic acid and Vitamin B 12 supplements
Erythropoetin Stimulating Agents : Epoetin alfa*
Epoetin beta
Darbepoetin alfa
Epoetin alfa / beta : 50 -100 IU / Kg SC per week
Darbepoetin alfa : 40 mcg SC every 2 weeks
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36. Refractory anaemia
• Blood loss
• Secondary hyperparathyroidism
• Substrate deficiency
• Active inflammation or malignancy
• Aluminium overload
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37. Bone mineral disorder
(CKD-MBD)
• Renal bone disease – significantly increase mortality in CKD patients
• Hyperphosphatemia – one of the most important risk factors
associated with cardiovascular disease in CKD patients
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39. Bone Disorders Causative factors
• Osteitis Fibrosa Cystica
• Osteomalacia
• Adynamic bone disease
• Mixed osteodystrophy
• Secondary
Hyperparathyroidism
• Vitamin D deficiency
• Acidosis
• Aluminium accumulation
• Osteoporosis in elderly
• Osteopenia caused by
steroids
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40. Treatment
Reduce dietary phosphate intake
Phosphate binders : calcium carbonate
calcium acetate
aluminium hydroxide
magnesium carbonate ( rarely used )
sevelamer hydrochloride
lanthanum carbonate
The use of calcium salts is limited by development of
hypercalcemia
Calcium acetate poses a less problem as less calcium is absorbed 40
41. Calcimimetics – Cinacalcet
Agent that increase calcium sensitivity of the calcium sensing
receptor expressed by parathyroid gland
Down regulating the parathyroid hormone secretion
Reduce hyperplasia of parathyroid gland
Calcitriol 0.25 mcg OD
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42. Immunization
• Hepatitis B vaccination : 4 doses (0,1,2,6 months )
higher dose ( 40 mcg / ml )
• Pneumococcal vaccination :
single dose one time
(revaccination 5 yrs after initial vaccination)
• Influenza vaccination : recommended annually
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43. Preparation for Renal Replacement Therapy
Patients of CKD Stage IV approaching Stage V should be referred for
Vascular access if hemodialysis is preferred
Peritoneal dialysis catheter placement if peritoneal dialysis is preferred
AVF is most preferred access for HD patients
Ideally created 6 months prior to start of HD
Non dominant upper extremity
And that arm is to be preserved – no iv lines
AVG : 3-6 weeks prior to start of HD
PD Catheter : 2 weeks prior to start of HD
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