11. Chronic Kidney Disease
» = a GFR of < 60 for 3 months or more.
» Most common causes:
Diabetes Mellitus
Hypertension
» Management:
– Blood pressure control!
– Diabetic control!
– Smoking cessation
– Dietary protein restriction
– Phosphorus lowering drugs/ Calcium replacement
Most patients have some degree of hyperparathyroidism
– Erythropoietin replacement
Start when Hgb < 10 g/dL
– Bicarbonate therapy for acidosis
– Dialysis?
12. Assessing the patient with acute
renal failure – Urinalysis
Hematuria
» Non-glomerular:
– Urinary sediment: intact red blood cells
– Causes:
Infection
Cancer
Obstructive Uropathy
» Rhabdomyolysis
– myoglobinuria; Hematuria with no RBCs
» Glomerular:
– Urine sediment: dysmorphic red blood cells, red cell casts
– Causes:
Glomerulonephritis
Vasculitis
Atheroembolic disease
TTP/HUS (thombotic microangiopathy)
14. Indications for Hemodialysis
Refractory fluid overload
Hyperkalemia (plasma potassium concentration >6.5
meq/L) or rapidly rising potassium levels
Metabolic acidosis (pH less than 7.1)
Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36
mmol/L])
Signs of uremia, such as pericarditis, neuropathy, or an
otherwise unexplained decline in mental status
Severe dysnatremias (sodium concentration greater than
155 meq/L or less than 120 meq/L)
Hyperthermia
Overdose with a dialyzable drug/toxin
16. PRE-RENAL ACUTE RENAL
FAILURE
MOST COMMON CAUSE OF ARF
RESULTS FROM DECREASED RENAL
PERFUSION
TREATMENT OF THE CAUSE RESTORES
RENAL FUNCTION TUBULAR FUNCTION
INTACT *
PROLONGED PRE-RENAL FAILURE MAY
LEAD TO ATN
19. POST-RENAL ACUTE RENAL
FAILURE
ACCOUNTS FOR 2-15% OF ALL ARF
OBSTRUCTION TO URINE FLOW
» INCREASED TUBULAR PRESSURE
» VASOCONSTRICTION
– DECREASED RENAL BLOOD FLOW
MUST BE BILATERAL TO RESULT IN
ARF
» UNLESS : SINGLE KIDNEY OR PRIOR
CHRONIC RENAL FAILURE
20. POST RENAL ACUTE RENAL
FAILURE
SUSPECT OBSTRUCTION IN ANURIA
ETIOLOGY MAY BE AGE
DEPENDENT
» YOUNG = CONGENITAL ABNORMALITY
» OLDER MALE = PROSTATIC
ENLARGEMENT
ARF MOST OFTEN ASSOCIATED
WITH LESIONS IN:
» BLADDER, PROSTATE OR URETHRA
29. Hyperkalemia
Never occurs in the absence of renal
excretory problem
Pseudohyperkalemia
» Leukocytosis
» Thrombocytosis
» Prolonged Application of Tourniquet
30. Hyperkalemia
Significance of urine output
Role of increased catabolism or tissue
breakdown
Factors affecting shift of Potassium out
of cells
Etiololgy of the renal failure
31. Treatment of Hyperkalemia
Urgency
Role of the EKG in making the decision
Clinical setting in which it occurs
» Acute renal failure
» Chronic renal failure
32.
33. Table 5-3. Treatment of hyperkalemia
Medication Mechanism of action Dosage Peak effect
Calcium Antagonism of 10-30 ml of 10% solution IV -5 min
gluconate membrane over 2 min
Insulin and Increased K+entry Insulin, 10 U IV bolus 30-60 min
Glucose into the cells followed by 0.5 mU/kg of
body weight per minute in
50 ml of 20% glucose
Sodium Increased K+entry 44-50 mEq IV over 5 min; 30-60 min
bicarbonate into the cells can be repeated within 30
min
Albuterol Increased K+entry
into the cells 20 mg in the nebulized form 30-60 min
Kayexalate Removal of the 20 g of resin with 100 ml of 2-4 hr
excess K+ 20% sorbitol; can be
repeated every 4-6 hr
Hemodialysis Removal of the Dialysis bath K+ concentration 30-60 min
excess K+ variable
34. INDICATIONS FOR DIALYSIS IN
ACUTE RENAL FAILURE
UREMIC SYMPTOMS
~ nausea
~ neurologic
SEVERE FLUID OVERLOAD
REFRACTORY ELECTROLYTE
DISORDERS
~hyperkalemia
SEVERE REFRACTORY ACIDOSIS
35. INDICATIONS FOR DIALYSIS IN
ACUTE RENAL FAILURE
PERICARDITIS
NEUROPATHY
MENTAL STATUS CHANGE
SEIZURES
BLEEDING
TOXINS----ETHYLENE GLYCOL,
METHANOL
PROPHYLACTIC
~recent studies fail to document benefit
36. Chronic Renal Failure
Medical treatment
IV glucose and insulin
Na bicarb, Ca, Vit D, phosphate binders
Fluid restriction, diuretics
Iron supplements, blood, erythropoietin
High carbs, low protein
Dialysis - After all other methods have
failed
03/05/2011 36
37. Dialysis
½ of patients with CRF eventually
require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
» Hemodialysis
» Peritoneal dialysis
03/05/2011 37
38. Dialysis
Peritoneal dialysis
» Semipermeable
membrane
» Catheter inserted through
abdominal wall into
peritoneal cavity
» Cost less
» Fewer restrictions
» Can be done at home
» Risk of peritonitis
» 3 phases – inflow, dwell
and outflow
Automated peritoneal
dialysis
» Done at home at night
» Maybe 6-7 times /week
CAPD
» Continous ambulatory
peritoneal dialysis
» Done as outpatient
» Usually 4 X/d
03/05/2011 38
42. Chronic Renal Failure
Post op care
» ICU
» I/O
» B/P
» Weight changes
» Electrolytes
» May have fluid volume deficit
» High risk for infection
03/05/2011 42
43. Transplant Meds
Patients have decreased resistance to
infection
Corticosteroids – anti-inflammarory
» Deltosone
» Medrol
» Solu-Medrol
Cytotoxic – inhibit T and B lymphocytes
» Imuran
» Cytoxan
» Cellcept
T-cell depressors - Cyclosporin
03/05/2011 43
45. Hydronephrosis,
Hydroureter, and Urethral
Stricture
Outflow obstruction
» Urethral stricture
– Causes bladder distention and progresses to the ureters
and the kidneys
» Hydronephrosis –
– Kidney enlarges as urine collects in the pelvis and kidney
tissue due to obstruction in the outflow tract
– Over a few hours this enlargement can damage the
blood vessels and the tubules
» Hydroureter
– Effects are similar, but occurs lower in the ureter
03/05/2011 45
46. Causes of Obstruction
Tumor
Stones
Congenital structural defects
Fibrosis
Treatment with radiation in pelvis
03/05/2011 46
47. Renal Calculi
Called nephrolithiasis or urolithiasis
Most commonly develop in the renal pelvis
but can be anywhere in the urinary tract
Vary in size –from very large to tiny
Can be 1 stone or many stones
May stay in kidney or travel into the ureter
Can damage the urinary tract
May cause hydronephrosis
More common in white males 30-50 years of
age
03/05/2011 47
48. Renal Calculi
Predisposing factors
» Dehydration
» Prolonged immobilization
» Infection
» Obstruction
» Anything which causes the urine to be alkaline
» Metabolic factors
– Excessive intake of calcium, calcium based antacids or
Vit D
– Hyperthyroidism
– Elevated uric acid
03/05/2011 48
49. Family or personal history. If someone in your
family has kidney stones, you're more likely to
develop stones, too. And if you've already had one or
more kidney stones, you're at increased risk of
developing another.
Dehydration. Not drinking enough water each day
can increase your risk of kidney stones. People who
live in warm climates and those who sweat a lot may
be at higher risk than others.
50. Certain diets. Eating a diet that's high in protein,
sodium (salt) and sugar may increase your risk of
some types of kidney stones. This is especially true
with a high-sodium diet. Too much salt in your diet
increases the amount of calcium your kidneys must
filter and significantly increases your risk of kidney
stones.
Being obese. High body mass index (BMI), large
waist size and weight gain have been linked to an
increased risk of kidney stones.
51. Digestive diseases and surgery. Gastric bypass
surgery, inflammatory bowel disease or chronic
diarrhea can cause changes in the digestive process
that affect your absorption of calcium and water,
increasing the levels of stone-forming substances in
your urine.
Other medical conditions. Diseases and conditions
that may increase your risk of kidney stones include
renal tubular acidosis, cystinuria,
hyperparathyroidism, certain medications and some
urinary tract infections.
52. Symptoms
Severe pain in the side and back, below the ribs
Pain that radiates to the lower abdomen and groin
Pain on urination
Pink, red or brown urine
Cloudy or foul-smelling urine
Nausea and vomiting
Persistent need to urinate
Urinating more often than usual
Fever and chills if an infection is present
Urinating small amounts
54. Types of stones
Calcium stones. Most kidney stones are calcium
stones, usually in the form of calcium oxalate.
Oxalate is a naturally occurring substance found in
food and is also made daily by your liver. Some fruits
and vegetables, as well as nuts and chocolate, have
high oxalate content.
Calcium stones may also occur in the form of calcium
phosphate. This type of stone is more common in
metabolic conditions, such as renal tubular
acidosis. It may also be associated with certain
migraine headaches or with taking certain seizure
medications, such as topiramate (Topamax).
55. Struvite stones. Struvite stones form in response to
an infection, such as a urinary tract infection. These
stones can grow quickly and become quite large,
sometimes with few symptoms or little warning.
Uric acid stones. Uric acid stones can form in people who don't
drink enough fluids or who lose too much fluid, those who eat a
high-protein diet, and those who have gout. Certain genetic
factors also may increase your risk of uric acid stones.
Cystine stones. These stones form in people with a
hereditary disorder that causes the kidneys to excrete
too much of certain amino acids (cystinuria).
56. Treatment
Small stones
Drinking water. Drinking as much as 2
to 3 quarts (1.9 to 2.8 liters) a day may
help flush out your urinary system.
Pain relievers.
Medical therapy. alpha blocker, relaxes
the muscles in your ureter, helping you
pass the kidney stone more quickly and
with less pain.
57. Although tamsulosin was the most
commonly studied medication,
they observed no significant
differences with other alpha blocker
medications, such
asalfuzosin, doxazosin, naftopidil, sil
odosin, orterazosin, prazosin
61. Cautions
Use with caution in coronary artery disease, liver
disease, general anesthesia
Orthostatic hypotension may occur
Priapism rarely reported
Discontinue if angina symptoms occur or worsen
Patients with sulfa allergy have rarely developed
allergic reaction; avoid use if previous sulfa allergy
reactions have been life-threatening
Not for use as antihypertensive drug
May exacerbate heart failure
62. Infertility
Males: Abnormal ejaculation including ejaculation
failure, ejaculation disorder, retrograde ejaculation,
and ejaculation decrease has been associated with
therapy; studies in rats revealed significantly reduced
fertility in males considered to be due to impairment
of ejaculation, which was reversible
Females: Drug is not indicated for use in women;
female fertility in rats was significantly reduced,
considered to be due to impairment of fertilization
63. For big size stones
Lithotripsy
Surgical removal
Life style changes
Supportive care
Calcium stones. thiazide diuretic or a phosphate-
containing preparation.
Uric acid stones. Your doctor may prescribe
allopurinol (Zyloprim, Aloprim) to reduce uric acid
levels
65. Diagnosis
Digital rectal exam
Urine test. Analyzing a sample of your urine can help rule out
an infection or other conditions that can cause similar
symptoms.
Blood test. The results can indicate kidney problems.
Prostate-specific antigen (PSA) blood test. PSA is a
substance produced in your prostate. PSA levels increase when
you have an enlarged prostate. However, elevated PSA levels
can also be due to recent procedures, infection, surgery or
prostate cancer.
70. Symptoms of Prostatitis
Difficulty, frequency (nocturia), Pain or burning
sensation when urinating (dysuria)
Cloudy urine
Blood in the urine
Pain in the abdomen, groin or lower back
Pain in the area between the scrotum and rectum
(perineum)
Pain or discomfort of the penis or testicles
Painful ejaculation
Flu-like signs and symptoms (with bacterial
prostatitis)
71. Treatment of Prostatitis
Antibiotics.
Alpha blockers.
Anti-inflammatory gents. Nonsteroidal
anti-inflammatory drugs (NSAIDs) might
make you more comfortable.
74. Serious Side effects and
patients counselling
Allergic reaction - (affects less than 1 in 1,000
people). The signs may include finding it
difficult to breathe, having an itchy rash,
having a swollen face, throat, or tongue
Long-lasting and painful erection (usually not
during sexual activity) - affects less than 1 in
10,000 people
75. Serious Side effects and
patients counselling
A severe skin reaction with symptoms that
could include skin blistering and exfoliation
(known as Stevens-Johnson syndrome,
erythema multiforme, or exfoliative
dermatitis). It is very rare, affecting less than
1 in 10,000 people (or of unknown frequency)
Drowsiness, Swollen hands or feet,
Shortness of breath, Heart rhythm disorders
Orthostatic hypotension
76. Prazosin
Benign Prostate Hypertrophy (Off-label)
Initial: 0.5 mg PO q12hr
Maintenance: 2 mg PO q12hr
77. 5-Alpha-Reductase Inhibitors
Finasteride is indicated for the treatment
of symptomatic BPH in men with an
enlarged prostate.
It is beneficial in men with prostates
larger than 40 g and can improve
symptoms and reduce prostatic size by
20-30%.
Dihydrotestosterone blockers
78. 5-Alpha-Reductase Inhibitors
Finasteride is indicated for the treatment
of symptomatic BPH in men with an
enlarged prostate.
Finasteride improves urinary flow rate
by 2 mL/s.
79. 5-Alpha-Reductase Inhibitors
Benign Prostatic Hyperplasia
Proscar: 5 mg PO qDay; assess response
after 12 weeks to 6 months
Androgenic Alopecia (Men Only)
Propecia: 1 mg PO qDay for at least 3
months
Female Hirsutism (Off-label)
5 mg PO qDay
80. Side effect
Hypo Gonadeism
Erectile dysfunction
Dosage Modifications
Renal impairment: Dose adjustment not
necessary
Hepatic impairment: Caution in liver
dysfunction; monitor
85. Calcification is mainly
Chemical analysis of prostatic
calcification revealed mixture of calcium
phosphate (75%) and calcium
carbonate (25%) while bladder calculus
was mixed phosphate
Bacterial Ecoli has main role as well
86. Cancerous Prostate
Upon removal of prostate sometimes
the cells they are cancerous which is
confirmed from the biopsy
9 of 10 cases of the prostate residue
which contain cancer cells is intact or
not completely removed during the
TURP
87. Cancerous Prostate
In this case aggressive treatment
measure are taken in consideration to
stop the proliferation of the cells. Often
two approaches are used
1- Radiation therapy
2- Chemotherapy
3- Supportive therapy
88. Radiations
Gamma radiations are used using
Iridium-192 or Gamma radiations, X-
ray and proton beam therapy
The 2 main types of radiation therapy
used for prostate cancer are:
External beam radiation
Brachytherapy (internal radiation)
90. Side effects of Radiations
Bowel problems: Radiation can irritate
the rectum and cause a condition
called radiation proctitis. This can lead
to diarrhea, sometimes with blood in the
stool, and rectal leakage.
91. Side effects of Radiations
Urinary problems: Radiation can
irritate the bladder and lead to a
condition called radiation cystitis. You
might need to urinate more often, have
a burning sensation while you urinate,
and/or find blood in your urine
92. Side effects of direct
Radiations
Tiredness
Fatigue
Impotence/ lack of sexual desire
Lymphadenopathy
93. Brachytherapy (internal radiation)
Localized therapy via seeding or implant
Brachytherapy (also called seed
implantation or interstitial radiation
therapy) uses small radioactive pellets,
or “seeds,” each about the size of a
grain of rice. These pellets are placed
directly into your prostate.
95. Recommendations
Radiotherapy seeds are a treatment for early
stage prostate cancer. The cancer must be
contained completely within the prostate.
If your prostate gland is large you might need
hormone therapy for 3 months before the
radiotherapy treatment. The hormone therapy
shrinks the prostate and makes it easier to
put the seeds into the right place
96. Types of BT and isotopes used
Permanent BT: such as iodine-125 or
palladium-103
Temporary BT: Radioactive iridium-192
or cesium-137 is then placed in the
catheters, usually for 5 to 15 minutes
97. Others
Cryotherapy (also
called cryosurgery or cryoablation) is the
use of very cold temperatures to freeze and
kill prostate cancer cells.
Two gases are commonly used, nitrous
oxide and carbon dioxide
98. Cryoptherapy Side effect
Impotence
Poor bowl and urine control
Urine fistula which led to the leaking of
urine in bladder, can be repaired
surgically
99. Hormonal therapy
Medications that stop your body from
producing testosterone. Certain
medications — known as luteinizing
hormone-releasing hormone (LHRH) or
gonadotropin-releasing hormone (GnRH)
agonists and antagonists — prevent your
body's cells from receiving messages to
make testosterone. As a result, your testicles
stop producing testosterone.
100. Hormonal therapy
Medications that block testosterone
from reaching cancer cells. These
medications, known as anti-androgens,
usually are given in conjunction
with LHRH agonists.
Surgery to remove the testicles
(orchiectomy)
101. Degarelix
Degarelix is a GnRH receptor
antagonist indicated for patients with
advanced prostate cancer.
A single dose of degarelix 240 mg
causes a decrease in the plasma
concentrations of LH and FSH and
subsequently of testosterone.
102. Degarelix
The initial dose is 240 mg subcutaneous
injection (given as 2 injections of 120
mg at a concentration of 40 mg/mL).
The maintenance dose is 80 mg
subcutaneous injection (at a
concentration of 20 mg/mL) every 28
days. The first maintenance dose
should be given 28 days after the
starting dose.
103. Possible side effects
Reduced or absent sexual desire
Erectile dysfunction (impotence)
Shrinkage of testicles and penis
Hot flashes, which may get better or go away with time
Breast tenderness and growth of breast tissue
Osteoporosis (bone thinning), which can lead to broken bones
Anemia (low red blood cell counts)
Decreased mental sharpness
Loss of muscle mass
Weight gain
Fatigue
Increased cholesterol levels
Depression
104. Chemotherapy
Chemo is sometimes used if prostate
cancer has spread outside the prostate
gland and hormone therapy isn’t
working. Recent research has also
shown that chemo might be helpful if
given along with hormone therapy.
105. Chemotherapy
For prostate cancer, chemo drugs are
typically used one at a time. Some of
the chemo drugs used to treat prostate
cancer include:
Docetaxel (Taxotere)
Cabazitaxel (Jevtana)
Mitoxantrone (Novantrone)
Estramustine (Emcyt)
106. Docetaxel (Taxotere)
Indicated for hormone-refractory metastatic prostate
cancer in combination with prednisone
75 mg/m² IV over 1 hr q3Weeks with daily prednisone
5 mg PO q12hr
Dose modifications
Febrile neutropenia, ANC <500/mm³ for >1 week, or
severe/cumulative cutaneous reactions, moderate
neurosensory S/S
Reduce to 60 mg/m²
If AEs persist: Discontinue
107. Side effects
Hair loss
Mouth sores
Loss of appetite
Nausea and vomiting
Diarrhea
Increased chance of infections (from having too few
white blood cells)
Easy bruising or bleeding (from having too few blood
platelets)
Fatigue (from having too few red blood cells)