APPROACH to a patient of CKD and its.pptx

1. CHAIRPERSON – Dr. H.S.SANDHU
Speaker – Dr. Amit Madaan

2.  Remove toxic waste products
 Remove excess water and salts
 Play a part in controlling blood pressure
 Produce erythropoetin (epo) which stimulates
red cell production
 Helps to keep calcium and phosphate in
balance for healthy bones
 Maintains proper pH for the blood

3.  Azotemia: Elevated blood urea nitrogen
◦ (BUN>28mg/dL) & Creatinine
(Cr>1.5mg/dL)
 Uremia: azotemia with symptoms or signs of
renal failure
 End Stage Renal Disease (ESRD): uremia
requiring transplantation or dialysis
 Chronic Renal Failure (CRF): irreversible
kidney dysfunction with azotemia >3 mos.
 Creatinine Clearance (CCr): rate of filtration
of creatinine by the kidney (marker for GFR)
 Glomerular Filtration Rate (GFR): the total
rate of filtration of blood by the kidney.

4.  Analyze the incidence and epidemiology of
chronic kidney disease
 Explain renal Function and physiology
 Discuss the clinical management of CKD
including current guidelines for
monitoring and treatment

5.  CHRONIC KIDNEY DISEASE(CKD) encompasses
a spectrum of different pathophysiologic
processes associated with abnormal kidney
function , and a progressive decline in
glomerular filtration rate…..
 Estimation of creatinine clearance ( mL/
min)
= ( 140 – age × body weight , kg )
72 × P. Cr(mg/dl)
COCKCROFT- GAULT EQUATION

6.  Stages of CKD are:
Stage Description
GFR
(mL/min/1.73m
2
)
At increased risk
90
(with CKD risk
factors)
1.
Kidney damage
with normal
or GFR
90
2.
Kidney damage
with mild GFR
60-89
3. Moderate GFR 30-59
4. Severe GFR 15-29
5. Kidney Failure
<15
(or dialysis)

7. USRDS, 2004

9.  25% of cardiac output goes to the kidneys
 The glomerulus filters up to 130mL/minute =
180L/Day
◦ This glomerular filtration rate (GFR) is a key indicator
of kidney function
 Tubules conserve important metabolites and
reduce the filtration volume to ~ 1.5 L urine
/day
 Normal glomeruli.. The normal glomeruli do
not allow passage of much proteins ;until
extensive kidney damage,when more protein
and larger proteins will pass through.

10.  Susceptibility Factors
◦ Age
◦ Race
◦ Socioeconomic Factors
◦ Genetic Factors / Family History
 Initiation Factors
◦ Diabetes
◦ Hypertension
◦ Autoimmune Diseases
◦ Urinary infections and stones

11.  CKD Patients are in the highest risk group
for cardiovascular disease
 Cardiovascular events are the major cause
of morbidity and mortality in CKD patients
 Early intervention and aggressive treatment
is essential
◦ Manage traditional CVD risk factors
 hypertension, cholesterol, smoking, exercise, weight, etc.
◦ Manage specific CKD risk factors
 prothrombotic factors, chronic inflammation, , oxidative
stress, etc.

12.  CARDIOVASCULAR and PULMONARY
DISTURBANCES ----
 ARTERIAL HYPERTENSION
 PULMONARY EDEMA
 PERICARDITIS
 CARDIOMYOPATHY
 HYPOTENSION and ARRHYTHMIAS (DIALYSIS
RELATED)
 ACCELERATED ATHEROSCLEROSIS

13. 2.11
3.65
11.29
21.8
36.6
0
5
10
15
20
25
30
35
40
≥ 60 45-59 30-44 15-29 < 15
Go, et al., 2004
Age-Standardized
Rate
of
Cardiovascular
Events
(per
100
person-
yr)
Estimated GFR (mL/min/1.73 m2)

14.  MANAGEMENT of CVD in CKD :-
 In CKD patients with Diabetes or proteinuria >
1 g/24 hrs,BP should be lowered to
125/75…….
 Salt restriction and Diuretics should be the
First line of therapy……
 ACE Inhibitors and ARBs slow the rate of
decline of kidney function ,even in Dialysis
patients,but caution should be there
regarding development of HYPERKALEMIA…….
 
 The thiazide diuretic METOLAZONE ,in
addition to improving GFR,can also help in
reduction of BP.
 CAUTION :-- Potassium sparing diuretics
should be avoided in these patients.

15. • Most practices screen fewer than 20% of their
Medicare patients with diabetes
• Patients are referred late to a nephrologist,
especially African-American men
• Less than 1/3 of people with identified CKD
get an ACE Inhibitor

16. 
 PERICARDIAL DISEASE -
---
 Diagnosed by features,like Pericardial pain
with respiratory accentuation;Friction
rub…….
 Its a feature of advanced uraemia….
 IMPORTANT ---- UREMIC PERICARDITIS is
an ABSOLUTE INDICATION for DIALYSIS…..

17.  FLUID,ELECTROLYTE and ACID-BASE
DISTURBANCES ----
 VOLUME EXPANSION
 HYPONATREMIA
 HYPERKALEMIA
 METABOLIC ACIDOSIS…..
 MANAGEMENT of FLUID OVERLOAD STATE-
 IN stages 3-5 CKD,Thiazide diuretics have a
limited utility in the treatment of volume
overload state …..
 Administration of LOOP DIURETICS,like
FUROSEMIDE and TORSEMIDE becomes a
must..

18.  TORSEMIDE has been found to be,2 to
2.5 times POTENT than FUROSEMIDE….
 METOLAZONE ---- In common with loop
diuretics,it is able to evoke a clinically
useful response even in stage 4,5
CKD…..;although its a THIAZIDE
DIURETIC….. DAILY DOSE(5-20 mg)…
 ONGOING DIURETIC RESISTANCE with
INTRACTABLE EDEMA and HYPERTENSION
in advanced CKD SERVES AS AN
INDICATION FOR DIALYSIS………

19.  Weakness
 Lethargy
 Muscle cramps
 Paresthesias
 Hypoactive DTRs
 Dysrhythmias

20.  K > 5.5 -6
 Tall, peaked T’s
 Wide QRS
 Prolong PR
 Diminished P
 Prolonged QT
 QRS-T merge –
sine wave

23.  Calcium gluconate (carbonate)(10 ml of a 10%
solution ,given over 10 min)
 Sodium Bicarbonate
 Insulin/glucose(Neutralized insulin )
 Lasix (20-400 mg)
 B2 agonists,in a nebulized form..
 Hemodialysis

24. ◦ HEMATOLOGIC ABNORMALITIES IN
CKD ::--
 These include ANEMIA and ABNORMAL
HEMOSTASIS …
ANEMIA
 A Normocytic,normochromic Anemia is
observed as early as stage 3 CKD and is
almost universal by stage 4…..
 Clinical manifestations include,Angina.. ;Heart
Failure,Cognition impairment;Impaired host
defence against infection…

25. CAUSES OF ANEMIA IN CKD ::--
Relative deficiency of EPO (Erythropoietin)
Diminished RBC survival …..
Bleeding Diathesis….
Hyperparathyroidism/Bone marrow fibrosis…..
Chronic inflammation….
Folate or VIT. B12 DEF….
IRON deficiency….

26.  TREATMENT ::--
 RECOMBINANT HUMAN EPO….. 4000 U s.c.
Weekly…….
 Recently,modified EPO
products,likeDARBOPOETIN-ALPHA has been
tried…..
 Advantage is,that routine use of these
products can obviate the need of repeated
BTs….
 Thus,transfusion assosciated infections and
the complications,like Iron overload has
reduced …

27.  IMPORTANT---- Frequent BTs can lead
to development of ALLOANTIBODIES,that
could sensitize the patient to donor
kidney antigens and make renal
transplantation more difficult…..
 Other treatment options are oral or iv
iron therapy…
 Iron supplementation is usually necessary
to ensure an adequate response to EPO
in patients,because the demand for iron
by the marrow often exceeds the
amount,that is immediately available for
erythropoiesis……

28.  DISORDERS OF CALCIUM AND PHOSPHATE
METABOLISM ::--
 The principal complications are seen in
skeleton and the vascular bed……
TYPES
HIGH BONE
TURNOVER
INCREASED PTH
LEVELS
OSTEITIS
FIBROSA
CYSTICA
LOW BONE
TURNOVER
LOW OR
NORMAL PTH
LEVELS
ADYNAMIC
BONE DISEASE
and
OSTEOMALACIA

29.  PATHOPHYSIOLOGY of HIGH
TURNOVER BONE DISEASE ::--
 1.Declining GFR leads to reduced excretion of
phosphate,and thus phosphate retention….
 2.The retained phosphate stimulates increased
synthesis of PTH and growth of parathyroid
gland.
 3.Diminished levels of ionized calcium
,resulting from diminished CALCITRIOL
production by the kidney,also stimulates PTH
production…
 ( SECONDARY
HYPERPARATHYROIDISM )

30.  TERTIARY or AUTONOMOUS
HYPERPARATHYRODISM
 Patients tend to have
HYPERCALCEMIA,instead of HYPO and may
require Surgical parathyoidectomy……
 OSTEITIS FIBROSA CYSTICA --- Its the
classical lesion of hyperparathyroidism…..
Pathological term used is BROWN
TUMOUR…..
 Clinically,manifests as BONE PAIN and
FRAGILITY and EPO RESISTANCE ,related to
BONE MARROW FIBROSIS….

31.  LOW BONE TURNOVER DISEASE
 Includes two subsets,Adynamic bone
disease and Osteomalacia….
 OSTEOMALACIA --- Accumulation of
unmineralized bone matrix,that may be
caused by vit D DEFICIENCY….
 ADYNAMIC BONE DISEASE -- Reduced
bone volume and mineralization and may
result from excessive suppression of PTH
production….
 This suppression ,in turn is a result of
use of VIT D preparations or from
excessive Ca exposure in the form of Ca
containing phosphate binders…

32.  OTHER CONSEQUENCES -----
 HYPERPHOSPHATEMIA has been found to
be related to CV Mortality…..
 Assosciated with Vascular Calcification….
Of coronary arteries and even Heart
Valves….
 CALCIPHYLAXIS is seen almost exclusively
in patients with advanced CKD….
 Starts from LIVEDO RETICULARIS and
advances to PATCHES OF ISCHEMIC
NECROSIS…

33.  MANAGEMENT------
 Careful attention to PHOSPHATE
CONCENTRATION….
 Appropriate use of phosphate binding
agents….
 CALCIUM ACETATE and CALCIUM CARBONATE
 These agents,are taken with meals and
complex the dietary phosphate to limit its GI
absorption….
 SIDE EFFECT---- Total body Ca accumulation
resulting in HYPERCALCEMIA,paticularly in
patients with LOW TURNOVER BONE DISEASE…

34.  A New drug SEVELAMER has been found
to be very useful in the management of
HYPERPHOSPHATEMIA…..
 Its a non-Ca containing polymer…..
 Thus,does not predispose CKD patients to
hypercalcemia….. ,and may attenuate Ca
deposition in the vascular bed…..
 CALCITRIOL is used almost universally
,and helps in suppression of PTH….But,it
may result in HYPERCALCEMIA….

35.  CALCIMIMETIC AGENTS ----
 These enhance the sensitivity of the
parathyroid cell to the suppressive effect
of Calcium….
 These produce a dose-dependent
reduction in PTH and PLASMA Ca conc…..
 KDOQI Recommendations --
--
 Target PTH levels should be b/w 150
and 300 pg/ml……

36.  NEUROMUSCULAR ABNORMAliTIES ::--
 FATIGUE
 PERIPHERAL NEUROPATHY
 HEADACHE
 LETHARGY
 ASTERIXIS
 RESTLESS LEG SYNDROME
 SEIZURES
 A DEPRESSED LEVEL OF
CONSCIOUSNESS,RANGING FROM
CONFUSION TO COMA (URAEMIC
ENCEPHALOPATHY) (AN ABSOLUTE
INDICATION OF DIALYSIS)

37.  GI and NUTRITIONAL PROBLEMS ::--
 ANOREXIA ,NAUSEA AND VOMITING
 PEPTIC ULCER
 ASCITES
 URAEMIC FETOR – A Urine like odour on
the breath,derives from the breakdown of
UREA to AMMONIA and has assosciated
DYSGEUSIA…..
IMPORTANT ---- PROTEIN RESTRICTION may
be useful to decrease nausea and
vomiting,but it puts the patients at
increased risk of MALNUTRITION…

38.  ENDOCRINE-METABOLIC Disturbances
---
 CALCIUM and PHOSPHATE
DISTURBANCES,as already described…
 CARBOHYDRATE RESISTANCE
 HYPERURICEMIA
 ATHEROGENIC LIPID PROFILE
 PROTEIN-ENERGY MALNUTRITION
 INFERTILITY and SEXUAL DYSFUNCTION

39.  LABORATORY INVESTIGATIONS IN
CKD::-
 Tests for SLE and VASCULITIS….
 SERUM and URINE PROTEIN
ELECTROPHORESIS
 In GLOMERULONEPHRITIS,HEPATITIS and HIV
serology….
 RENAL BIOPSY
 SELDOM INDICATED,when there is
suspicion of ACTIVE NEPHRITIS or
ACCELERATED DECLINE IN GFR….

40. 40
The microscopic appearance of the "end stage kidney" is similar regardless of
cause, which is why a biopsy in a patient with chronic renal failure yields little
useful information. The cortex is fibrotic, the glomeruli are sclerotic, there are
scattered chronic inflammatory cell infiltrates, and the arteries are thickened.
Tubules are often dilated and filled with pink casts and give an appearance of

41.  IMAGING STUDIES
 RENAL ULTRASOUND -- MOST USEFUL…
 Can verify the presence of two
kidneys;kidney size and rules out renal
masses and evidence of obstruction….
 RADIOGRAPHIC CONTRAST IMAGING
STUDIES are not indicated ….
 A DISCREPANCY OF >1cm SIZE ,can
suggest RENOVACULAR DISEASE….

42.  3-4 times a week
 Takes 2-4 hours
 Machine filters
blood and
returns it to
body

43.  Temporary site
 AV fistula
◦ Surgeon constructs by combining an artery and a
vein
◦ 3 to 6 months to mature
 AV graft
◦ Man-made tube inserted by a surgeon to connect
artery and vein
◦ 2 to 6 weeks to mature

44.  RENAL TRANSPLANTATION
 Transplant of the human kidney is the
treatment of choice for advanced CKD…..
 Mortality rates after transplantation are
highest in the first year…and are more,with
advancing age….
 Most grafts,succumb at varying rates to a
chronic vascular obliterative process termed
CHRONIC ALLOGRAFT NEPHROPATHY……
 Both cellular and humoral (antibody
mediated) effector mechanisms play roles in
kidney transplant rejection…..

45.  DRUGS,like AZATHIOPRINE,MYCOPHENOLATE
MOFETIL ; STEROIDS and CYCLOSPORINE are
tradiotinally used to prevent graft rejection….
 Recently,drugs like TACROLIMUS,SIROLIMUS
have been found to have a better role….
 INFECTIONS,WHICH are common in a renal
transplant patient are ----
 Herpes,Oral candidiasis,UTI s
 Pneumocystis carinii,CMV…;Hepatitis B,C…..

46.  MEDICATION DOSE ADJUSTMENT ::--
 ANTIMICROBIALS,NEEDING DOSE REDUCTION
 Loading dose of most drugs is not affected
by CKD,but the maintenance dose of most
drugs need to be adjusted….
 OHAs and METFORMIN should be avoided….
 NSAIDs can further worsen renal function…..
AMINOGLYCOSIDES COTRIMOXAZOLE
VANCOMYCIN CEFOTAXIME
AMPHOTERICIN B NORFLOXACIN
ACYCLOVIR CIPROFLOXACIN

47.  Chronic Kidney Disease is a worldwide killer
that is under-diagnosed and under-treated.
 Clinical Laboratorians have a critical and
central role in addressing CKD: its causes, its
complications, and its treatment……
 An early dignosis and a multidisciplanary
approach is required,for its proper
management….

48. Thank you