chronic kidney disease

1. CHRONIC KIDNEY DISEASE
By
Hussain Bangi
Al-Ameen Medical College
Bijapur
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2. OUTLINE
• Introduction
• Definition
• Stages of CKD
• Epidemiology
• Etiology
• Risk Factors for CKD
• Renal Response to Nephron Loss
• Progression of Renal Damage
• Systemic Features
• Diagnostic Evaluation
• Management
• End Stage Renal Disease
• Summary
2

3. INTRODUCTION
• Chronic kidney disease is characterized by an irreversible deterioration of renal
function that gradually progresses to end-stage renal disease (ESRD) and
eventually requires renal replacement therapy.
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4. DEFINITION
A patient has CKD if either of the following criteria are present:
1. Kidney damage ≥ 3months, as defined by structural or functional abnormalities
of the kidney, with or without decreased GFR, manifested by 1 or more of the
following features:
• Abnormalities in the composition of blood or urine
• Abnormalities in imaging tests
• Abnormalities on kidney biopsy
2. GFR < 60ml/min/1.73m2 for ≥ three months, with or without the other signs of
kidney damage described above
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5. STAGES OF CKD
STAGE DESCRIPTION GFR (ml/min/1.73m2)
1 Kidney damage with normal or increased GFR >90
2 Kidney damage with mild decrease in GFR 60 - 89
3 Moderate decrease in GFR 30 – 59
4 Severe decrease in GFR 15 - 29
5 Kidney Failure <15
5D Kidney Failure, dialysis dependent <15, on dialysis
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6. EPIDEMIOLOGY
• Globally, the prevalence of CKD among children, < 16 year old, is 1.5 – 3.0 per
1,000,000 child population.
• Incidence & prevalence of CKD
– Increases with age
– More common in African Americans
– More common in adults than children
– Among children, more common in children older than 6 years
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7. ETIOLOGY
Glomerulonephritis
• Idiopathic
• Associated with multisystem diseases: SLE, polyarteritis nodosa
• Henoch - Schonlein purpura, microscopic polyarteritis
Familial Nephropathy
• Alport syndrome, congenital nephrotic syndrome
Congenital Anomalies
• Bilateral renal dysplasia, hypoplasia, polycystic kidney disease
• Reflux nephropathy
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8. ETIOLOGY (contd.)
Obstructive Uropathy
• Pelviureteric or ureterovesical junction obstruction
• Posterior urethral valve, calculi
Amylodiosis
Hemolytic Uremic Syndrome
Miscellaneous
• Bilateral wilms tumor
• Renal cortical necrosis
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9. ETIOLOGY (contd.)
Paediatric Patients,
Reflux/Obstruction/Dys
plasia, 0.37, 38%
Paediatric Patients,
Glomerulonephritis/FS
GS, 0.27, 27%
Paediatric Patients,
Cystic Disease, 0.05,
5%
Paediatric Patients,
HUS, 0.03, 3%
Paediatric Patients,
Other, 0.27, 27%
Adult Patien
Diabetes, 0.43
Adult Patients,
Hypertension, 0.27,
27%
Adult Patients,
Glomerulonephritis,
0.08, 8%
Adult Patients, Cystic
Disease, 0.02, 2%
Adult Patients,
Other, 0.2, 20%
Adult Patients
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Pediatric Patients

10. RISK FACTORS FOR CKD
• VUR associated with recurrent urinary tract infections & renal scarring
• Obstructive uropathy
• Prior history of acute nephritis or nephrotic syndrome
• Renal failure in perinatal period
• Family H/O polycystic kidneys or genetic renal conditions
• Renal dysplasia or hypoplasia
• Low birth weight infants
• Prior history of HSP
• Diabetes, hypertension
• SLE, vasculitis
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11. Renal Response to
Nephron Loss
Functional Changes
• Adaptive
Hyperfilteration
• Maintenance of
tubuloglomerular
balance
Structural Changes
• Hypertrophy of
Cellular & Matrix
constituents of the
glomerulus
• Increase in size &
volume of tubules
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12. RENAL RESPONSE TO NEPHRON LOSS (contd.)
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13. PROGRESSION OF RENAL DAMAGE –
RISK FACTORS
NON – MODIFIABLE RISK FACTORS
• Foetal Programming : low birth weight
• Angiotensin converting enzyme (ACE) gene
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14. PROGRESSION OF RENAL DAMAGE –
RISK FACTORS (contd.)
MODIFIABLE RISK FACTORS
• HYPERTENSION
• PROTEINURIA
• Obesity
• Dyslipidemia
• Mineral homeostatsis
• Hyperuricemia
• Anemia
Important & Independent Risk Factors
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15. PROGRESSION OF RENAL DAMAGE (contd.)
Pathophysiologic consequences of
hypertension and proteinuria in
chronic kidney disease
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16. SYSTEMIC FEATURES
GROWTH RETARDATION
Factors contributing:
– Poor Nutrition
– Metabolic Acidosis
– Bone Disease
– Anaemia
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17. SYSTEMIC FEATURES (contd.)
MALNUTRITION
Factors contributing
• Anorexia
• Nausea and Vomiting
• Abnormal sense of taste
• Imposition of a variety of appropriate or inappropriate dietary restrictions
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18. SYSTEMIC FEATURES (contd.)
Factors contributing:
• Lack of erythropoietin production
• Iron Deficiency
• Chronic Inflammation
• Bone Marrow Suppression
• Increased red cell turnover
• Malnutrition
• Aluminium Toxicity
ANAEMIA
develops once the renal function < 50%
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19. SYSTEMIC FEATURES – ANAEMIA (contd.)
Clinical effects of Anaemia:
• Fatigue
• Loss of appetite
• Depression
• Decreased quality of life
• Sleep disturbances
• Decreased exercise tolerance
• Impaired Cognitive function
• Left Ventricular Hypertrophy
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20. SYSTEMIC FEATURES (contd.)
NEUROLOGICAL ABNORMALITIES
• Infants and young children with moderate CKD are at risk for encephalopathy
• Features
– Hypotonia
– Delayed motor development
– Seizures
– Truncal ataxia and other signs of cerebellar dysfunction
– Uremic neuropathy
– Severe proximal muscle weakness
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21. SYSTEMIC FEATURES (contd.)
BONE AND MINERAL DISORDER [RENAL OSTEODYSTROPHY]
• Systemic disorder of bone & mineral metabolism manifested by either
one or a combination of the following:
– abnormlities of Ca++, phosphorous, PTH or vitamin D
– abnormalities in bone histology, linear growth or strength
– vascular or other soft tissue calcification
• As early as in CKD stage 2 vit D ↓ & serum PTH ↑
• Seen in 30% of patients with ESRD
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22. CHRONIC KIDNEY DISEASE –
MINERAL & BONE DISORDER (CKD - MBD)
Clinical Spectrum of CKD -MBD
• Secondary Hyperparathyroidism - Osteitis fibrosa cystica, Bone resorption,
fractures & deformities
• Alterations in growth plate cartilage – failure of linear growth
• Vit D3 deficiency – rickets/osteomalacia
• Adynamic bone lesions
• Hypotonia & delayed motor development
• Genu valgum, Scoliosis, compression fractures of vertebrae, thoracic deformities
and pathologic fractures of long bones
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23. SYSTEMIC FEATURES (contd.)
METABOLIC ACIDOSIS & DYSELECTROLYTEMIA
HYPERKALEMIA
HYPERTENSION
MISCELLANEOUS
• Anorexia
• Lack of energy
• Increased sleep
• Poor school performance
• Platelet dysfunction
• Gastric Ulceration
• Severe Itching
• Pericarditis
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24. DIAGNOSTIC EVALUATION
DETAILED HISTORY
• Age at onset/ duration
• Polyuria/ polydipsia/ enuresis/hematuria
• Fever/ rash / arthralgia/ arthritis/odema
• Recurrent UTI
• Antenatal detection of any renal anomalies
• Spinal abnormalities
• Uraemic symptoms (fatigue/anorexia/vomiting)
• History of renal disease in the family [Alport syndrome/ Nephronophthisis/
congenital nephrotic syndrome]
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25. CLINICAL EXAMINATION
• vitals [blood pressure]
• assessment for the presence & severity of peripheral odema
• evaluation of growth, pubertal development & nutritional status
• features of anaemia & bone disease
• pericardial rub/ diminished heart sounds
• psychological & intellectual functions
DIAGNOSTIC EVALUATION (contd.)
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26. LABOROTARY INVESTIGATIONS
• Complete blood counts
• ↓ Hb
• ↑ Total counts
• ↓ Platelet counts
• Renal function test
• ↑s. creatinine/B.urea
• Blood urea nitrogen
• Serum electrolytes
• ↑Na / ↑K+
• Serum calcium, phosphate, ALP & proteins
• Serum cholesterol
• PTH
• Iron studies
DIAGNOSTIC EVALUATION (contd.)
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27. Urine Analysis
• Look for red blood cells (RBCs), white blood cells (WBCs)
• Most children with chronic kidney disease have broad hyaline casts
• Proteinuria
Glomerular Filteration Rate (GFR)
Estimation of GFR - Schwartz formula
GFR = k X height[cm] / serum creatinine [mg/dl]
k = 0.4 for preterm infants),
k = 0.45 for full-term infants
k = 0.55 for those aged 2-12 yrs and adolescent girls
k = 0.7 years in adolescent boys
DIAGNOSTIC EVALUATION –
LABORATORY INVESTIGATIONS (contd.)
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28. Age Mean GFR ± SD (ml/min/1.73m2)
1 week term males & females 41 ± 15
2-8 weeks term males and females 66 ± 25
>8 weeks term males and females 96 ± 22
2 – 12 years males and females 133 ± 27
13-21 years males 140 ± 30
13-21 years females 126 ± 22
DIAGNOSTIC EVALUATION –
LABORATORY INVESTIGATIONS – GFR (contd.)
Normal GFR in Neonates, Children and Adolescents
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29. Cystatin C
• Low molecular weight protein [13.36 kD]
• Freely filtered by the glomerulus & metabolized after tubular reabsorption
DIAGNOSTIC EVALUATION –
LABORATORY INVESTIGATIONS (contd.)
Reference Intervals
Preterm Infants 1.34 – 2.57
Fullterm Infants 1.36 – 2.23
>8 days – 1year 0.75 – 1.87
1 – 3 years 0.68 – 1.90
3 – 16 years 0.51 – 1.31
Reference Intervals for Cystatin C
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30. DIAGNOSTIC EVALUATION(contd.)
IMAGING STUDIES
1. Ultrasonography:
• To assess renal size, anomalies & obstruction
• To grade glomerulonephropathy
2. Radionuclide Studies
• 99m-Technetium dimercaptonsuccinic acid (DMSA) – to look for renal scars
• Voiding cystourethrography – to assess the dynamics of the urinary bladder
3. Skeletal survey
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31. DIAGNOSTIC EVALUATION - ULTRASONOGRAPHY (contd.)
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32. MANAGEMENT
• Adequate management of early stages of CKD retards the decline in renal
function
• Treatment is aimed at maintaining the well being and quality of life
RETARDING THE PROGRESSION OF CKD
1. Control of hypertension
2. Reduction in proteinuria
3. Other strategies
– Management of anaemia
– Prevention and management of dyslipidemia
– Prevention of acidosis
– Non hypercalcemic doses of vitamin D analogs
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33. MANAGEMENT (contd.)
NUTRITION
Dietary Management
Goals –
a) Reduce nitrogen intake
b) Maintain nitrogen balance
c) Cover essential amino acid requirement
d) Supply enough calories
• Energy: Intake equivalent to the RDA of healthy children of the same age
• Infant : 100 – 120 kCal/kg/day
• Children : 80 – 100 kCal/kg/day
• 55 – 60% from carbohydrates
• 30% from fats
• 10% from proteins
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34. MANAGEMENT – NUTRITION – DIETARY MANAGEMENT (contd.)
• Protein:
High protein – aggravates acidosis, hyperkalemia & hyperphosphataemia
Low protein – reduce BUN, improve renal function and reduce GI & neurological symptoms
50% Protein Intake from high biological value proteins(meat, poultry, fish, eggs, milk, cheese,
yoghurt)
Type of CKD 0-1 yr 1-5 yrs 5-10 yrs
Mild (GFR: 20 – 40) 1.8 1.4 1
Moderate (GFR: 5 – 20) 1.4 1 0.8
Severe (GFR: <5) 1 0.8 0.6
Protein Allowance in CKD according to GFR (g/kg)*
Children on dialysis+
Haemo Dialysis → + 0.4g/kg/day Peritoneal Dialysis → +0.8g/kg/day
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35. MANAGEMENT – NUTRITION – DIETARY MANAGEMENT (contd.)
• Fats:
• Saturated fats - < 10% of total calories
• Diets high in PUFA (corn oil, medium chain triglyceride oil & complex carbohydrates)
• Vitamins:
• Recommended dietary intake – 100% of RDA
B1,B2 and folic acid – 1mg each
Pyridoxine & Pantothenic acid – 10mg each
Vitamin C – 50mg
Vitamin B12 – 5mg
Biotin – 300mg
• Vitamin A > 2 x RDA – hypercalcemia, anaemia and hyperlipidemia
• Excessive Vitamin C – oxalate deposition in kidney
• GFR <40 ml/min/1.73m2 – folic acid supplemented to prevent hyperhomocysteinemia
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36. MANAGEMENT – NUTRITION – DIETARY MANAGEMENT (contd.)
• Fluids:
• Fluids should be given without producing water retention
• In case of water retention – give diuretic and restrict sodium
• Thirst or insensible loss + last day’s output
• Next Step Consider dialysis - if water retention and weight gain increase despite diuretic
• Sodium:
• Restrict salt intake to 300-600 mg/day in infants & 1-2g/day in older children
• Potassium:
• Restrict potassium intake
• Hyperkalemia – calcium gluconate, sodium bicarbonate, insulin & glucose, nebulized,
albutrol and Potassium exchange resin (1g/kg/day)
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37. GROWTH
• Resolve nutritional deficiencies
• Improve acid base balance
• Correction of salt depletion, ca++ & vitamin D deficiency
• If growth retardation persists despite these measures recombinant human growth
hormone (rhGH) therapy to be started.
MANAGEMENT (contd.)
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38. MANAGEMENT (contd.)
ANAEMIA
Key Elements –
• Erythropoietin Stimulating Agents – ESA
• Recombinant Human Erythropoietin – rHuEPO (Epogen, Procrit, Eprex)
• Darbepoetin - ᾱ (Aranesp)
S/C: 100 units/kg/week in two doses
I/V: 150 units/kg/week in three doses
• Iron supplementation
• Oral
• Intravenous
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39. 2. Darbepoetin - ᾱ
• Starting dose
ESA naïve pt’s: 0.5µg/kg/wk
pt’s converting from rHuEPO: 0.42µg/kg/wk
for every 100u/kg/wk of rHuEPO
• Complication:
• Injection site pain
• Pruritus
MANAGEMENT – ANAEMIA
Erythropoietin Stimulating Agents (ESA) (contd.)
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40. Iron Supplementation
1. Oral Iron
• 3 – 5 mg/kg/day of elemental iron(max 150 – 300 mg/day)
• Adequate therapy in children not on haemodialysis
• Given 1 - 2 hrs before food
• Absorption affected by phosphate binders, H2 receptor antagonists & PPIs
MANAGEMENT – ANAEMIA (contd.)
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41. 2. Intravenous Iron
• Preparations:
a) Iron Dextran(INFeD)
b) Iron Gluconate(Ferrlecit)
c) Iron Sucrose(Venofer)
• Acute Dosing – Given when TSAT < 20% or ferritin<100ng/ml
Recommended Dose: 1.5mg/kg/dose with a max. of 125mg/dose
• Chronic Dosing – Started at 1mg/kg/week - one dose a week
• Complications:
• Iron dextran: acute anaphylactic reactions
• Iron gluconate: loin pain, hypotension, emesis, paraesthesias
• Iron sucrose: rash, flushing, hypotension
MANAGEMENT – ANAEMIA
Iron Supplementation (contd.)
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42. MANAGEMENT (contd.)
CKD - MBD
• Control of levels of blood phosphate – most important factor in prevention & treatment of
secondary hyperparathyroidism
• Daily intake of phosphorous: 800 -1000mg
• Dairy products, chocolate, chicken, nuts, dried beans, aerated drinks to be avoided
Treatment Modalities
1. Phosphate binders:
• Calcium salts [calcium carbonate & calcium acetate]
• Sevelamer hydrochloride
2. Vitamin D & its analogues
3. Calcimimetic agents
4. Surgical intervention
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43. HYPERTENSION
• Target level < 90th percentile of bp for age , gender & height
• Salt restriction & diuretics
• Antihypertensive drugs:
1. Thiazides [hydrochlorothiazide 2mg/kg/24r] : GFR upto 30ml/min/1.73m2
2. Loop diuretics [furosemide 1-2mg/kg/dose] : GFR < 30
3. Calcium channel blockers [amlodipine]
4. Beta blockers [atenolol/metoprolol]
5. Centrally acting agents [clonidine]
MANAGEMENT (contd.)
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44. MANAGEMENT (contd.)
IMMUNIZATION
• All standard immunizations according to the schedule
• Withhold live vaccines when on immunosuppressive medication
• Administer live vaccines before transplantation
• These children should be offered Pneumococcal, Varicella and Rotavirus vaccines.
• Yearly influenza vaccine
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45. END- STAGE RENAL DISEASE
• State in which renal dysfunction has progressed to a point at which homeostasis &
survival can no longer be sustained with native kidney function & medical
management
• Ultimate goal : successful kidney transplantation
• Initiation of renal replacement therapy : stage 4 CKD
• Birth to 5 years: peritoneal dialysis
> 12 yr of age : hemodialysis
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46. SUMMARY
• CKD is irreversible loss of renal function
• Glomerulonephritis, congenital renal & urological anomalies & reflux nephropathy
account for majority of paediatric CKD
• Hypertension & Proteinuria are the most important factors for progression of CKD
• Presenting features include anaemia, growth retardation, malnutrition,
hypertension, bone disease, acidosis or encephalopathy
• Adequate management of early stages retards decline in renal function
• Psychological and emotional support to parents
• Renal replacement therapy initiated when GFR < 15ml/min/1.73m2
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47. THANK YOU
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