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Chronic Kidney Disease ( CKD) medicine .
- 1. Chronic Kidney Disease By ChetnaTrivedi Under the guidance of : Deependra S Patel Dr.U P Singh Devendra satpute Dr. R P Pandey Devsingh rajgaund Dev vats singh Chouhan
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- 3. Chronic Kidney Diseaseencompasses a spectrum of pathophysiologic processes associated with abnormal kidney function, often with a progressive decline in glomerular filtration rate (GFR). Definition
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- 6. Epidemiology •6% of theadult population in the United States - CKD at stages 1 and 2. •4.5% of the U.S. population -stages 3 and 4 CKD. •The relative contribution of each category varies among different geographic regions.
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- 8. Etiology Diabetic nephropathy Glomerulonephritis Hypertension associatedCKD Autosomal dominant polycystic kidney disease Other cystic and tubulo interstitial nephropathy
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- 10. Risk Factors ofCKD Chronic Nonrenal (systemic) Disease diabetes , metabolic syndrome Auto inflammatory disease (lupus ,vascularised , cancer immunotherapy) Infection ( HIV, HBV HCV ) Nephrotoxic exposure Hypertension
- 11. Demographic , Anthropomorphic,Geographic age sex family history region specific- Central America,Sri Lanka,Australia Viral infection HIV infection SARS-CoV-2 Lifestyle smoking diet physical activity
- 12. Risk Factors Childhood,adolescent states and Diseases Prematureand SGA birth Increased BMI Persistent asymptomatic microscopic hematuria Elevated BP Childhood Kidney Disease (even resolved) Adult Onset Prior acute Kidney injury Pre-eclampsia
- 13. Involve two broadmechanism: 1.Specific mechanism- underlying etiology. Genetic abnormalities Immune complex deposition Inflammation in various type of glomerulonephritis Toxic exposure 2.Nonspecific mechanism- hyperfiltration and hypertrophy of viable nephron (RAAS activation) Pathophysiology
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- 17. Clinical Manifestations Stages 1and 2 CKD are asymptomatic stages 3 and 4, have complications complications: anemia decreased appetite with progressive malnutrition abnormalities in calcium, phosphorus, and mineral-regulating hormones, abnormalities in sodium, potassium, water, and acid-base homeostas
- 19. Fluid, Electrolyte, AndAcid- base Disorders Sodium and Water Homeostasis sodium retention and attendant extracellular fluid volume (ECFV) expansion. expansion causes hypertension, nephron hyperfiltration and injury Hyponatremia causes water restriction.
- 20. Potassium Homeostasis Potassium excretionby aldosterone-dependent secretion in the DCT and potassium excretion in the GI tract Hyperkalemia precipitated in increased dietary potassium intake Hemolysis transfusion of stored red blood cells metabolic acidosis medications that inhibit renal potassium excretion
- 21. common in CKD produceless ammonia and, cannot excrete the quantity of protons required to maintain acid-base balance . Hyperkalemia combination of hyperkalemia and hyperchloremic metabolic acidosis present metabolic acidosis is mild; the pH <7.32 Metabolic Acidosis
- 22. Treatment Dietary salt restriction useof loop diuretics Hyperkalemia often responds to dietary restriction of potassium 1. the use of kaliuretic diuretics 2. avoidance of potassium supplements and dose reduction or avoidance of potassium-retaining medications 3. Metabolic Acidosis - oral sodium bicarbonate supplementation 4.
- 23. Bone Manifestations ofCKD Can be classified into high bone turnover with increased PTH levels Osteitis fibrosa cystica Osteomalacia low bone turnover with low or normal PTH levels Adynamic bone disease Disorders of calcium and phosphate metabolism
- 24. Calcium, Phosphorus, and theCardiovascular System Hyperphosphatemia and hypercalcemia are associated with increased vascular calcification calcification in the media of coronary arteries and heart valve
- 25. Other Complications ofAbnormal Mineral Metabolism vascular occlusion with extensive vascular and soft tissue calcification patches of ischemic necrosis, on the legs, thighs, abdomen, and breasts. Calciphylaxis
- 26. Treatment low-phosphate diet phosphate-binding agents- Calcium-basedphosphate binders calcium acetate ,.calcium carbonate Non calcium -based phosphate binder Lanthanum Calcitrol. Calcimimetic agents- enhance the sensitivity of parathyroid cells to the suppressive effect of calcium
- 27. CKD-related risk factors- Anemia Hyperphosphatemia Hyperparathyroidism IncreasedFGF-23 Sleep apnea Systemic inflammation Vascular Disease Cardiovascular Abnormalities
- 28. 2. Heart Failure 3.Hypertension 4. Left ventricular hypertrophy 5. Dilated cardiomyopathy 6.Pericardial Disease Cardiovascular Abnormalities
- 29. Treatment Hypertension In patients withdiabetes or proteinuria >1 g per 24 h, blood pressure reduced to <130/80 mmHg Salt restriction Antihypertensive agent- (ACE) inhibitors (ARBs) They slow the rate of decline of kidney function by reduction of systemic arterial pressure and reduction in the intraglomerular hyperfiltration and hypertension
- 30. 2. Cardiovascular Disease Hypertensionand dyslipidemia promote atherosclerotic disease Gliflozins (SGLT2 inhibitors)- helps in kidney protection 3. Pericardial Disease dialysis
- 31. Hematologic Abnormalities Anemia normocytic, normochromicanemia Seen in stage 3 and 4 Clinical manifestations- fatigue and diminished exercise tolerance angina heart failure
- 32. Hematologic Abnormalities decreased cognitionand mental acuity impaired host defense against infection Treatment- Recombinant Human ESA Iron supplementation Vitamin B12 And Folate supplement
- 33. Causes of Anemiain CKD Relative deficiency of erythropoietin Diminished red blood cell survival Bleeding diathesis Iron deficiency Hyperparathyroidism/bone marrow fibrosis Chronic inflammation Folate or vitamin B₁₂, deficiency Hemoglobinopath Comorbid conditions: hypo-/hyperthyroidism, pregnancy, HIV- associated disease, autoimmune disease, immunosuppressive drugs Causes of anemia in CKD
- 34. Gastrointestinal And Nutritional Abnormalities Uremicfetor urine-like odor from the breath breakdown of urea to ammonia in saliva unpleasant metallic taste (dysgeusia). Gastritis Peptic Disease Mucosal Ulceration
- 35. Glucose metabolism impaired Plasmalevels of insulin elevated In women estrogen levels are low, menstrual abnormalities, infertility, inability to carry pregnancies to term Endocrine-metabolic Disturbances
- 36. Diagnostic Evaluation Laboratory Investigation 1. Serumand urine protein electrophoresis, looking for multiple myeloma, in >35 years old In the presence of glomerulonephritis, hepatitis B and C and HIV should be tested. Renal Function Tests to determine the pace of renal deterioration
- 37. Diagnostic Evaluation Serum concentrationsof calcium, phosphorus, vitamin D, and PTH to evaluate metabolic bone disease. Hemoglobin concentration, iron, vitamin B12, and folate should also be evaluated. A 24-h urine collection may be helpful, because protein excretion >300 mg may be an indication for therapy with ACE inhibitors or ARBu
- 38. Diagnostic Evaluation 2.Imaging Studies Renalultrasound- can verify the presence of two kidneys determine if they are symmetric provide an estimate of kidney size rule out renal masses and evidence of obstruction.
- 39. Diagnostic Evaluation Doppler sonography,nuclear medicine studies, or CT or magnetic resonance imaging (MRI) Voiding Cystogram- when there is a suspicion of reflux nephropathy (recurrent childhood urinary tract infection, asymmetric renal size with scars on the renal poles) Kidney Biopsy- Ultrasound-guided percutaneous biopsy Indication- suspicion of a concomitant active process such as interstitial nephritis or accelerated loss of GFR
- 40. Treatment There are fourbasic aims of management of any CKD Retarding progression Keep the patient symptom free Prevent and treat complications RRT
- 41. • Smoking cessation •Weight reduction • Dietary protein control- A protein-controlled diet (0.8 g/kg/d) • Alcohol intake- Alcohol consumption discouraged • Exercise- A total of 30 minutes, 5 times a week • Dietary salt intake - dietary sodium intake of < 100 mmol/day (~ 5 g) Lifestyle management for patients with CKD
- 42. It includes treatmentof anemia hypertension metabolic acidosis bone disorders cardiovascular disease Conservative management of clinically relevant factor
- 43. Emergency indication ofdialysis: Refractory pulmonary odema Refractory hyperkalemia Severe metabolic acidosis Uremic pericarditis Uremic encephalopathy Types of Dialysis Peritoneal dialysis Hemodialys Dialysis
- 44. Indications- anorexia and nauseanot attributable to reversible causes such as peptic ulcer disease evidence of malnutrition fluid and electrolyte abnormalities, hyperkalemia or ECFV overload Renal Replacement Therapy
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