Approach to the patient with chronic kidney disease Gülçin Kantarcı, M.D. Nephrology Department.
Approach to the patient with chronic kidney disease
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Approach to the patient with chronic kidney disease
Gülçin Kantarcı, M.D.Nephrology Department
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Learning objectives and training goals of this lecture
• Define chronic kidney disease. • Explain the pathophysiology of chronic kidney disease. • Describe the clinical findings of chronic kidney disease. • Take preventive measures against the development of
chronic kidney disease.• List the possible etiology of chronic kidney disease and
make a differential diagnosis.• Arrange the initial treatments and refer to a specialist.
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REFERENCE &SUGGESTED READING
• Current Medical Diagnosis and Treatment, Maxine A. Papadakis, Stephen J. McPhee, Eds. Michael W. Rabow, Associate Ed. http://accessmedicine.com
Chapter 22. Kidney Disease • http://www.uptodate.com .(Definition and
staging of chronic kidney disease in adults, Screening for chronic kidney disease, Epidemiology of chronic kidney disease)
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chronic renal diseases (CKD)
• CKD is defined as abnormalities of kidney structure or function, present for ≥3 months, with implications for health
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Criteria for CKD
KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification 2012
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Staging of CKD
KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification 2012
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DIAGNOSIS OF CKD GFR
Serum creatinine (muscle mass, dietary meat intake, simetidin,
trimetoprim) Creatinine Clearance = Ucr x V
P crCockcroft formula= 140-age
72 x P cr
Estimated CrCl (MDRD Study)
1440
x Body weight (women x 0.85)
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GFR = 141 X min(Scr/κ,1)α X max(Scr/κ,1)-1.209 X 0.993Age X 1.018 [if female] X 1.159 (if black)
• The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation was developed in an effort to create a formula more precise than the MDRD formula, especially when actual GFR is > 60 mL/min per 1.73 m2. Researchers pooled data from multiple studies to develop and validate this new equation.
• The CKD-EPI equation performed better than the MDRD (Modification of Diet in Renal Disease Study) equation, especially at higher GFR, with less bias and greater accuracy.
CKD-EPI
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CKD Symptoms
• In the early stages, CKD is asymptomatic. Symptoms develop slowly with the progressive decline in GFR, are nonspecific, and do not manifest until kidney disease is far advanced (GFR < 10–15 mL/min/1.73 m2).
• General symptoms of uremia may include fatigue and weakness; anorexia, nausea, vomiting, and a metallic taste in the mouth are also common. Patients or family members may report irritability, difficulty in concentrating, insomnia, restless legs, paresthesias, and twitching. Generalized pruritus without rash may occur.
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GFR 35-50% of normal symptom-freeBUN and Cr. levels
Normalrenal functions
maintained*endocrine*excretory*regulatory
GFR 20-35% of normal azotemia still asymptomatic
GFR < 20% of normal overt renal failure
UREMIC SYNDROME
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Uremic Syndrome
Renal excretory failure› Uremia› Hyperkalemia
Renal endocrine failure› Anemia› Renal osteodystrophy
Renal metabolic failure & acidosis
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Clinical Abnormalities in Uremia
• Fluid & electrolyte disturbances
• Acid-Base disorders• Cardiovascular complications• Hematologic complications• Neurologic complications• Bone ,phosphate & calcium abnormalities• Endocrine disorders
• The most common physical finding in CKD is hypertension.
• It is often present in early stages of CKD and tends to worsen with CKD progression as sodium excretion is impaired.
• In later stages of CKD, this sodium retention may lead to typical physical signs of volume overload.
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Hematologic complications in CRF
Normochromic normocytic anemia› biosynthesis of erythropoetin› Bone-marrow depressive effect of uremic toxins› Hemolysis› GI loss of blood
Abnormal hemostasis› bleeding time› Abnormal platelet aggregation &adhesiveness› activity of platelet factor 3
Enhanced susceptibility to infection
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Neurologic complications
Uremic encephalopathy Inability to concentrate, drowsiness Insomnia, behavioral changes Neuromuscular irritability
› Hiccups, cramps, fasciculations› Asterixis, chorea, stupor, seizures
Peripheral neuropathyRestless Legs
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Bone phosphate & calcium abnormalities in CRF
biosynthesis of 1,25-dihidroksikolekalsiferol Hypocalcemia Hyperphosphatemia Hyperparathyroidism Acidosis
• RenalOsteodystrophy• Osteomalacia
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Endocrine disorders in CRF
Secondary hyperparathyroidism Glucose intolerance Disturbances of insulin metabolism
› Hyperinsulinemia› Peripheral insulin resitance
Pituitary, throid & adrenal are normal Libido and fertility
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Essentials of Diagnosis
• Decline in the GFR over months to years.• Persistent proteinuria or abnormal renal morphology may be present.• Hypertension in most cases.• Symptoms and signs of uremia when nearing end-stage disease.• Bilateral small or echogenic kidneys on ultrasound in advanced disease.
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TREATMENTSlowing Progression
• Treatment of the underlying cause of CKD is vital. Control of diabetes should be aggressive in early CKD; risk of hypoglycemia increases in advanced CKD, and glycemic targets may need to be relaxed to avoid this dangerous complication.
• Blood pressure control is vital to slow progression of all forms of CKD; agents that block the renin-angiotensin-aldosterone system are particularly important in proteinuric disease
• Current guidelines suggest a blood pressure goal of 130/80 mm Hg for patients with CKD; a goal of 125/75 mm Hg is recommended for patients with proteinuria.
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Dietary Management
• Every patient with CKD should be evaluated by a renal nutritionist. Specific recommendations should be made concerning protein, salt, water, potassium, and phosphorus intake to help manage CKD progression and complications.
• Protein restriction to 0.6–0.8 g/kg/d may retard CKD progression • Salt and water restriction. A goal of 2 g/d of sodium is reasonable for
most patients. A daily intake of 2 L of fluid maintains water balance.• Potassium restriction. Restriction is needed once the GFR has fallen
below 10–20 mL/min/1.73 m2, or earlier if the patient is hyperkalemic. Patients should receive detailed lists describing potassium content of foods and should limit their intake to < 50–60 mEq/d (2 g).
• Phosphorus restriction. The phosphorus level should be kept in the ‘normal’ range (<4.5 mg/dL) predialysis,
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Medication Management• Many drugs are excreted by the kidney; dosages should be adjusted
for GFR. • Insulin doses may need to be adjusted. • Magnesium-containing medications, such as laxatives or antacids,
should be avoided as should phosphorus-containing medicines, particularly cathartics.
• Morphine metabolites are active and can accrue in advanced CKD; • Drugs with potential nephrotoxicity (NSAIDs, intravenous contrast)
should be avoided• The anemia of CKD is primarily due to decreased erythropoietin
production, which often becomes clinically significant during stage 3 CKD. Many patients are iron deficient as well due to impaired GI iron absorption.
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END STAGE RENAL FAILURE
HEMODIALYSIS
TRANSPLANTATIONPERITONEAL DIALYSIS
Treatment of End-Stage Renal Disease
When GFR declines to 5–10 mL/min/1.73 m2 (with or without overt uremic symptoms), renal replacement therapy (hemodialysis, peritoneal dialysis, or kidneytransplantation) is required to sustain life.
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Kidney transplant sources
• Living Related Unrelated
Deceased
Xenotransp
lant ???
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Vascular access for HD
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Native AV Fistula
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Vascular access for HD
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Principle of hemodialysis
cellophane sausage casings, a cooling system from an old Ford, parts from a crashed German fighter plane, and washing machine tubs.
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Principle of PD
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When to Refer
• Patient education is important in understanding which mode of therapy is most suitable, as is timely preparation for treatment; therefore, referral to a nephrologist should take place in late stage 3 CKD, or when the GFR is declining rapidly. Such referral has been shown to improve mortality• A patient with other forms of CKD such as those with significant proteinuria (> 1 g/d) or polycystic kidney disease should be referred to a nephrologist at earlier stages.
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Prognosis in ESRD• Compared with kidney transplant recipients and age-matched
controls, mortality is higher for patients undergoing dialysis. There is likely little difference in survival for well-matched peritoneal versus hemodialysis patients.
• Survival rates on dialysis depend on the underlying disease process. Five-year Kaplan-Meier survival rates vary from 36% for patients with diabetes to 53% for patients with glomerulonephritis. Overall 5-year survival is currently estimated at 39%. Patients undergoing dialysis have an average life-expectancy of 3–5 years, but survival for as long as 25 years may be achieved depending on comorbidities.
• The most common cause of death is cardiac disease (50%). Other causes include infection, cerebrovascular disease, and malignancy.
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Case 1
• 35 years old male• Nocturia since 2006• He had a history of pyelonephritis with kidney
stones• Since then he had no hospital admission
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PHYSICAL EXAMINATION
• BP: 186/100mmHg P: 90/min/R • Weight 72 kg, Height 175 cm Temperature: 36.4 0CRaised JVPDyspneic with crackles over the lung bases
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Laboratory tests
• Hb: 10.6g/dl Htc:31.9% Na: 137mEq/L• Serum BUN: 78mg/dl ;Kr: 3.6mg/dL• Urine specific gravity: 1012• Ca 8.3mg/dL Pi 4.6 mg/dL
Albumin 3.6 g/dL Fe 16 ug/dL (59 - 158 ) TIBC 205 ug/dL (228 - 428)
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140-age)x Wt 72 x pCr
For Female= x0.85
Estimated CrCl (Cockcroft-Gault formula)
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http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm
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Stage 4 CKD
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URINARY USG
• RK 85 mm, 5x7 mm mid pole kidney stone• LK 88 mm, 7x6 mm apical pole kidney stone• GII Renal Parenchimal Dis.Proteinuria: 354 mg/day
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• Renal bx. ?• Urinary CT?• Urinary Ca? • Stone analysis?
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How would you manage this patient?
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Treatment Strategies
• Anemia EPO, Parenterally forms of iron• Hyperphosphatemia Phosphate binders• HT Do not use ACEIs+ARBs• Do not use contrast agents• Do not use NSAIDs
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Case 2
• 48 years old female• Left flank pain, vomiting, fever • History of PCKD ( diagnosed in 1999)• Her mother died because of intracranial
hemorage (AVM? and AVA?)
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PHYSICAL EXAMINATION
• BP: 100/60mmHg P: 118/min/R • Weight 59 kg, 38.2 0C• Dyspne(+), tachipne (+)• turgor , Pale face,• Looks weak and unwell • fullness of neck veins (+)
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Laboratory tests• WBC: 12.860/mm3
• Hb: 12.2g/dl Htc:37.3% Na: 137mEq/L• BUN: 156mg/dl ;Kr: 10.3mg/dL • ABG analysis PH 7.26 HCO3 12.8 BE-12• Urine specific gravity: 1010• S.Na 133mEq/l S.K 6.7mEq/l• Ca 8.3mg/dL Pi 6.8 mg/dL• CRP 184
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URINARY USG
• RK 186 mm with multiple cystis and stones, • LK 167 mm with multiple cystis and stones
• R ureter and pelvis dilatated
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• Culture of the urine ?• Culture of blood?• Urine analysis ?• Urinary CT ?( Contrast agent)
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How would you manage this patient?
?
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Case 3
• 28 years old male• dyspnea, vomiting, bad feutor• History of urinary tract infections before age 12. • His brother on dialysis because of VUR
nephropathy
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PHYSICAL EXAMINATION
• BP: 110/70mmHg P: 88/min/R • Weight 72 kg, 36.5 0C• Dyspne(-), tachipne (-)• turgor n, fale face,
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Laboratory tests• Hb: 9.6g/dl Htc:31% MCV 79
• Na: 135mEq/L, K 3.5mEq/LCa 7.6mg/dL Pi 9.6 mg/dL Albumin 3.6 g/dL ; CRP 30 Fe 27 ug/dL (59 - 158 ) TIBC 308 ug/dL (228 - 428) • Serum BUN: 168mg/dl ;Kr: 12.3mg/dL
• Urine specific gravity: 1010, • Urinary sediment: 8-10 leucocytes, 2-3 waxy casts in
every field of microscopic areas
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US • Solitery enlarged left kidney and proximal
segments of ureter
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Urinary bt( Without contrast)
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• PTH 354 pg/ml• Uric acid 8.9 mg/dl• Culture of urine : (-)
What is your likely diagnosis ?
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Nephropathy of VUR
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What else do you need to confirme your diagnosis?
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Voiding cystouretrography
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How would you manage this patient ?
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END STAGE RENAL FAILURE
HEMODIALYSIS
PERITONEAL DIALYSIS TRANSPLANTATION
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• Anemia EPO, Parenterally forms of iron• Hyperphosphatemia Phosphate binders• HT Do not use ACEIs+ARBs• Do not use contrast agents• Do not use NSAIDs• Nephrectomy or Defflux inj. Befor renal
transplantation
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Case 4
• 57 years old female• Dispnea and vomiting • History of NIDDM ( diagnosed in 1985)• Her father died because of CAD• Her mother had the history of dialysis & died
because of sepsis
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PHYSICAL EXAMINATION
• BP: 190/60mmHg P: 92/min/R • Weight 72 kg, BMI 30• edeama (+++/+++)• turgor n, pale face,• Dyspneic and orthopneic with crackles over the
lung bases, tachipne (+)
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LABORATORY FINDINGS
• Hb:8.7 Htc: 25% WBC:7200
• BUN:58mg/dL Cr:3.2mg/dL K:6.7mEq/L Na:135mEq/L
• S.alb 3.1 g/dl
• Urinalysis = D 1010 35-40 WBC
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Chronic Kidney Failure(Due to diabetic nepropathy)
Stage 5
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![Page 75: Approach to the patient with chronic kidney disease](https://reader038.fdocuments.in/reader038/viewer/2022103100/56813389550346895d9a9108/html5/thumbnails/75.jpg)
END STAGE RENAL FAILURE
HEMODIALYSIS
PERITONEAL DIALYSIS TRANSPLANTATION