Chronic Kidney DiseaseChronic Kidney Disease

Dr.Lissy Thomas.Dr.Lissy Thomas.Senior Consultant, Senior Consultant,

Nephrology.Nephrology.

Case -1Case -1

Diabetic for 20 yrs, work up showed Cr Diabetic for 20 yrs, work up showed Cr 1.0, urine with +++ protein.1.0, urine with +++ protein.

Report from previous yr showing the Report from previous yr showing the same results.same results.

Does he have chronic kidney disease? Does he have chronic kidney disease?

Case 2Case 2

21 yr old male , admitted with road traffic 21 yr old male , admitted with road traffic accident , developed renal failure requiring accident , developed renal failure requiring dialysis during the hospital stay.dialysis during the hospital stay.He is undergoing dialysis treatment, 15He is undergoing dialysis treatment, 15 thth dialysis on the 40dialysis on the 40 thth hospital stay. hospital stay.He has no significant medical history and He has no significant medical history and a routine checkup done a month prior to a routine checkup done a month prior to admission was showing normal urine admission was showing normal urine analysis and renal function.analysis and renal function.

Case 3Case 3

A 82 yr old , urine Cr 1.2, urine analysis A 82 yr old , urine Cr 1.2, urine analysis normal. He is only 50 kg wtnormal. He is only 50 kg wt

Doctor calculated GFR before Doctor calculated GFR before administering antibiotic and it was less administering antibiotic and it was less than 50ml/minute.than 50ml/minute.

What would you tell his son if he ask you What would you tell his son if he ask you about his kidney function?.about his kidney function?.

Case 4Case 4

50 yr old diabetic with normal urine 50 yr old diabetic with normal urine analysis and no microalbuminuria ,with analysis and no microalbuminuria ,with serum Cr 0.8.(done 2 weeks before serum Cr 0.8.(done 2 weeks before hospital admission).hospital admission).

Admitted with fever and urosepsis with Admitted with fever and urosepsis with hypotension- Cr 2.6, urine with plenty of hypotension- Cr 2.6, urine with plenty of pus cells , RBC and +++ protein.pus cells , RBC and +++ protein.

Calculation of GFRCalculation of GFR

(140-age) x weight (in kg)(140-age) x weight (in kg)

72 x P72 x PCrCr

For females multiply the result by 0.85For females multiply the result by 0.85

Management of CKDManagement of CKD

Treatment of reversible causes .Treatment of reversible causes .

Preventing the progression of renal Preventing the progression of renal disease.disease.

Treatment of complications of CKD .Treatment of complications of CKD .

Treatment of complications of ESRD.Treatment of complications of ESRD.

Identifying and preparing pts for RRTIdentifying and preparing pts for RRT

Reversible causes Reversible causes

Decreased renal perfusion.Decreased renal perfusion.

RASRAS

Diuretic use.Diuretic use.

Hypotension –drugs, cardiogenic.Hypotension –drugs, cardiogenic.

Sepsis.Sepsis.

Drugs which lower GFR –ACEI,NSAID.Drugs which lower GFR –ACEI,NSAID.

Reversible causes -contdReversible causes -contd

Nephrotoxic drugsNephrotoxic drugs

Avoid nephrotoxic drugs in pts with CKD,Avoid nephrotoxic drugs in pts with CKD,

IV contrast, NSAID, Aminoglycosides.IV contrast, NSAID, Aminoglycosides.

amphoterecin etcamphoterecin etc

Reversible causes -contdReversible causes -contd

Urinary tract obstructionUrinary tract obstruction

BPH and outlet obstructionBPH and outlet obstruction

Kidney stone and obstruction.Kidney stone and obstruction.

Slowing rate of progression of CKDSlowing rate of progression of CKD

By reducing the intraglomerular HTN.By reducing the intraglomerular HTN.

BP control <130/80.BP control <130/80.

Reduced protein intake.Reduced protein intake.

Lowering cholestrol.Lowering cholestrol.

Smoking cessation.Smoking cessation.

Treatment of complications of CKDTreatment of complications of CKD

Volume overload-Volume overload-Hyperkalemia.Hyperkalemia.Metabolic acidosis.Metabolic acidosis.Hyperphosphatemia.Hyperphosphatemia.Secondary hyperparathyroidism.Secondary hyperparathyroidism.HTNHTNAnemia.Anemia.Dyslipedemia.Dyslipedemia.

Treatment of complications of Treatment of complications of ESRDESRD

Uremic bleeding.Uremic bleeding.

Malnutrition.Malnutrition.

Pericarditis.Pericarditis.

Thyroid dysfunction.Thyroid dysfunction.

Uremia and uremic symptoms.Uremia and uremic symptoms.

Choices of RRTChoices of RRT

Transplantation.Transplantation.

Hemodialysis.Hemodialysis.

Peritoneal Dialysis.Peritoneal Dialysis.

TransplantationTransplantation

Not all pts appropriate candidate.Not all pts appropriate candidate.

Improve quality of life.Improve quality of life.

Donor availability main problem.Donor availability main problem.

Living related, living unrelated and Living related, living unrelated and Cadaveric donors.Cadaveric donors.

Details later….Details later….

Hemodialysis.Hemodialysis.

Home verus in-center therapy.Home verus in-center therapy.

Usual maintenance dialysis 3 Usual maintenance dialysis 3 times/week,each session 4 hrs.times/week,each session 4 hrs.

Long nocturnal hemodialysis.- usually 5-6 Long nocturnal hemodialysis.- usually 5-6 nights per week, each session 8-10 hrs.nights per week, each session 8-10 hrs.

Short daily dialysis at home- gaining Short daily dialysis at home- gaining popularity. popularity.

Peritoneal dialysis.Peritoneal dialysis.

At home dialysis.At home dialysis.

Very convenient for pt’s who wish to work.Very convenient for pt’s who wish to work.

For pt’s who wish to travel.For pt’s who wish to travel.

For very young children and infants.For very young children and infants.

For pt’s with severe cardiovascular illness.For pt’s with severe cardiovascular illness.

For pt’s with difficult vascular access.For pt’s with difficult vascular access.

Contraindications to PDContraindications to PD

Unsuitable peritoneum- due to prior Unsuitable peritoneum- due to prior surgery, malignancy.surgery, malignancy.

Hernia.Hernia.

Poorly controlled diabetes.Poorly controlled diabetes.

Back pain may get worse.Back pain may get worse.

Contra indications for dialysis.Contra indications for dialysis.

No absolute contraindications.No absolute contraindications.

Pt’s with advanced disease in an organ Pt’s with advanced disease in an organ system other than kidneys usually excluded ( eg system other than kidneys usually excluded ( eg

–end stage heart disease, liver disease etc).–end stage heart disease, liver disease etc).

Pts with advanced malignancy.Pts with advanced malignancy. Un co-operative patients.Un co-operative patients.

Preparation for hemodialysis.Preparation for hemodialysis.

Access placement.Access placement.

3 types of access- primary A-V fistula,3 types of access- primary A-V fistula,

A-V graft.A-V graft.

double lumen cuffed double lumen cuffed

tunneled catheter.tunneled catheter.

Primary A-V fistula.Primary A-V fistula.

Usually on non-dominant upper extremity.Usually on non-dominant upper extremity.

End –to-side vein-to-artery anastomosis.End –to-side vein-to-artery anastomosis.

Usually wrist (radio-cephalic) or upper arm Usually wrist (radio-cephalic) or upper arm (brachio -cephalic OR brachio-basilic).(brachio -cephalic OR brachio-basilic).

Better to do it 6 months prior to anticipated Better to do it 6 months prior to anticipated dialysis.dialysis.

A-V graftA-V graft

By anastomosing a synthetic conduit By anastomosing a synthetic conduit between artery and vein.between artery and vein.

Usually a polytetrofluroethylene (PTFE) Usually a polytetrofluroethylene (PTFE) graft.graft.

A-V graftA-V graft

Straight fore arm- radio-cephalic.Straight fore arm- radio-cephalic.

Looped fore arm- brachio-cephalic.Looped fore arm- brachio-cephalic.

Straight upper arm -brachial –axillary.Straight upper arm -brachial –axillary.

Looped upper arm – axillary –axillary.Looped upper arm – axillary –axillary.

Complications of graft/ fistulaComplications of graft/ fistula

Infection.Infection.

Thrombosis.Thrombosis.

Aneurysm – in 3-5%.Aneurysm – in 3-5%.

Hand ischemia due to steal ,more (6%)in Hand ischemia due to steal ,more (6%)in brachiocephalic.brachiocephalic.

High output heart failure ( pt’s with severe High output heart failure ( pt’s with severe heart failure should be excluded from heart failure should be excluded from having permanent access.)having permanent access.)

Tunneled cuffed catheter.Tunneled cuffed catheter.

Mostly from IJ.Mostly from IJ.

Can be used immediately.Can be used immediately.

Usually in pt’s with no access, or in pt’s Usually in pt’s with no access, or in pt’s with failed access.with failed access.

Infection most common, severe Infection most common, severe complication.complication.

Can get clotted too.Can get clotted too.

Preparation for PDPreparation for PD

Insert PD catheter 2-3 weeks prior to Insert PD catheter 2-3 weeks prior to initiation of PD.initiation of PD.

Two type of PD.- CAPD,CCPD.Two type of PD.- CAPD,CCPD.

If pt choose CCPD, buy machine early If pt choose CCPD, buy machine early etc.etc.

Indications to start dialysis.Indications to start dialysis.

Pericarditis/ pericardial effusion, pleuritis.Pericarditis/ pericardial effusion, pleuritis.

Neurological dysfunction- encephalopathy, Neurological dysfunction- encephalopathy, psychiatric disturbances, seizure etc.psychiatric disturbances, seizure etc.

Bleeding diathesis due to uremia.Bleeding diathesis due to uremia.

Fluid overload refractory to diuretics.Fluid overload refractory to diuretics.

Hyperkalemia refractory to treatment.Hyperkalemia refractory to treatment.

Indications.Indications.

Metabolic acidosis refractory to treatment.Metabolic acidosis refractory to treatment.

Hyper phosphatemia and hypocalcemia Hyper phosphatemia and hypocalcemia refractory to treatment.refractory to treatment.

Deterioration in nutritional status Deterioration in nutritional status accompanied by nausea, vomiting.accompanied by nausea, vomiting.

Refractory anemia.Refractory anemia.

Otherwise unexplained decline in Otherwise unexplained decline in functioning.functioning.

Hemodialysis.Hemodialysis.

Pts blood pumped through the dialysis Pts blood pumped through the dialysis machine to remove waste products and machine to remove waste products and excess water.excess water.

Dialysis apparatusDialysis apparatus

Dialyzer.Dialyzer.

Dialysate.Dialysate.

Tubings.Tubings.

Machine.Machine.

Solute clearanceSolute clearance

Diffusion.Diffusion.

ConvectionConvection

Diffusion.Diffusion.

Primary means of waste removal.Primary means of waste removal.

Depends on - concentration of solute, Depends on - concentration of solute, membrane surface area, porosity and membrane surface area, porosity and thickness of membrane, size of solute thickness of membrane, size of solute ,flow rate of blood and dialysate,flow rate of blood and dialysate

Usual blood flow – 300-500mlUsual blood flow – 300-500mlUsual dialysate flow – 500 -800 mlUsual dialysate flow – 500 -800 ml

Convective TransportConvective Transport

Most important for large solutes .Most important for large solutes .

By high rate of fluid transport, solutes By high rate of fluid transport, solutes dragged along with fluid.dragged along with fluid.

Fluid removal.Fluid removal.

By hydrostatic pressure gradient By hydrostatic pressure gradient generated by the dialysis machine.generated by the dialysis machine.

The TMP cause fluid to cross from high The TMP cause fluid to cross from high pressure blood compartment to low pressure blood compartment to low pressure dialysate compartment.pressure dialysate compartment.

DialyzerDialyzer

Hollow fiber.Hollow fiber.

Parellel plateParellel plate

Difft category of dialyzersDifft category of dialyzers

Type of membrane .Type of membrane .

Synthetic, cellulose, substituted Synthetic, cellulose, substituted cellulose etc.cellulose etc.

DialyzerDialyzer

Blood volume capacityBlood volume capacity

Usually 60-120 ml ( blood lines 100-Usually 60-120 ml ( blood lines 100-150 ml)150 ml)

Surface area- Large surface area –better Surface area- Large surface area –better clearance.clearance.

DialyzerDialyzer

Ultrafiltration coefficient- Low KUf low Ultrafiltration coefficient- Low KUf low permeability of water,so higher TMP to permeability of water,so higher TMP to achieve UF and vice versa.achieve UF and vice versa.

But newer machines with controlled UF.But newer machines with controlled UF.

Dialyzer.Dialyzer.

Usually reported as small solute clearance Usually reported as small solute clearance and large solute clearance ,and at difft and large solute clearance ,and at difft blood flows.blood flows.

Usually we use small clearance one for Usually we use small clearance one for first dialysis, and large clearance one for first dialysis, and large clearance one for large pts.large pts.

DialyzerDialyzer

Capacity to reuse.Capacity to reuse.

Sterilization – usually by ethylene oxide, Sterilization – usually by ethylene oxide, but pts with allergies can use the ones but pts with allergies can use the ones with gamma irradiation, steam with gamma irradiation, steam autoclaving.autoclaving.

Dialysate.Dialysate.

Sodium – 135 – 155 meq/lSodium – 135 – 155 meq/l

K 0 – 4 meq/lK 0 – 4 meq/l

Calcium 1.25 – 1.75 mmol/lCalcium 1.25 – 1.75 mmol/l

Magnesium 0 – 0.75 mmol/lMagnesium 0 – 0.75 mmol/l

Chloride 87- 120 meq/lChloride 87- 120 meq/l

Bicarbonate 25-40 meq/lBicarbonate 25-40 meq/l

Glucose 0 -0.20 gm/dlGlucose 0 -0.20 gm/dl

Dialysis tubings.Dialysis tubings.

Arterial line carry blood from pt to the Arterial line carry blood from pt to the dialyzer.dialyzer.

Venous line carry dialyzed blood back to Venous line carry dialyzed blood back to patient.patient.

Dialysis machine.Dialysis machine.

Blood pump to move blood between Blood pump to move blood between patient and dialyzer.patient and dialyzer.

A delivery system to transport dialysis A delivery system to transport dialysis solution.solution.

Monitoring devices –pressure monitors, Monitoring devices –pressure monitors, venous air trap and air detector,tempt venous air trap and air detector,tempt sensor etcsensor etc

Acute complicationsAcute complications

Hypotension.Hypotension.

Cramps.Cramps.

Nausea, vomiting.Nausea, vomiting.

Headache.Headache.

Chest pain.Chest pain.

Fever and chills.Fever and chills.

Hypotension.Hypotension.

Rapid fluid removalRapid fluid removalInaccurate dry weight.Inaccurate dry weight.Cardiac- arrhythmias,pericardial effusion.Cardiac- arrhythmias,pericardial effusion.Intake of antihypertenisives.Intake of antihypertenisives.Low Hb, low sugar.Low Hb, low sugar.Intake of meals immediately before or during Intake of meals immediately before or during dialysis.dialysis.Low sodium dialysate.Low sodium dialysate.Reaction to dialyzer membrane (not now)Reaction to dialyzer membrane (not now)

Treatment of hypotensionTreatment of hypotension

Place pt in trendelenburg position.Place pt in trendelenburg position.

Stop UF.Stop UF.

Reduce blood flow.Reduce blood flow.

Give saline.Give saline.

Further treatment based on etiology.Further treatment based on etiology.

Disequilibrium syndrome.Disequilibrium syndrome.

First described in 1962.First described in 1962.

Neurological symptoms of varying Neurological symptoms of varying severity.severity.

New pts just being started on dialysis at New pts just being started on dialysis at greater risk.greater risk.

Predisposing factors – increased BUN, Predisposing factors – increased BUN, extremes of age, severe MA, preexisting extremes of age, severe MA, preexisting seizure disorder.seizure disorder.

Symptoms.Symptoms.

Nausea, Vomiting.Nausea, Vomiting.

Restlessness and headache.Restlessness and headache.

Blurred vision, confusion.Blurred vision, confusion.

Seizure, coma.Seizure, coma.

Death.Death.

Treatment.Treatment.

Prevention.Prevention.

R/O other causes for the symptom.R/O other causes for the symptom.

Treatment of seizure.Treatment of seizure.