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a precise presentation over CKD made for house officers/medical interns . It focuses over signs and symptoms and in-hospital management of resulting problems , material taken majorly from medscape, CMDT and oxford hand book
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CHRONIC KIDNEY DISEASEDr Beenish Sohail Bhutta
WHAT IS CKD ?
National Kidney Foundation (NKF) defines CKD as
evidence of renal damage (based on abnormal UA [proteinuria, hematuria] or
structural abnormalities (found with US) or
GFR < 60 mL/min for 3 or more months
PATHOPHYSIOLOGY In CKD, reduced clearance of certain solutes
principally excreted by the kidney results in their retention in the body fluids.
CKD is rarely reversible and leads to progressive decline in renal function. Reduction in renal mass leads to hypertrophy of the remaining nephrons with hyperfiltration, and the GFR in these nephrons is transiently increased, placing a burden on remaining nephrons, leading to progressive glomerular sclerosis and interstitial fibrosis
STAGING
Stage Description GFR
1 Kidney damage with normal or inc GFR
≥90
2 Kidney damage with mild reduction in GFR
60-89
3 Moderate dec in GFR 30-59
4 Sever dec in GFR 15-29
5 Kidney Failure <15 or dialysis
EITIOLOGY Diabetic kidney disease Hypertension Vascular disease (renal artery stenosis,
vasculitidies, atheroemboli, renal vein thrombosis)
Glomerular Disease ( primary or secondary) Cystic kidney disease Urinary tract obstruction or dysfunction Recurrent kidney stone disease Congenital defects of kidney or bladder Unrecovered acute kidney injury
PATIENT PRESENTS WITH..
MAJOR CONSEQUENCES OF CKD Metabolic acidosis
Salt and water retention
Anemia
Uremia
Endocrine disorder
Disorder of mineral metabolism
SIGNS OF METABOLIC ACIDOSIS IN STAGE 5 Protein energy malnutrition
Loss of lean body mass
Muscle weakness
SIGNS OF SALT AND WATER RETENTION IN STAGE 5 Peripheral edema
Pulmonary edema
Hypertention
SIGNS OF ANEMIA IN CKD Fatigue
Reduced exercise capacity
Impaired cognitive and immune function
Reduced quality of life
New onset heart failure or increased severity of heart failure
SIGNS OF UREMIA Pericarditis
Encephalopathy
Perpheral neuropathy
Restless leg syndrome
GI symptoms: N V D , anorexia
Skin : dry skin, pruritis, echymosis
Fatigue, inc somnolence
Platelet dysfunction
Sexual dysfunction
PHYSICAL SIGNS IN ADVANCED CKD
LABS
Complete blood count (CBC) Basic metabolic panel Urinalysis (Patients with a P/C ratio above
200 mg/mg should undergo a full diagnostic evaluation. A value of greater than 300-350 mg/mg is within the nephrotic range.)
Serum albumin levels: Patients may have hypoalbuminemia due to urinary protein loss or malnutrition
Lipid profile: Patients with CKD have an increased risk of cardiovascular disease
LABS
Evidence of renal bone disease can be derived from the following tests:
Serum phosphate
25-hydroxyvitamin D
Alkaline phosphatase
Intact parathyroid hormone (PTH) levels
FURTHER EVALUATION Serum and urine protein electrophoresis: Screen for
multiple myeloma Antinuclear antibodies (ANA), double-stranded DNA antibody
levels: Screen for SLE Serum complement levels: Results may be depressed with
some glomerulonephritides Cytoplasmic and perinuclear pattern antineutrophil
cytoplasmic antibody (C-ANCA and P-ANCA) levels: Positive findings are helpful in the diagnosis of Wegener granulomatosis and polyarteritis nodosa; P-ANCA is also helpful in the diagnosis of microscopic polyangiitis
Anti–glomerular basement membrane (anti-GBM) antibodies: Presence is highly suggestive of underlying Goodpasture syndrome
Hepatitis B and C, human immunodeficiency virus (HIV), Venereal Disease Research Laboratory (VDRL) serology: Conditions associated with some glomerulonephritides
IMAGING Renal ultrasonography: Useful to screen for hydronephrosis,
which may not be observed in early obstruction, or for involvement of the retroperitoneum with fibrosis, tumor, or diffuse adenopathy; small, echogenic kidneys are observed in advanced renal failure
Retrograde pyelography: Useful in cases with high suspicion for obstruction despite negative renal ultrasonograms, as well as for diagnosing renal stones
Computed tomography (CT) scanning: Useful to better define renal masses and cysts usually noted on ultrasonograms; also the most sensitive test for identifying renal stones
Magnetic resonance imaging (MRI): Useful in patients who require a CT scan but who cannot receive intravenous contrast; reliable in the diagnosis of renal vein thrombosis
Renal radionuclide scanning: Useful to screen for renal artery stenosis when performed with captopril administration; also quantitates the renal contribution to the GFR
BIOPSY Biopsies are also indicated to guide
management in already-diagnosed conditions, such as lupus, in which the prognosis is highly dependent on the degree of kidney involvement. Biopsy is not usually indicated when renal ultrasonography reveals small, echogenic kidneys on ultrasonography, because this finding represents severe scarring and chronic, irreversible injury.
TREATMENT
HYPERTENTION HTN control with weight loss and tobacco cessation Salt intake reduced to 2g/day Initial Rx to include ACE inhibitor or angiotensin II receptor
blocker (ARB) Goal BP is <130/80 mm Hg; for those with proteinuria > 1-
2 g/d, goal is < 125/75 mm Hg When an ACE inhibitor (zestril 5-10mg HS) (ranitec
5-10mg, 20mg HS) or an Losartan (eziday 25-50mg HS) is initiated or uptitrated, patients should have serum creatinine and potassium checked within 5–14 days. Hyperkalemia or a rise in serum creatinine > 30% from baseline or dec of GFR <15% from baseline mandates reduction or cessation of the drug.
Second-line antihypertensive agents include calcium(HERBESSOR 30 mg OD, AMODIP 10mg OD) channel-blocking agents.
HYPERKALEMIA
IV calcium gluconate 10 % in 10 ml N/S over 10-20 mins
Salbutamol (SALBO 5mg) nebulizer Low potassium diet 4 ampules of 25 % dextrose water with 12-14
units of insulin Lasix 40mg OD if systolic more than 90
mmHg Discontinue Aldactone Emergency dialysis in case of potentially
lethal hyperkalemia
PULMONARY EDEMA Prop up and give high flow Oxygen with face
mask Lasix 120-250mg IV over 1 hour Hemodylisis or hemofiltration in
unresponsive cases CPAP Venesection (100-200ml)
DISORDER OF BONE METABOLISM Dietary phosphorus restriction to 1000 mg/d . Oral phosphorus binders, such as calcium
carbonate(Qalsan D) (650 mg/tablet) or calcium acetate(LOPHOS) (667 mg/capsule), block absorption of dietary phosphorus and given in TDS or QID at the beginning of meals.
These should be titrated to a serum phosphorus of < 4.6 mg/dL in stage 3–4 of CKD (GFR of 15–59 mL/min) and
< 4.6–5.5 mg/dL in ESRD patients
TREATMENT OF HYPOCALCEMIA Maximal elemental calcium doses of 1500 mg/d
(eg,nine tablets of calcium acetate),
doses should be decreased if serum calcium rises above 10 mg/dL
Typical calcitriol(BONE-ONE) dosing is 0.25 or 0.5 mcg orally daily or every other day initially. Cinacalcet is a calcimimetic agent that targets the calcium-sensing receptor on the chief cells of the parathyroid gland and suppresses PTH production.
Cinacalcet, 30–90 mg PO x OD, can be used if elevated serum phosphorus or calcium levels prohibit the use of vitamin D analogs
MANAGEMENT OF ANEMIA Serum ferritin < 100–200 ng/mL or iron
saturation < 20% is suggestive of iron deficiency.
Iron therapy should be withheld if the serum ferritin is > 500–800 ng/mL, or Hb is 12 even if the iron saturation is < 20%.
Ferrous sulphate, gluconate or fumarate 325 mg from OD to TDS may be given,
Erythropoiten (Epokine, Heamex, 50IU/Kg once or twice a week)
Darbepoetin alfa ( Aranesp) is started at 0.45 mcg/kg and can be administered every 2–4 weeks.
SIDE EFFECTS of ERYTHROPOETIN: Allergic reactions Hypertension Hyperviscosity Pure red cell aplasia
TREATING COAGULOPATHIES Raising the Hb to 9–10 g/dL in anemic
patients can reduce bleeding time via increased blood viscosity
Desmopressin ( Minirin 25 mcg intravenously every 8–12 hours for two doses) is a short-lived but effective treatment for platelet dysfunction and it is often used in preparation for surgery.
Dialysis
TREATING ACIDOSIS serum bicarbonate level should be
maintained at > 21 mEq/L
Administration of bicarb should begin with 20–30 mEq/d divided into two doses per day and titrated as needed
DRUGS WHICH REQUIRE DOSE REDUCTION OR COMPLETE CESSATION Antivirals Benzodiazepines Colchicine Digoxin Exenatide Fenofibrate Gabapentin Insulin Lithium Metformin* Opioid analgesics Saxagliptin Sitagliptin Sotalol Spironolactone Sulphonylureas (all) Vildagliptin
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