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hronic Kidney Disease

Chronic kidney disease; consider as one ofthe major problems in our community, and

diabetes mellitus is one of the most

common cause of chronic disease.

What we mean by chronic kidney

disease?-By chronic disease we mean that there is a loss of the function

of the kidney.

Usually its progressive in nature, leading to advance stage of

renal lose, these what we call end stage renal disease in which

the person cannot take over, and the kidneys fail to take over

and the person is in risk to die.>>> so it's important to knowabout the function about the kidneys.

ofstatusfluidthemaintainis toThe function of the kidneys, theblood pressure, theelectrolyticThethe people,

and u"erythropoiesisin, because it has a rolehemoglobin

e kidney is the site where theshould know that th

foraggedstimulator cwhich is theerythropoietinis producted in theerythropoietin85% of the"erythropoiesis

,hemostasisphosphorousandcalciumas well as the",kidney

this is why is very important to know about the calcium and

phosphorous, of course other electrolytes and menials are also

have something related to kidney works in the tubules or

glomeruli.

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PS; Just to know that one in five our patient's>> diabetes willprogress in a chronic a disease and amount of 30% of patient's

with diabetic they ended in end stage renal disease.

-U should know that the diabetes to develop chronic kidney

disease needs around not less than ten years, because of

multiple mechanism or pathological mechanism.

- u should know that the uncontrolled diabetes lead to

glaciation of all the membranes including the RBC's leading to

thickening of this membranes and loss of the function of this

membranes decrease the perfusion of such membranes and

the organs as well, this will lead to what we call

glomerulosclerosis and chronic disease.

witharepatientsheof t50%:arounddiabetesIn type onediabetes type one which is insulin dependent, its the gubanittype of diabetes.

about 45-50% of this patient's develop diabetic nephropathy

and chronic disease within 15 to 25 years,, this the natural

course of diabetes.

autonomicthe,retinaas the;t affect other sitesiOf course-

but u should,,systemvascularas well as the,nervous system

common cause of chronicmostis thediabetesknow that the

endand its the most common cause ofisease worldwide,d.diseaselstage rena

depends on theits%20 to 30less" is aroundits:"In type 2time of onset of diabetes, if diabetes is started at the age of 30,

means that there is time to develop diabetic nephropathy,

because we said that its need not less than ten years,

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-u should know that if u dont control the blood sugar of urpatients or ur self "if u have diabetes", u have the possibility to

develop diabetic nephropathy over 10 to 15 years, and to

develop progressive renal disease to advance chronic renalfailure because of loss of the function of the nephrons over the

next five to ten years leading to end stage renal disease.

that the function of the;we meanby end stage renal disease-

kidney is totally lost, not more than 7 to 10 percent of the

function of the nephron maintain.

re: patient with diabetes they accelerate theHypertension-

progression into end stage renal disease or chronic kidney

.not controlledhypertensionhave atheyasdisease

secondalso its thepercentageow the hypertensionN,wideal disease worldnreof the end stagecommon cause

possibly also in our country it's whys very important to control

blood pressure.

end stagethereach, the patients mightover 20 to 25 years-

renal disease, within 10 to 15 years ,,,this is very important to

know about diabetes and hypertension.

by it we mean;perinephritisis chronicird common causeTh,immune background,processnflammatoryithat we have

leading to lose of the function of the nephron there is

glomerulonephritis, glamorous is affected and sclerosed,

leading to lose of the function of the nephron.

PS; we know that there is around one million of nephrons andglamorous of course is in each kidney, And u should know that

if u have lost of this nephrons this will lead to progressive end

stage renal disease.

Diabetes and

hypertension

both if they

coexist this will

accelerate the

condition of this

patient instead

of reaching end

stage renal

disease

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this is,l nephritisTubulointerstitiathe chronicisThe fourth

,infectionsystem,tractthe urinaryobstruction ofse ofbecau

affecting thedrugs,renal diseases with cystic lesionsfamiliar

tubules or because of others, leading to Tubulointerstitialanalgesicorpyelonephritisin form ofis, thisnephritis

.childreninnephropathyrefluxorropathyneph

- if we have a boy or girl with symptoms of urinary tract

infection or abdominal pain or dysuria "pain in urination" plz

send ur child to do some investigation "urine analysis" if there

are RBC's or WBC's in urine, this predict that something wrongwith the urinary tract system, because it might be a cause of

reflux,

defect in the valve between the ureter and the urinaryand thats onevesicoureteral refluxer thats what we calldblad

of the common cause of coronary disease even in adults, but

indiseaserenalstageits the most common cause of endeven .at the time of adulthoodaberrantwhich becomechildren,

n theand by it we mea,GFRofage there is a decreaseWith-

glomerular filtration rate, it's around 110+-20.

So(from 90 to 31ml/min),,, this is the actual GFR"CRIATININE

CLEARANCE",,, this reflected by lab investigation by serum

creatinine level which is between (0.4mg up to 1.2mg) this isthe normal values,

with age; after the age of 30 or 25 there is a decrease in GFR

around (1ml/year) ,,,,, this means that with time as the age of

70 or 80 the normal GFR of that person how is around 80 years

is 110 for example minus 16,, its around 50ml/min, "its normal

for his age",

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this why this patient is compensating if u give him any drug or

any toxic agent or the expose for hypotension or u give them

something affecting the kidney functions, "nonsteroidal :eg"

this will lead to acute renal failure, drop of his GFR, because,,normaliseinnatialso the self cre,his kidneysfortoxicthis

why??

-u will become DR, u will give ur patient nonsteroidal ",

diclofenac sodium, ibuprofen" or something else,, U should

remember this, u should know what's his age? What his serum

creatinine level, because if u give him this drug and he hasthis,70-some degree of renal impairment, or his age above 60

will lead to decrease his GRF and he might cause acute kidney

renalstagewhich might not recover leading to end,injury

e, but even at this time, time of acute kidney injury, ordiseas

for these elderly,problemacute renal failure, this is a big

.50%exceedingis very high,ratebecause the mortality

-The finishing as I mention that by chronic disease that there is

loss of the function of the kidneys for more than 3 month, at

that time u can say that this is a case of chronic disease, before

that we cannot say that, if there is loss of function of the

kidney we dont know when it started first, if it started acutely,acute injury, and u know what the cause of that infection

"hypertensions, hypotension, bleeding, diarrhea, vomiting, and

so on.

but if this creatinine clearance persist for more than 3 month,

means that the patient has develop chronic kidney disease.

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so: in stage one

the GFR is normal,

but there isstructural defect

or functional

defects in this

kidney

:diseasekidneyw there is a stages of chronicNo

but there is a,above 90clearance isinetincreain stage one:creatininenormallyalso the patient has a,kidneyddisease

chronic diseasecall it, normal serum keratin level, weclearance

stage 1.

what we mean by diseased kidney??, that the patient for

example has glomerulonephritis, or structural defect in the

kidney, or he has one kidney, he has experience ,,for

example a trauma or something, or stone obstruction,, and

he underwent a nephrectomy, has a simple function

kidney.

lessequationtinine clearance isaOnce cre:stage 2in.chronic disease stage 2we call it,/minthan 90 ml

when the creatinine clearance is less than 90, reaching to

. this what we call stage 2 chronicml/minfrom 89 to 60,60

disease.

0

10

20

30

40

50

60

70

80

90

15-29 30-59 60-89 90+

Estimated GFR (ml/min/1.73 m2)

Propo

rtionofpopulation(%)

Hypertension* Hemoglobin < 12.0 g/dL

Unable to walk 1/4 mile Serum albumin < 3.5 g/dL

Serum calcium < 8.5 mg/dL Serum phosphorus > 4.5 mg/dL

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is 59,less than 60tinine clearance isen the creais wh:3Stageup to 30 ml per min,

29 upless than 30,tinine clearance iscrea: when theStage 4to 15 ml,

,and inless than 15 mlwhich is the advance stage, isStage5:the end stage renal disease when the creatinine clearance is

less than 5 to 10 ml , at that time the patient come up tolerate,

and he can't hope well his kidney problem, and he need

support, this support we call it renal replacement therapy,

hemodialysistherapy we mean eitherreplacementwith renal

.or kidney transportationperitoneal dialysisor

is on top ofdiabetic nephropathyhere thejust to rememberthe list and its the most common cause of the end stage renal

Britishaccording to theglomerular diseasedisease in general,

is thehypertensiontheof courseand,ated nephrologyassoci

second or the third according to them,, as well as the

in this disease,includingof courseTubulointerstitial nephritis

patient who are co-experience, and they have also causes and

consider to be one of the causes of chronic disease.

- but plz dont forget that familiar renal diseases as alportsyndrome, cystic disease or fibrous disease and others are

causes of chronic disease.

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How to approach for this patient?? this is not ur job-just refer the patient to the internist for farther

investigations,

- if u see that the patient having diabetes or hypertension with

or without renal impairment,,, just to know something;;;

in ur clinic in the future any patient with diabetes type 2 which

unnecessary to be on incident, type 2 diabetes may be on

incidence or might be on oral, but type one, we never use oral

hypoglycemic drugs.

Summeryvery important to know that: we must know about diabetes,the most common cause of end stage renal disease and

hypertension the second common cause and both coexist which

means that the patient is in risk to developing the toleration of

his kidney function which is might lead to end stage renal

disease.

-around 50% of the patients are type one diabetes, type one

diabetes with is insulin dependent from which is the juvenile

type.

-Plz remember that its the most one, this patient has around 50%

to develop chronic disease and end stage renal disease

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for type2; at the time of diagnoses, f u see a patient with type

2 diabetes u can ask him, since when he has diabetes??,

sometime he remember something, and sometime he doesnt,

even he said that , I know I have diabetes since for example forthe last five years or ten years, does not mean that he has a

diabetes only for the last five or ten years, because he might

have diabetic since long time, and the diabetes of course in

most of the cases when started nobody knows.

so there is incipient diabetes, clinical diabetes, which means

that it's not necessary to say that this patient have diabetessince for example 2001 or 2000 or ,,, He diagnoses diabetes at

that time but he doesnt know his diabetes started when.

so at the time of diagnosis dont forget to send the patient for--clinical assessment to his blood pressurengincludi,,,specialist

because these patient have retinopathy, so theyeyesand his

.diseasechronicallyhave nephropathy

-It's very important this to send ur patient for evaluation at the

time of diagnosis of diabetes.

And the patient with diabetes plz send him for ophthalmology

exam, as well as for monitoring his blood pressure,, if it's not

control to give him the drug which is appropriate as well as ask

for kidney function and urinalysis.

Second point:

That diabetic patient, may there investigation will be normal,

urinalysis normal, kidney function serum creatinine level is

normal, GFR is normal or even high, and he is NO retinopathy,

of nephropathypossibilitytheexcludethis does notFor type 2as this stage, also there is no retinopathy, the vascular disease;

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also there is no micro vascular disease, this patient have a

possibility to have diabetic nephropathy,, why??

Because a stages 1 and 2 even stage 3, the patient has no

, what isnormalall areinvestigation, and the labclinical data

siWhich is used to predict or to disclosed if therethat test

??diabetic nephropathy

,albuminuriamicrohour collection for24urineis to ask for

albumin in the urine exceeding the normal values, normally the

kidney is not excrete protein more than 20 mg per day, in

diabetic nephropathy in stage3 and 2 the protein and urine

might exceed this up to 300 mg, but this cannot be detected by

theroutine lab investigations, urine analysis alone does not

tect if there is a protein inanalysis we can deeby urin,exclude

.ethe urin

but unfortunately this test is not sensitive to detect if

there is protein exceeding less than 300 mg, and if

there is less than 300mg, and above 30mg per day,

means that the patient having proteinuria in form of

micro albuminuria, which reflect that the patient

having diabetic nephropathy.

-As I mention before that the kidneys have many roles inhemostasis of the calcium phosphorus, as well as alkalis, this

way I concentrate on the calcium and phosphorous,

-I would like to remind u to the function of the kidneys, again it

has a role in the hemostasis of water, electrolytes and of

course the blood pressure, as well as the erythropoiesis

secretion, and the remaining is the calcium and phosphorous.

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, in thegutsabsorb from thethat itsas u knowthe calcium-presence of the vD3,, which is the active form 1avD3,,, this

vitamin is the active form of vitamin D, as u know that from the

cholesterol and sunlight they started from there;

there is 25 vitamins D3 in the liver and (1a) vitamin by (1a)

hydroxyls, as well as the clout factor and the 23g guts

fibroblast factors also there is convergent of 25 vitamin D to1.25 vitamin D3, this vitamin is responsible for resorption of the

calcium from the gut, and if u have problem with this with the

convergent of 25 vitamin D, means that u will not have the

active form of the vitamin D3, this means that u have

Hypocalcemia.

-in chronic disease as there loss of function of the nephron

there is,more that loss of the function of the kidney mass

which3of this active form of vitamin Ddecrease of production

leads to decrease of the absorption of the calcium, this will lead

to Hypocalcemia, this is why in chronic disease when the

creatinine clearance is less than 50 or 40ml/ min, there is

decrease of calcium level in the serum, at the same time we

have decrease of execration of the phosphorous, because ofthis is why we haveloss of the function of the kidney,

mightciperhyperphosphatemiaand the,miahyperphosphate

lead to farther decrease of the calcium level,

of theabsorptiondecrease of the-1so we have 2 mechanisms:

.level of the calciumthedecrease-2leading tokidney

Conclusion

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in chronic diseases we have decrease production of 1a vitamin

D3- which is responsible for absorption of the calcium,

this is why we have Hypocalcemia, and we have also reduction

of the excretion of phosphorous because of loss of the kidney

mass leading to hyperphosphatemia,

and both can coexist leading to farther decrease of the

calcium, this is why we have Hypocalcemia, and

hyperphosphatemia in chronic disease,

So we have Hypocalcemia and hyperphosphatemia.

Hypocalcemia perci is the stimulator for parathyroid hormone

,, leading to what??

Increase of PTH "hyperparathyroidism".

This because hyperparathyroidism is secondary because

Hypocalcemia, the chronically disease, we have Hypocalcemia

hyperphosphatemia, and hyperparathyroidism ,, very

important..

The PTH is save, or it

has adverse effects,

the PTH perci within theas a, it hvalues its normal

vascularthe balance between the calcium intramaintainrole to

.and the bones

,, why??the calcium is low, the PTH increasingsa,,owN

its act on the bones, leading to,,feedback mechanismBecause

resorption of the bones, this is why we have osteopenia and

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thiswhat's,,featuresthis what we call hyperparathyroidism

??features

leading to widening of theand others,lesionscysticisThere

medulla of the bones and thinning of the bones and this bones

become as fragile with cystic lesions, leading to fractures..

and because of vitamin D which is the deficiency of active form

of vitamin D, we have problems with the bones, because there

is no continuity, or mineralization of the bone, if we have boys

there is growth retardation, as well as we have rickets in

children, and we also have osteomalacia in adults.

andosteomalaciawe have;in chronic disease actually-

entity, but also we have anotherfeatureshyperparathyroidism

we call it mix type or a dynamic bone disease.

-These are symptoms seen in chronic kidney disease because as

we have a chronic diseases, means that the patient might have

hypertension because of the kidney as I mention before is the

responsible for maintaining of the blood pressure and

hemostasis or the electrolytes as well as the water,,

we haveof courseusually we have anemia andso

.hyperphosphatemiaandHypocalcemia

As I mention before the kidney has a role to generate -1a-

isvitamin Dwhere the,proximal tubuleswhich is the site at the

responsible for absorption of the calcium.

Here actually represent the normal cycle of the calcium, and

this is and down the abnormal in a chronic kidney disease, how

is the PTH in chronic disease and what happens to the bone

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actually and the kidney as u see its not functioning well,, this is

why there is no production of the active form of the vitamin D.

hyperparathyroidism or increase inithwhen the patient w

ffect inethere isthatproblems,bigthey have,PTH levels

asdeficiencybecause of the vitamineof the bonmineralization

of PTHthe increasedofbecauseresorption,because ofwell as

of the bonesdemineralizationwithalongas well as there is

stal depositioncalcium phosphorous cryo athere is als

everywhere, because of low calcium and high phosphorous

there is inhomogeneous deposition of the calcium phosphorusin the bones as well as it might deposit in other tissues far from

the bones, this lead to calcification of the tissues.. v imp

In patients with chronic disease and advance chronic diseaseactually might have calcification of the vessels, this is why we

have angina, ischemic heart diseases, we have calcified blood

vessels, leading to ischemia of the peripheral vessels limbs, andalso in the heart leading to conducting abnormalities as well as

in the valves it might lead to obstruction of the vessels leading

which is mean that"calciphylaxisinform ofischemiato sever

."in the tissuesdeadthere is

It's very important to know about this,, because patients with

severe form of chronic disease as the PTH is high and there is

no vitamin D, and if u supply them with replacement therapy

with calcium and -1a-,, this might lead to calcification here and

there and a patients with a chronic disease and Hypocalcemia

hyperphosphatemia, and high PTH, there are borne for

fracture..

,, this is why we should know that patients with advance stage

which they have andosteopeniafrompartadisease,of chronic

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hyper parathyroid seizuresin form ofcystic lesionsapart from

of site propose cystica and the deposition of calcium

gile bonesathey are also have fr,here and therephosphorous

and they have fractures and once u have patients withfractures bone this means the mortality rate is high in this

patients because it reflect that the disease so advance and the

patient Is in high risk for calcification in other sites as the heart

as the major vessels which might lead to obstructions of this

wein children,osteomalaciain adultthis we call itand,vessels

.ricketscall it

We have 4 types of hyperparathyroidism features:

Picture ofcalcified valve; we can see

here this is the valve with calcification

and thrombus as well, it's not

uncommon to see such a problem in

advance stages of chronically disease

who are not good treatment.

For management of chronic disease it's not your job, but u

should know that u should know something regarding the

chronic disease that patient with chronic disease, they are in a

risk of progressed this is why we should stop as possible the

acceleration of the process, to delay the progression to end

stage renal disease.

??woH

if the patient is diabetic we should control his diabetes aspossible.

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control his blood pressure.

is most of the patient has proteinuria and some degree of,snot in the normal valueproteinmmalnutrition, we give the

"80%"of the normal protein diet for normal people.

orprogressionWhat is that thing u should do in preventingQ:

to delay the progression of chronic disease?

the blood pressure, BECAUSE;trol the blood pressureCon-

stone incornercontrol is the most important and this is the

,,of chronic diseaseprogressiondelaying the

-Actually the mineral bone disease what we call in chronic

disease affecting the skeleton, the bones, the soft tissues, the

.renal dystrophyethis is why we call it befor,vessels

renalbone disease andmineralwe call itdaysnow a-

dystrophy by which we mean that the patient having more than

one feature of bone involving as osteomalacia or rickets,because the mineralization of the bone and there is osteoid

without mineralization,, this seen in children and in adults.

-If u see a children with growing

bones or retardation, please u

should know that this patient could

have vitamin deficiency and one ofcommon causes of vitamin

deficiency is the chronic disease

because ofdecrease of synthesis of the active form vitamin D,

, this is why this patient aresin adultosteomalaciais;econdS

prone for fractures and rupture for muscles, most of the

patient have muscle weakness.

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the PTHne disease which means thatois the dynamic bthird

is low or normal but the calcium is high and there is no

synthesis of bone and the turnover is too slow, this is why it will

lead to easy fracture and rupture of the muscles,

mineralization of the bone asinhomogeneousisthereforth

well as the sites this is why u can see the calcification

everywhere and u can see the vessels calcified, and this patient

also prone for a conductive abnormalities and might develop

arrhythmias and might affect their life.

Summary:

-Ur role is to detect chronic disease or elevate serum creatinine

level in any patient who is candidate to any medical treatment.

-Dont give any drug without knowing the kidney function ofthe patient because any patient might develop sever form of

kidney functions impair.

-Dont forget that the patient with diabetes as well as thehypertension we would like to control there diabetes , and to

control blood pressure

-Dont forget to ask for some lab investigations, it's one of urtarget it to decrease the incidence for chronic kidney disease or

end stage renal disease,, because this is v imp, our role actually

is to decrease the incidence of such problem.

- at the time of diagnose diabetes we must ask about some lab

investigations including urinalysis , detecting for protein,

Looking for protein in the urine and check their blood pressure,

to ask for some lab investigations and dont forget to send thepatient for ophthalmo copy to see if there is retinopathy,

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because patients with type 1 diabetes up to 95% of these they

might have retinopathy,

for type 2 up to 70% of these patient should have retinopathy,

although they might have clinical evidence or manifestation of

diabetic nephropathy.

For the bonesId like just to inform you that about the calciumthat is usually low and the phosphorous is high and PTH is high

and thats secondary hyperparathyroidism, and it will act onthe bones leading to resorption of the bone and of course it

might affect the muscles as well causing muscle weakness and

liability for fractures, some pts especially children might have

rickets and growth retardation so should give supplement of vit

D and calcium.

-For PTH it is always toxic in high levels also in addition to

resorption of bone it may lead to etching and other

manifestations.

the most important with a patient with established kidneydisease is to control BP, and even BP is normal you might give

drugs , in diabetic nephropathy even creatinine is normal and

kidney clearance is normal we might give them

antihypertensive agents to decrease the intra glomerular

pressure , because increase in intra glomerular pressure is themain cause to proteinuria.

-Some pts we give them ACG inhibitors or ARBS although they

have normal BP , our aim is to decrease intra glomerular

pressure.

For diabetic pts with type 1 or 2; our target is to decrease the

systemic BP up to 120/80 this is max which we need 100/70 is

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our target specially if there is proteinuria , if there is not 120/80

is acceptable and not more than 130/80 for pts with diabetes

and nephropathy this lead to decrease IGP and ameliorate

proteinuria which has toxic effect on the tubuloglomerular aswell as tubules leading to delay of the progression of the

disease.

- is a new term because the mineral bonechronically disease

disease and renal acidosis is the same, but mineral bone

disease we actually added the calcification of the vessels

because it is also important, even may be its more importantthan the bones because in the calcification of the vessels we

have problems like calciphylaxis or calcification of the valves so

we call it mineral blood disease.

is the same till-chronically disease and chronic renal fail

we use in most literature and in your text books you will see

chronically disease but you can see chronic renal failure it is thesame as acute renal failure and acute kidney injury, these are

terms that we use it nowadays frequently but CRF is a valid

term and chronic renal impairment as well.

Q; Regarding the calcification you mentioned earlier from 90-

130 as we get older that level decreases so if ?

As the serum creatinine level is normal for such pts in this age

for adult pts, of course creatinine clearance also depend on

some factors other than the ages like gender of the pt as well

as the age and the body built;

The CC as it above 90 ml/min this means that it is normal but

less than 90 ml/min this is abnormal, with age there is loss of

GFR around 10 ml/decade, some people believe above the age

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of 30 some above the age of 40, but a pt who is 40 he is 80 yrs

old, I expect that the GFR around 50 -55 ml/min, it is a case of

chronic disease but serum creatinine level is normal, in most of

these cases if you do kidney function test you will see thatserum creatinine is normal although GFR is low, this is because

what we call aging in the fluscelerosis, this is an entity, we can

consider this pt as having chronic kidney disease stage 2,

because there is structural defect if you do biopsy for this pt,

you will see that there is sclerosis in glomeruli this is why these

pts along with their low GFR or low creatinine clearance which

reflect the loss of nephrons, means about 50% of the nephrons

are functioning, the other 50% are lost;

if you will do biopsy; you will see that around 50% of the

nephrons are affected there is tubular loss, there is fibrosis and

tubular atrophy and glomerulosclerosis, it could be not totally

sclerosed it could be partially this is why the total around 50%

of the total function, this entity we call it aging

nephrosclerosis.

As you do biopsy for the muscles for example in young pt who

is 20 yrs old, and biopsy muscled for a pt who is 90 yrs old,

there will be difference, there is fibrosis and loss of the actin

and myosin and so on,

this is why we know that these pts they maintain normal

kidney function in regards to their ages, we cannot say they

have chronic disease according to this because to this

calcification they have chronic disease stage 2.

Q:Repeating the stages??

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-Stage 1 normal CC, but to call it chronic disease there is

disease in the kidney, there is solitary function kidney or

interstitial nephritis or diabetic nephropathy but doesnt affect

the CC so CC is normal but there is defect in the function of thekidneys

- Stage 2 : 89-60, Stage 3 : 59- 30, Stage 4 : 29- 15, Stage 5 :

less than 15, Stage 6 : from 5-10

Im pleased If you know these :D

-creatinine clearance, stages of chronically disease

-diabetes is one of the most important causes and end stage

cause.

-hypertension at diabetes is very bad.

-coexistence and tethering is that the Ca is low Ph is high, PTH

is high

-Mineral bone disease with calcifications and bone deformity in

children as well as growth retardation.

-Fracture prognosis about pts with chronically disease or

advance stage, usually the homeostasis of Ca and Ph is clinically

obvious when the CC is less than 30ml/min , but actually it is

started when the pt is in stage 3 when CC is less than 60ml/min.

Special thanks to; malak abuaqolah

Plz return to the slides,

" ,, ,, "

DONE by; asma'a almawas