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Prof. Jamal Al WakeelProfessor of Internal Medicine, Nephrology
ConsultantNephrology Unit, Department of Medicine
Chronic Kidney Disease
Chronic Kidney Disease
• Objective– Epidemiology of CKD
• Definition of CKD• Classification• Symptoms, signs and complications• Management of CKD
Case Study
67 yrs. old man with previous history of hypertension came to Emergency with history of nausa , generalize weakness and lossing weight . The nurse recorded that his vital signs are:
• BP – 190/105 mmHg• Pulse rate – 50 beats/min
What will your approach be for this case?
History
• History of major complain• History of present illness
– Duration– course of the disease– Associated symptoms– History of hypertension– History of system affected
• History of weight loss in 6 months• ↓ appetite • Nausea and vomiting• History of urinary symptom• History of uremia
History
• Systemic review• Past Medical illness• Surgical• Medication• Family• Social• Allergy
Examination
Examination
• Posture• Look ill• BMI – 27 m2
• Blood pressure -185/80 mmHg sitting both arm• Pulse rate – 50 beats/min• Breathing pattarn• Pale• Edema• Mouth • Itching marks• Hand examination
Cardiovascular examination
• JVP – 5cm • S1 + S2• ESM grade II at apex• No pericardial rub
Chest examination
• Scratch mark in the back• Right side – stony dullness• ↓TVF in right side• Bilateral basal crepitation • ↓breathing sound at right side
Abdominal examination
• Scratch mark• No organomegaly • No bruits• No shifting dullness
CNS
• Drowsy • Fundus examination • No asthraxis • Normal power• Normal Sensation• Normal Coordination
Clinical Diagnosis
• CKD• Hypertension stage III• Anemia• Functional murmur• Itching• Right pleural effusion• Fluid overload with pulmonary edema• Bready cardia
European Society of Nephrology Classification of Blood Pressure Levels
Category Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Optimal blood pressure
<120 <80
Normal blood pressure
<130 <85
High-normal blood pressure
130-139 85-89
Grade 1 hypertension (mild)
140-159 90-99
Grade 2 hypertension (moderate)
160-179 100-109
Grade 3 hypertension (severe)
>/= 180 >/= 110
Isolated systolic hypertension
>140 <90
Investigation
• CBC– Hemoglobin –98g/L– WBC – 5,000/L– Platelet – 120,000/L– MCV – 82 fL
• Biochemistry– NA – 139 mmol/L– K – 6.3 mmol/L– Cr –330 μmol/L– Urea – 24 mmol/L
Investigation
• Ca – 1.9 mmol/L• PO4 – 3.9 mmol/L
• Albumin – 29 g/L• Uric acid 690 mmol/L• Bicarbonate 14 mmol/L• Cholride 105 mmol/L
Urine analysis
• pH -6• Urine RBC = negative • WBC – 5 cu/L • Protein = ++ve• Specific gravity – 1010• Broad waxy cast .
Ultrasound
• Small right and left kidney – 8cm • ↑ echogenicity
Diagnosis
• CKD - cause possible hypertension -stage G 3 b(eGFR 36ml\mint) A +3• Hyperkalemia• Metabolic acidosis –high anion gap• Anemia• Hypocalcemia • Hyperphosphatemia • Hyperuricemia
Prevalence of CKD
• CKD in aged ≥20 yrs is >10% -18%
. The prevalence of CKD increases with age:
• 4% at age 29-39 y • 47% at age >70 y
Prevalence of CKD
Prevalence of CKD• Prevalence of CKD in Saudi Arabia – 5-8%
• Prevalence of ESRD in Saudi Arabia-19,527o Hemodialysis – 12,844o Peritoneal dialysis – 1,327o Renal Transplantation – 5,356
Dialysis Population-Current and Projected (1995-2015)
19951996199719981999200020012002200320042005200620072008200920102011201320150
2000
4000
6000
8000
10000
12000
14000
16000
3869
4322 4861
52066008
70297383
7833752678098482
953310280
1116812040
1263313356
13928
15074
Saudi J Kidney Dis Transplant 2012;23 (4):881-889
Risk Factors CKD
Diabetes Mellitus 35%
Hypertension 25%
Old age 50%
Low GFR
Obesity
Cardiovascular disease
Family history
Smoking
CKD Complications and Managements
Stroke
Cardiovascular Disease
Recognized as the 9th leading cause of death in the United States
Mineral and Bone Disorder
pHAcidosis
Drug DosingInfection
Acute coronary syndrome
Heart failure Heart rhythm
disturbances
AnemiaESRD
Mineral abnormalities of Chronic Kidney Disease (CKD)
↓GFR
↑Phosphorus↑ FGF 23
↓Calcium ↑PTH
↓25(OH) Vitamin D
↓1,25(OH) Vitamin D
Consequences of CKD-MBD
National Kidney Foundation. Am J Kidney Dis. 2003;42(suppl 3):S1-S201.Block GA, et al. J Am Soc Nephrol. 2004;15:2208-2218.Kestenbaum B, et al. Eur J Clin Invest. 2007;37:607-622.Goodman WG, et al. Am J Kidney Dis. 2004;43:572-579. Moe S, et al. Kidney Int. 2006;69:1945-1953.
Abnormal calcium, phosphorus, PTH,
vitamin D metabolism Calcification
Laboratory Abnormalities Calcification
Vascular or other soft tissue calcification
Renal Osteodystrophy
Abnormal bone turnover, mineralization, volume,
linear growth, or strength
• Bone pain• Fractures• Parathyroid hyperplasia• Parathyroidectomy
• Cardiovascular events• Hospitalization• Mortality
Clinical Consequences
© 2008 Amgen. All rights reserved.
KDIGO® Classification of Renal Osteodystrophy/Renal Bone Disease
KDIGO® is a registered trademark of the National Kidney Foundation, Inc.
Moe S, et al. Kidney Int. 2006;69:1945-1953. Reprinted by permission from Macmillan Publishers Ltd, 2008.
Definition:Renal osteodystrophy is an alteration of bone morphology in patients with CKD. It is one measure of the skeletal component of the systemic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy.
TMV Classification System for Renal Osteodystrophy
Low
Normal
High
Turnover Mineralization Volume
Normal
Abnormal
Low
Normal
High
Chronic Kidney Disease
Kidney damage
Structural abnormalities
Functional abnormalities
GFR < 60 ml/min/1.73 m2
for ≥3 months
Criteria for CKD (either of the following present for >3 months)
Markers of kidney damage
(one or more)
Albuminuria (AER ≥30mg/24 hours; ACR≥30mg/g [≥3mg/mmol])
Urine sediment abnormalities
Electrolyte and other abnormalities due to tubular disorders
Abnormalities detected by histology
Structural abnormalities detected by imaging
History of kidney transplantation
Decreased GFR GFR <60 ml/min/1.73 m2 (GFR categories G3a–G5)
Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate.
Reversible Causes of Kidney Injury
Reversible Factors Diagnostic Clues
Infection Urine culture and sensitivity tests
Obstruction Bladder catheterization, then renal ultrasound
Extracellular fluid volume depletion
Orthostatic blood pressure and pulse:↓blood pressure and ↑pulse upon sitting up or standing from a supine position
Hypokalemia, hypercalcemia, and hyperuricemia (usually >15 mg/dL)
Serum electrolytes, calcium, phosphate, uric acid
Nephrotoxic agents Drug history
Hypertension Blood pressure, chest radiograph
Congestive heart failure Physical examination, chest radiograph
KDIGO recommendation -classified based on:–Cause –GFR category–Albuminuria category (CGA)
Causes of End-Stage Renal Disease
in Hemodialysis Patients in Saudi Arabia- 2012
GFR Categories in CKD
GFR categor
y
GFR (ml/min/1.73 m2)
Terms
G1 > 90 Normal or high
G2 60-89 Mildly decreased*
G3a 45-59 Mildly to moderatelyDecreased
G3b 30-44 Moderately to Severely decreased
G4 15-29 Severely decreased
G5 <15 Kidney failure
* Relative to young adult level In the absence of evidence of kidney damage, neither GFR category G1 or G2 fulfill the criteria for CKD.
CKD ClassificationEstimation and Measurement of GFR
Estimate and/or Measure GFR
Filtration Markers (Endogenous)
Creatinine Clearance (CrCl)
eGFR equationseCKD- EPI cr
eCKD-EPI-cyc
Filtration Markers (Exogenous)
Inulin, iothalamate, EDTA, diethylene
triamine petaacetic acid, iohexol
Cr CL is not measured GFR
CKD ClassificationEstimation and Measurement of GFR
Cystatin C
Virtually found in all tissues and
body fluids
Potent inhibitor of lysosomal
proteinases
Important extracellular inhibitors of
cysteine proteases
Calculators
Cockcroft-Gault
Formula GFR Calculation
MDRD Calculation
CKD – EPICalculation
Albuminuria categories as follows:
*note that where albuminuria measurement is not available, urine reagent strip results can be substituted
Category
AER(mg/24 hours)
ACR(mg/mmol)
ACR(mg/g)
TERMS
approximate
equivalent
A1 < 30 <3 <30 Normal to mildly increased
A2 30-300 3-30 30-300 Moderately increased*
A3 >300 >30 >300 Severely increased**
Albuminuria categories in CKD
*Relative to young adult level** Including nephrotic syndrome (albumin excretion usually > 2200 mg/24 hours [ACR .2220/g; >220 mg/mmol])1
Kidney International Supplements (2013) 3, 5-14
G1 Normal or high > 90 1 if CKD
G2 Mildly decreased 60-89 1 if CKD
G3a Mildly to moderately Decreased
45-59
G3b Moderately to severely decreased
30-44
G4 Severely decreased
15-29 3
G5 Kidney Failure <15
A1 A2 A3
Normal toMildly
Increased
ModeratelyIncreased
Severely Increased
< 30 mg/g< 3 mg/mmol
30-300 mg/g3-30 mg/mmol
>300 mg/g>30
mg/mmol
Persistent albuminuria categoriesDescription and range
GFR categories (ml/min/1.73 m2
Description and Rang
e
Guide to Frequency of Monitoring(number of times per year) byGFR and Albuminuria Category
Green low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red: very high risk.
Kidney International Supplements (2013) 3, 5-14
Signs and Symptoms
Amenorrhea Impotence Infertility
Anemia (Musocal pallor)
Plural effusion, plural edema
Bruising
,Epistaxis,Hyperparathyrodism
Glomerular Filtration Rate mL/min
Diagnosis of CKD
Basic Laboratory studies used in the diagnosis of CKD can include the following:
• Complete blood count (CBC)• Biochemistries(Na, K, Urea, Cr, HCO3, Ca,
PO3, Uric, Albumin, Alk ph)• Urinalysis• Glucose• Lipid profile:
– increased risk of cardiovascular disease
Diagnosis of CKD• Laboratory studies used in the diagnosis
the cause of CKD – ANA – HBsAg– HCV.– C3,C4
– HbA1c• Investigation used in the diagnosis the
complications of CKD – PTH – VIT D3
– ECH – ECG
Diagnosis of CKD
• DifferentAcute Kidney Injury form CKD
• Reversible factors
Management of CKD
• The medical care should:– Delaying or halting the progression of
CKD– Treatment of the underlying condition– Treating the complications– Timely planning for long-term for RRT
Prevention progssof CKD
Glycemic Control
BP control and Proteinuria RAAS
Diet &protrein PO3&salt
Correct Acidosis
Hyperlipidemia
Target HbA1c – KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD - 2012
Individualize Target HbA1c
Patient with comorbidities or limited life expectancy and risk of hypoglycemia
HbA1c >7.0%
Young patient, recent Diabetes Mellitus ~7.0%
Target Blood Pressure in CKD
Diabetics and Non-diabetics
Albuminuria Target BP Drug of choice
<30 mg/d ≤140/90 CBC, Diuretic, RAAS
>30 mg/d ≤ 130/80 ARB or ACE-I
Proteinuria control in CKD
Diabetics and Non-diabetics
Abumineria Causes of Renal Disease
Drug of choice
A2 or >30 mg/d>3 mg/mmol
DM ARB or ACE-I
A3 or >300mg/d NonDM CKD
ARB or ACE-I
CKD Management In Adults
• Treatment of hyperlipidemia to target level• Treat acidosis• Treat metabolic bone disease• Avoidance of nephrotoxins including:
– Intravenous (IV) radiocontrast media– Nonsteroidal anti-inflammatory agents (NSAIDs)– Aminoglycosides
Renal Diet
• Low salt diet – 3 g/day• Low potassium diet
– <50 – 60 mEq/d (2g) , half of normal intake
• Low protein diet - 0.6 to 0.8 g/kg per day• Low phosphorous diet – 800 – 1000
mg/day• Water intake – daily water intake 2 L• Restricted Magnesium
• Vaccination • Preserve both arm for fistula • Early refer to nephrologist
CKD Management In Adults
Treatment of Complications
• Volume overload:– restrict SALT– loop diuretics
• Metabolic acidosis:– oral alkali supplementation
Treatment of Complications• Anemia: hemoglobin level ↓10 g/dL – check iron -iron Tablet or IV erythropoiesis-stimulating agents (ESAs)
– epoetin alfa– darbepoetin alfa– Methoxy polyethylene glycol-epoetin beta(Mircera)
• Hyperkalemia Low K Diet Resonium Ca ,Na resonium• Hyperphosphatemia
– dietary phosphate binders (Ca Carbonate,Ca Acetate,Sovlomier,lanthium)
– dietary phosphate restriction• Hypocalcemia:
– calcium supplements with or without calcitriol• Hyperparathyroidism:
– Calcitriol– vitamin D analogs
Treatment of Complications
• Uremic manifestations: –Long-term renal replacement therapy
»hemodialysis, »peritoneal dialysis » renal transplantation
Indications for renal replacement therapy
• Severe metabolic acidosis• Hyperkalemia• Pericarditis• Encephalopathy• Intractable volume overload• Failure to thrive and malnutrition• Peripheral neuropathy• Intractable gastrointestinal symptoms• In asymptomatic patients
– GFR of 5-9 mL/min/1.73 m²
Hemodialysis
Peritoneal Dialysis
Renal Transplantation
Renal Transplant Rejection
Renal Transplant Medication
