chronic kidney disease.ppt

SOMETHING ABOUT CHRONICC KIDNEY DISEASE

1. Chronic Kidney Disease Presented by Dr SHASHANK medicine

2. Chronic Kidney Disease (CKD) Involves progressive, irreversible loss of kidney function Defined as either presence of Kidney damage Pathological abnormalities Glomerular filtration rate (GFR) <60 ml/min for 3 months or longer

3. CKD death Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Screening for CKD risk factors CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant Normal Increased risk Kidney failure Damage  GFR

4. Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 88-94) Stage Description GFR (ml/min/1.73 m 2 ) Prevalence* N (1000s) % 1 Kidney Damage with Normal or  GFR  90 5,900 3.3 2 Kidney Damage with Mild  GFR 60-89 5,300 3.0 3 Moderate  GFR 30-59 7,600 4.3 4 Severe  GFR 15-29 400 0.2 5 Kidney Failure < 15 or Dialysis 300 0.1 *Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two measurements.

5. Chronic Kidney Disease Leading causes of ESRD Diabetes Hypertension Last stage of kidney failure End-stage renal disease (ESRD) occurs when GFR <15 ml/min

6. CKD – Risk Factors Diabetes Mellitus Hypertension Cardiovascular Disease Obesity Metabolic Syndrome Age and Race Acute Kidney Injury Malignancy Family history of CKD Kidney Stones Infections like Hep C and HIV Autoimmune diseases Nephrotoxics like NSAIDS

7. Chronic Kidney Disease Clinical Manifestations Uremia Syndrome that incorporates all signs and symptoms seen in various systems throughout the body

8. Manifestations of Chronic Uremia Fig. 47-5

9. Chronic Kidney Disease Clinical Manifestations Urinary system Polyuria Results from inability of kidneys to concentrate urine Occurs most often at night Specific gravity fixed around 1.010 Oliguria Occurs as CKD worsens Anuria Urine output <40 ml per 24 hours

10. Chronic Kidney Disease Clinical Manifestations Metabolic disturbances Waste product accumulation As GFR ↓ , BUN ↑ and serum creatinine levels ↑ BUN ↑ Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headaches occur

11. Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Sodium May be normal or low Because of impaired excretion, sodium is retained Water is retained Edema Hypertension CHF Potassium Hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysrhythmias

12. Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Calcium and phosphate alterations Magnesium alterations Metabolic acidosis Results from Inability of kidneys to excrete acid load (primary ammonia)

13. Chronic Kidney Disease Clinical Manifestations Hematologic system Anemia Due to ↓ production of erythropoietin From ↓ of functioning renal tubular cells Bleeding tendencies Defect in platelet function Infection Changes in leukocyte function Altered immune response and function Diminished inflammatory response

14. Chronic Kidney Disease Clinical Manifestations Cardiovascular system Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis

15. Chronic Kidney Disease Clinical Manifestations Respiratory system Kussmaul respiration Dyspnea Pulmonary edema Uremic pleuritis Pleural effusion Predisposition to respiratory infections Depressed cough reflex “Uremic lung”

16. Chronic Kidney Disease Clinical Manifestations Gastrointestinal system Every part of GI is affected Due to excessive urea Mucosal ulcerations Stomatitis Uremic fetor ( urinous odor of the breath) GI bleeding Anorexia N/V

17. Chronic Kidney Disease Clinical Manifestations Neurologic system Expected as renal failure progresses Attributed to Increased nitrogenous waste products Electrolyte imbalances Metabolic acidosis Demyelination of nerve fibers Altered mental ability Seizures and Coma Dialysis encephalopathy Peripheral neuropathy

18. Chronic Kidney Disease Clinical Manifestations Neurologic system Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate Reproductive system Infertility Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction

19. Chronic Kidney Disease Clinical Manifestations Musculoskeletal system Renal osteodystrophy Syndrome of skeletal changes Result of alterations in calcium and phosphate metabolism Weaken bones, increase fracture risk Two types associated with ESRD: Osteomalacia Osteitis fibrosa

20. Renal Osteodystrophy

21. Chronic Kidney Disease Clinical Manifestations Integumentary system Most noticeable change Yellow-gray discoloration of the skin Due to absorption/retention of urinary pigments Pruritus Uremic frost Dry, pale skin Dry, brittle hair Thin nails Petechiae Ecchymoses

22. Chronic Kidney Disease Diagnostic Studies Laboratory tests (cont’d) Urinalysis Urine culture Hematocrit Hemoglobin Urea Creatinine Renal ultrasound Renal scan

23. Chronic Kidney Disease Collaborative Care Drug therapy Hyperkalemia IV insulin and glucose IV 10% calcium gluconate Raises threshold for excitation Sodium bicarbonate Shift potassium into cells Correct acidosis Sodium polystyrene sulfonate ( Kayexalate ) Cation -exchange resin Resin in bowel exchanges potassium for sodium Evacuates potassium-rich stool from body Educate patient that diarrhea may occur due to laxative in preparation

24. Chronic Kidney Disease Collaborative Care Drug therapy Hypertension (cont’d) Antihypertensive drugs Diuretics β -Adrenergic blockers Calcium channel blockers Angiotensin -converting enzyme (ACE) inhibitors Angiotensin receptor blocker agents

25. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy Phosphate intake restricted to < 1000 mg/day Phosphate binders Calcium carbonate (Tums) Bind phosphate in bowel and excreted Sevelamer hydrochloride ( Renagel ) Lowers cholesterol and LDLs

26. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Phosphate binders (cont’d) Should be administered with each meal Side effect: Constipation Supplementing vitamin D Calcitriol ( Rocaltrol ) Serum phosphate level must be lowered before administering calcium or vitamin D

27. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Controlling secondary hyperparathyroidism Calcimimetic agents Cinacalcet ( Sensipar ) ↑ Sensitivity of calcium receptors in parathyroid glands Subtotal parathyroidectomy

28. Chronic Kidney Disease Collaborative Care Drug therapy Anemia Erythropoietin Epoetin alfa ( Epogen , Procrit ) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Side effect: Hypertension

29. Chronic Kidney Disease Collaborative Care Drug therapy Anemia (cont’d) Iron supplements If plasma ferritin <100 ng /ml Side effect: Gastric irritation, constipation May make stool dark in color Folic acid supplements Needed for RBC formation Removed by dialysis Avoid blood transfusions

30. Chronic Kidney Disease Collaborative Care Drug therapy Complications Drug toxicity Digitalis Antibiotics Pain medication (Demerol, NSAIDs)

31. Chronic Kidney Disease Collaborative Care Nutritional therapy Protein restriction 0.6 to 0.8 g/kg body weight/day Water restriction Intake depends on daily urine output

32. Chronic Kidney Disease Collaborative Care Nutritional therapy Sodium restriction Diets vary from 2 to 4 g depending on degree of edema and hypertension Sodium and salt should not be equated Patient should be instructed to avoid high-sodium foods Salt substitutes should not be used because they contain potassium chloride

33. Chronic Kidney Disease Collaborative Care Nutritional therapy Potassium restriction 2 to 4 g High-potassium foods should be avoided Oranges Bananas Tomatoes Green vegetables

34. Chronic Kidney Disease Collaborative Care Phosphate restriction 1000 mg/day Foods high in phosphate Dairy products Most foods high in phosphate are also high in calcium

35. Thank you