CKD presentation-Dr. Reyad 19.3.2024.pptx

How to approach a patient with CKD

1. Chronic Kidney Disease Dr. Enamul Hassan Reyad

2. Definition of CKD 3/18/2024 2 CKD is defined as abnormalities of Kidney structure or function, present for>3 Months, with implications for health and CKD is classified based on cause, GFR category, and albuminuria category (CGA).

3. Common Clinical Features • Symptoms are often absent until renal failure There may be long term history or hypertension, diabetes or past h/o AKI    Vague symptoms like- •  Loss of appetite  &  weight •  Nausea, weakness, Hiccups •  Dyspnoea •  Recurrent hypoglycemia •  Muscle cramps, restless legs •  Pruritus •  Signs like Edema, Peripheral neuropathy, Hypertension •  Pericardial friction rub, asterixis not attributable to other cause

4. Approach to patients of CKD There is history of hypertension, diabetes, abnormal urinalysis. History of intake of drugs like NSAIDs, antimicrobials, chemotherapeutic agents, ARVs, Lithium should be elicited Any family history of kidney disease with visual, auditory or cutaneous manifestations   helps in diagnosis of heritable form of CKD

5. D i a g n o s i n g A K I on CKD AKI m a n a g e m e n t p l an H ow to Pre v e n   t   AKI   I dentify all CKD 3 - 5 patients as increased risk for AKI   Early identification of patients at risk with acute illness,and  consider temporary cessation of ACE Inhibitor/ARB/diuretics with hypovolaemia /hypotension    Minimise and mon i tor NSAIDs with CKD H o w t o d i ag n o s e A K I I n c r ease i n s e r u m cre at in i ne • => 25 µ mol/I w i th i n 48 h ours  or Increase in serum creatinine to=>1.5 times baseline which is known or presumed to have occurred within the prior 7 days; or    Significant reduction in urine output compared with normal output

6. Investigations CBC S. Creatinine  S. Electrolytes Urine ACR Serum Iron, Folate, Vit B12 levels Serum calcium, phosphate, vit D and Parathyroid levels, Lipid profile HIV, HBsAg and HCV Autoimmune screening Serum and urine protein electrophoresis 24hr urine protein estimation

7. Imaging Studies   Renal USG •  Can verify presence of two kidneys •  Estimate kidney size •  Symmetry •  Renal masses and obstructions •  Bilaterally small kidneys suggests CKD of long duration •  Kidney size maybe normal in CKD due to Diabetic nephropathy, Amyloidosis, HIV nephropathy •  Polycystic kidney disease presents as enlarged kidneys with multiple cysts

8. Diagnosis of renovascular disease can be done by  Doppler sonography, MRI. DEXA scan to assess the  severeity  of metabolic bone disease. IF suspicious of reflux nephropathy, micturating cystourethrogram may be indicated. Oral  phosphate-containing bowel preparations  should not be used in people with a GFR <60 ml/min/1.73 m2 (GFR categories G3a-GS)  Measures to prevent contrast induced nephropathy   IV or Intrarterial dye to be avoided.   Avoidance of hypovolemia   Minimization of dye load Choosing least nephrotoxic dyes

9. Usually done by USG guided, Surgical or Laparoscopic approach In patients with bilaterally small kidneys renal biopsy is not advised because Technically difficult More chance of  bleeding and other adverse effects  More scarring. So disease may not be apparent Contraindications : Uncontrolled hypertension Active UTI Bleeding diathesis Morbid obesity Renal biopsy

10. Criteria of CKD ( Either of the following present > 3months) Markers of kidney damage (one or more) - Albuminuria (AER <30 mg/ 24 hours; ACR <30 mg/g [<3 mg/ 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

11. MANAGEMENT The medical care of patients with CKD should focus on the following : Delaying or halting the progression of CKD Diagnosing and treating the pathologic manifestations of CKD Timely planning for long-term renal replacement therapy

12. Stage Description GFR ,  ml/min per 1 . 73 m 2 Action* 1 Kidney damage with normal or increased GFR > 90 Diagnosis and treatment, treatment of comorbid conditions, slowing progression and CVD risk reduction 2 Kidney damage with mild decreased GFR 60-89 Estimating  progression 3 Moderate decreased GFR 30-59 Evaluat i ng and treat i ng complications 4 Severe decreased   GFR 15-29 Preparation for  k i dney replacement therapy 5 Kidney failure < 15 (or dialysis) Kidney replacement  ( if  uremia present)

13. Slowing the progression of CKD •  Reducing intraglomerular Hypertension and Proteinuria •  ARB or ACE-I be used in diabetic adults with CKD and urine albumin excretion 30-300 mg/24 hours •  ARB or ACE-I be used in both diabetic and non-diabetic adults with KD and urine albumin excretion  >300  mg/24 hours Target  blood  pressure -130/80 mmHg  ,  125/75 mm Hg if proteinuria >  1 g/day •  ACE inhibitors and ARBs first line agents •  Adverse effects from these agents include cough and angioedema with ACE inhibitors, anaphylaxis, and  hyperkalemia,and  reduced GFR with either class

14. D Decreased p erfus i on pressure i n t h e p resence of ACE-I or ARB Slightly increased vasodilatory prostaglandins Low G F R D ecreased angiotensin 1 1

15. Slowing the progression of Diabetic renal Disease Control of Blood Glucose Optima l  blood glucose control significantly  reduces  the risk of  developing  microalbuminuria, macroa l buminuria and/or overt nephropathy in peop l e with Type 1 or Type 2 diabetes. Preprandial  glucose be kept  in  the  5.0-7 . 2 mmol/L ,  ( 90-130 mg/dl ) He mog l obinA1C shou ld  be <  7% .  Hb A1C  may be  maintained above  7%  if ha v ing  recurrent  hypoglycemia. Management Lifestyle modification Oral hypoglycemic Gliptins lncretin  mimetic Insulin Metformin can be continued in people with GFR  >45 m l/ min/1.73 m2 (GFR categories G1- G3a); its use  should be reviewed in those with GFR 30-44 m l/ min/1.73 m2 (GFR category G3b); and it should be  discontinued in people with GFR  < 30  ml/min/1.73 m2

16. DIET ​ At least 50% of the  protein intake be of high biologic  value ​ Stage 4  &  stage 5 CKD - 0 . 8 g/kg/day Caloric requirement - 35cal/kg/day ​ Salt - 2 g of sodium equivalent to 5 g of NaCl/day except in salt loosing nephropathies ​

17. MANAGING OTHER COMPLICATIONS OF CHRONIC KIDNEY DISEASE ​

18. Management Of Fluid, Electrolyte and Acid - Base Disorders   Dietary salt restriction and use of loop diuretics. Salt supplementation and sodium rich diet may be required in rare patients of salt loosing nephropathy. Itractable  ECFV expansion despite salt restriction and diuretic therapy maybe an indication to start renal replacement therapy. Metabolic Acidosis   RTA with Anion Gap metabolic acidosis responds to Sodium Bicarbonate supplementation  (1or 2 tablets BD) Sodium Bicarbonate supplementation when serum bicarbonate level below 20 - 23 mmol/I

19. Hyperkalemia Dietary K+ restriction Kaliuretic diuretics K+ binding  resins like Calcium  resonium , Calcium polystyrene  sulphonate . Cease ACE  inhibitor/A RB/spironolactone  if K+ persistently  >   6 . 0 mmol/L not responding to above therapies Dialysis in case of intractable hyperkalemia

20. Disorders of Calcium and Phosphate Metabolism Low phosphate diet and use of phosphate - binding agents Calcium acetate and calcium carbonate bind to dietary phosphate in GI tract. Adverse effect - Hypercalcemia. Calcitriol suppresses PTH secretion by both direct and indirect mechanisms. Calcitriol also causes hypercalcemia  and  hyperphosphatemia. Cinacalcet  (30-90mg/day) -  Calcimimetic  drug that causes dose dependent reduction  in PTH and  plasma  calcium concentration.

21. Hypertension Goal is to prevent the extrarenal complications of HTN like cardiovascular disease and stroke. In CKD patients with diabetes or proteinuria  > 1g/day BP should be reduced to below <130/80 mmHg Salt restriction (<2 g of sodium/day) ACE inhibitors and ARBs slow the decline in renal function ACE inhibitors and ARBs are contraindicated in case of renal artery stenosis and Hyperkalemia. Can precipitate AKI on CKD

22. ACEI and ARB should be continued if reduction in GFR is less than  <25% after 2 months. ​ If the reduction in GFR is more than 25% below the baseline value, the  ACE inhibitor or ARB should  be ceased. ​ Caution should  be exercised if baseline K+ is>5.5 mmol/L, as rises in serum K+ of approximately  0.5 mmol/L are expected. ​ both non-loop diuretics (e.g., thiazides) and loop diuretics (e.g., frusemide) are effective in all stages of CKD as adjunct  antihypertensive therapy. ​ Beta-blockers may be useful in people with coronary heart  disease,tachyarrhythmias  and heart failure. ​ Calcium channel blockers may be used for people with angina, the elderly and those with systolic hypertension ​

23. MANAGEMENT OF CARDIOVASCULAR  DISEASE Lifestyle changes, including regular exercise at least 30 mins/day, 5 days a week Manage dyslipidemia If aged > 50 years with any stage of CKD (irrespective  of lipid levels): Statin if eGFR is >  60 mt/min / 1.73 m2 Statin or statin/ezetimibe combination if eGFR is < = 60ml/min/1.73 m2 If age< 50 years with any stage of CKD (irrespective  of lipid levels): - Statin if presence of one or more of : coronary disease Previous ischaemic stroke diabetes estimated 10-year incidence of fatal or non-fatal myocardial infarction above 10%

24. Pericardial Disease ​ Uremic pericarditis is an absolute indication for urgent initiation of dialysis. ​ Hemodialysis should be performed without heparin. ​ Pericardial drainage procedure in patients with recurrent pericardial effusion with signs of impending tamponade. ​

25. Anemia Recombinant human erythropoietin Iron supplementation is essential for optimal response  to  erythropoietin Once ESA commenced, maintain:  Ferritin  200 -500  µg/L; TSAT  20 -30% IV iron  supplementation  for GI intolerance or patients on  hemodialysis  . B12 and   Folate  supplementation  should  be done. Anemia  resistant to ESA  in presence of adequate  iron  stores  maybe due to Acute or chronic inflammation Inadequate dialysis Severe  hyperparathyroidism Chronic  blood  los s

26. Blood transfusions increase the risk of ​  Hepatitis ​ Iron overload ​  Transplant sensitization ​ ​  ESA in CKD maybe associated in with an increased risk of stroke in those with type 2 DM and an increased risk of thromboembolic events ​  Target Hb must be 10 - 11.5 g/dl ​

27. Muscle cramps • Encourage stretching and massaging of the affected area. • Correction of electrolyte imbalance. Pruritus • Evening Primrose Oil, Skin emollients • If both pruritus and restless legs are present, consider gabapentin • For persistent pruritus, consider ultraviolet light B (UVB) therapy Restless legs • Dopaminergic agents or dopamine agonists • Benzodiazepines Sleep apnoea • Weight  reduction • CPAP therapy

28. Referral to Nephrologist eG F R  <  30 ml/min/1.73m 2   (Stage 4  or 5 CKD of    any  cause) Persistent significant  alburninuria  (urine  ACR =>30 '  mg/mmol) A  sust ained decrease  in  eGFR of 25%  or more  OR  a sustained decrease in  eGFR o 15 ml/min/1.73m 2   within 2  months CKD with h ypertension that is  hard  to get  to  target  despite at least  three  anti hypertensive agents

29. Renal Replacement Therapy

30. Criteria For Initating Dialysis • Presence of uremic symptoms especially Uremic pericarditis and uremic encephalopathy ​ • Hyperkalemia unresponsive to conservative measures ​ • Persistent ECFV expansion despite diuretic therapy ​ • Acidosis refractory to medical therapy ​ • Bleeding diathesis ​ • GFR below 10 ml/min/ 1.73 m2 ​

31. Treatment opt i ons i n ESRD Hemodialysis Peritonial dialysis   -Continuous ambulatory peritoneal dialysis (CAPD)   -Continuous cyclic peritoneal dialysis (CCPD) Transplantation

32. Immun i zation i n CKD pat i ents Hepatitis B Vaccine • Recombinant 40 microgram/ml IM in deltoid region at 0, 1, 2 and 6 months as earliest as possible in any stage of CKD Anti HBs antibody titer should be assessed at 2months after completing course and then annually. If titre below 10 mU / ml , a booster dose should be given . Pneumococcal vaccine A single IM/SC dose of 0.5 ml of pneumococcal vaccine should  be administered to all dialysis patients of 2years of age or older • Revaccination after 5 years.

33. Influenza Vaccine Influenza vaccine should be given IM annually before beginning of influenza season to patients who are 6 months or older and on dialysis. Hib Conjugate Vaccine • . 5 ml IM Hib ( HbOC ) - One to three doses . Booster dose given at 15 months . Hib (PRP-OMP) - Two doses 1 month apart and booster at 12 months. Hib (PRP) - One dose only, no booster dose required Live Attenuated Vaccine Usually contraindicated

34. Thank you