Management of ckd

1. MANAGEMENT OF Pt. WITH CHRONIC KIDNEY DISEASE-CKD PRESENTED BY: INUSAH ADAMS TERNOPIL STATE MEDICAL UNI. UKRAINE. March,2015

2. PLAN OF PRESENTATION DEFINITION ETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION DIAGNOSIS TREATMENT COMPLICATIONS INDICATIONS FOR DIALYSIS

3. WHAT IS CHRONIC KIDNEY DISEASE? It is kidney damage (structurally or functionally) for ≥ 3 months with or without decrease glomerular filtration rate (GFR) OR GFR < 60ml/min for ≥ 3 months with or without kidney damage OR Persistent microalbuminuria /Persistent proteinuria/Persistent hematuria OR Structural abnormalities of the kidneys (polycystic kidney disease, reflux nephropathy) proven by ultrasound

4. ETIOLOGY OF CHRONIC KIDNEY DISEASE? Diabetes mellitus Hypertension Glomerulonephritis Pyelonephritis Renal artery stenosis Renal calculi Polycystic kidney disease Congenital defects of the kidney or bladder Secondary causes (SLE, rheumatoid arthritis, HIV, drugs-gold, heroin use etc .) Drugs (NSAIDS, Aminoglycoside etc.)

5. PATHOPHYSIOLOGY OF CKD?

6. PATHOPHYSIOLOGY OF CKD? Regardless of the primary cause of nephron loss, some usually survive or are less severely damaged  These nephrons then adapt and enlarge, and clearance per nephron markedly increases . The RAAS is activated causing renal hypertension  If the initiating process progress, renal failure may ensue with the rapid development of ESRD.  Focal glomerulosclerosis develops in the glomeruli, and they eventually become non-functional.  proteinuria markedly increases and systemic hypertension worsens. Adapted nephrons enhance the ability of the kidney to postpone uremia, but ultimately the adaptation process leads to the demise of these nephrons. Adapted nephrons have not only an enhanced GFR but also enhanced tubular functions in terms of, for example, potassium and proton secretion. 

7. Classification of kidney injury RIFLE and the network criteria

8. CLINICAL PRESENTATION OF CKD? Asymptomatic in stage 1-3 with GFR > 30ml/min Symptomatic in stage 4-5 with GFR < 30ml/min Early signs :Polyuria/oliguria, Hematuria, Edema 2. Late signs hypertension Signs of anemia (pallor) Signs of hyperurecemia: Brain ( uremic encephalopathy): low concentration, confusion, lethargy, asterixis, coma, Heart: pericarditis GIT: nausea & vomiting, anorexia, diarrhea Reproductive system: erectile dysfunction, decreased libido, amenorrhea Blood system: platelet dysfunction with tendency to bleed, infections due to WBCs dysfunction peripheral neuropathy: numbness, paraesthesia, restless leg syndrome Skin: dry skin, pruritus, ecchymosis Others: fatigue, hiccups, muscle cramps,

9. DIAGNOSIS OF CKD? Kidney injury with or without decrease GFR for ≥ 3 months FBC : Anemia (normochromic, normocytic), leukopenia, thrombocytopenia Urinalysis: Dipstick proteinuria, if positive, do daily or 24hrs proteinuria test If proteinuria is ≤1g/24hrs, then consider urinary syndrome If proteinuria is 1 to 3g/24hrs, nephritic syndrome/ tubulointerstitial If proteinuria is ≥3.5g/24hrs , consider nephrotic syndrome RBCs, RBC casts, suggests glomerulonephritis Pyuria or/and WBC casts are suggestive of interstitial nephritis/pyelonephritis GFR evaluation; usually decreased

10. Diagnosis con’t Biochemical blood test: High creatinine, high BUN Electrolytes: Hyperkalemia, hyperphosphatemia, hypermagnesemia, hypocalcemia, low bicarbonate pH of blood: acidosis (metabolic) Hypoalbuminemia/ hypoproteinemia Plain abdominal x-ray ( useful to look for radio-opaque stones or nephrocalcinosis) Renal biopsy (reveals underlying primary cause but may be nonspecific ) Ultrasound findings : small echogenic kidneys in ESRD, hydronephrosis, polycystic kidneys

11. Ultrasound findings: small echogenic kidneys in ESRD

12. TREATMENT OF CKD? Treatment objectives • To detect chronic kidney disease early in susceptible individuals . • To control hypertension • To control blood glucose • To treat other underlying causes • To prevent complications and further worsening of kidney function

13. Non-pharmacological treatment Admit patient especially in stage of exacerbation Diet: Restrict dietary protein to< 40 g /day, Restrict Na+, K+, PO4- intake, avoid potassium containing foods e.g. banana Water and electrolyte balance: Daily fluid intake = previous day’s urine output + 600 ml (for insensible losses ) Strict fluid input and output chart Daily weighing General health advice e.g. smoking cessation • Avoid nephrotoxins e.g. NSAIDs , Herbal medication

14. Pharmacological treatment Treatment of underlying condition (diabetes, HPT, autoimmune d’ses etc .) Treatment of fluid overload Diuretics: Furosemide, oral /IV, 40-120 mg daily Treatment of hypertension (goal of BP<130/8OmmHg): ACEIs- Lisinopril, oral, 5-40 mg daily Or Ramipril, oral, 2.5-10 mg daily Or ARBs- Losartan, oral, 25-100 mg daily or Valsatan, oral, 80-160 mg daily Treatment of anemia Injection erythropoietin 50-100units IV/SC 3times weekly Treatment is initiated at Hb <10g/dl Tab. Ferrous sulphate 200mg 3times daily Treatment of hyperkalaemia/metabolic acidosis • 10% Calcium gluconate, IV, 10-20 ml over 2-5 minutes Plus • Sodium Bicarbonate, IV, 8.4% 50mEq , over 5 minutes Plus • Regular Insulin, IV, 10 units in 50-100 ml Glucose 50%

15. Pharmacological treatment con’t… Treatment of hyperphosphatemia: Phosphate binders (calcium acetate/ calcium carbonate 2 capsules (1334mg ) orally with food) Treatment of hypocalcemia: Calcium citrate 1g/day Vitamin D supplement; 2 tablets (800 IU) once daily Treatment of pruritus: Capsaicin cream or cholestyramine Treatment of bleeding: Desmopressin 0.3 mcg/kg IV over 15-30mins

16. Renal replacement therapy (RRT) Dialysis (hemodialysis or peritoneal dialysis) Kidney transplant with immunosuppressant usage hemodialysis= peritoneal dialysis in terms of efficiency But hemodialysis is superior to peritoneal dialysis due to the complication (peritonitis then subsequent septic shock) associated with peritoneal dialysis Indications f or dialysis are : fluid overload severe acidosis hyperkalemia pericarditis encephalopathy

17. Hemodialysis: 3-4hrs, 3 times per week (Monday, Wednesday and Friday)

18. Peritoneal dialysis

19. Kidney transplant plus immunosuppressant therapy

20. Complications of CKD? Anemia: due to lack of erythropoietin Metabolic acidosis (severe): due to lack of NH3 production by kidneys which is involved in acid-base buffer Hyperkalemia: due to lack of excretion Pericarditis: due to uremia Osteodystrophy (osteitis fibrosa cystica): due to lack of 1,25-dihydroxycholecalciferol and also Secondary hyperparathyroidism Fluid overload (anasarca): lack of excretion and Na+ retention Encephalopathy: due to uremia Hypertension: due to activation of RAAS. HPT is the common cause of death due to myocardial infarction. Maintain BP <130/80 Infections: uremia prevents degranulation of the neutrophils and so myeloperoxidase can’t be released to destroy bacteria Bleeding tendencies: due to platelets dysfunction from effects of uremia

21. Stay healthy The end