Management of Edema in chronic kidney disease

Edema

1. EDEMA MANAGEMENT IN NEPHROTIC SYNDROME

2. NEPHROTIC SYNDROME HYPOALBUMINEMIA NEPHROTIC RANGE PROTEINURIA UpUc >2 24 hr Up- 40mg/m2/ hr or 1000mg/m2/24hr EDEMA

3. UNDERFILL THEORY

4. OVERFILL THEORY The kidneys retain sodium excessively due to altered tubular function, possibly involving dysregulation of epithelial sodium channels ( ENaCs ) and reduced natriuretic response Plasma volume is increased rather than decreased, leading to normal or high blood pressure and reduced activation of compensatory systems like the renin-angiotensin-aldosterone system (RAAS) The increased intravascular volume causes fluid to shift into the interstitial space due to increased hydrostatic pressure, resulting in peripheral and generalized edema.

5. Feature Underfill theory Overfill theory Primary cause Hypoalbuminemia and fluid shift Primary sodium retention Plasma volume Decreased Increased Blood pressure Low or normal Normal or high RAAS activation Increased Suppressed or normal

6. Edema is classified based on percentage weight gain Patients with moderate to severe edema be assessed for intravascular volume status before initiating therapy with diuretics. GRADE OF EDEMA PERCENTAGE WEIGHT GAIN MILD 7% MODERATE 8-15% SEVERE >15%

7. Features of hypovolemia CLINICAL FEATURES BIOCHEMICAL PARAMETERS RADIOLOGICAL Abdominal pain, vomiting Lethargy Prolonged capillary refill time Cold extremities Tachycardia Low volume pulses Low blood pressure Postural hypotension Elevated hematocrit Blood urea (mg/dL) to creatinine (mg/dL) ratio >100 Fractional excretion of sodium<0.5 Urinary potassium index [urine K+/(urine Na++K+) >0.6] Ultrasonography  decreased inferior vena cava diameter, increased collapsibility index

8. Patients are advised to limit sodium intake (1-2 mEq /kg/day; 15-35 mg/kg salt)

9. ADEQUATE RESPONSE MONITORING Diuresis within 2-4 hr of oral furosemide 1-2% of weight reduction Hypovolemia Hypokalemia Metabolic alkalosis Input output charting Daily weight monitoring

10. Torsemide Pharmacological Aspect Specification Site of action Ascending loop of Henle Mechanism of action Inhibition of chloride binding site of Na + /K + /CL - Half life, route of administration 3-5 hours , oral & IV Dosage 10mg-20 mg may double the dose until desired diuretic effect Route of elimination 80%-liver 20%- kidney While torsemide has better efficacy and bioavailability than furosemide in adults with heart failure , information in nephrotic syndrome is lacking. 1.Abraham B, Megaly M, Sous M, et al.

11. Tolvaptan Vasopressin receptor antagonist Aquaretics Elimination of electrolyte-free water Hypervolemic hyponatremia in congestive heart failure Euvolemic hyponatremia in SIADH, N ephrotic syndrome Current literature on the use of tolvaptan for managing edema in nephrotic syndrome primarily consists of case reports and small studies

12. THANK YOU