30. Chronic renal disease. Flashcards
what is the aetiology of chronic renal disease ?
below 12 years of age
congenital anomalies of the kidney and urinary tract - CAKUT
renal hypoplasia , dysplasia , congenital nephrotic syndrome , cortical necrosis
obstructive uropathy - puv , puj obstruction
thrombotic microangiopathies (especially atypical haemolytic uraemic syndrome)
Wilms tumour
nephrolithiasis/nephrocalcinosis
after 12 years
focal segmental sclerosis
chronic glomerulonephritis
steroid-resistant nephrotic syndrome (SRNS), chronic glomerulonephritis (e.g. lupus nephritis, Alport syndrome)
what is CKD defined as ?
presence of kidney damage, either structural or functional, or
by a decline in glomerular filtration rate (GFR)
below 60 mL/min/1.73 m2 of body surface area for more than 3 months
classification of CKD in children
CKD
stage 1
GFR >90 (G1)
albuminurea - normal to mild increase <3mg/mmol (a1)
GFR 60-89 (g2)
“” (a1)
GFR - 45-59 (g3a)
“” (a1)
GFR >90 (g1)
moderate increase in albuminuria (a2)
<30mg/mmol
GFR -60-89 (g2)
moderate increase in albuminuria (a2)
<30mg/mmol
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stage 2
G1 A3
A3- Beverly increased
>30mg/mmol
G2 and A3
GFR - G3a
45-59
A2 - >3mg/mmol
GFR - G3b
30-44
A1 - <3mg/mmol
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stage 3
G3a / a3 g3b / a2 g3b/ a3 g4 / a1 g4/ a2
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stage 5
GFR - g4
15-29
a3
g5 - <15 = kidney failure
a1
a2
a3
clinical features of CKD?
Growth impairment is a common and perhaps the most visible complication of CKD in children
(one-third of total growth occurs in the first 2 years )
= malnutrition
= resistance to growth hormones
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Chronic kidney disease–mineral and bone disorder
renal osteodystrophy -osteitis fibrosa cystica, osteomalacia, adynamic bone disease, and osteoporosis
abnormalities in calcium, phosphorus, parathyroid hormone (PTH) or vitamin D metabolism
decreased production of active vit d
= hyperphosphotemia / reduce phosphorous excretion
reduced calcium in blood
high pth
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METABOLIC ACIDOSIS
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hyperkalemia
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Anaemia
pallor
-depressed neurocognitive ability
- lack of EOP
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uremia :
Fatigue Weakness Nausea and vomiting Loss of appetite Uremic fetor: characteristic ammonia- or urine-like breath odor Pruritus Skin color changes (e.g., hyperpigmentation, pallor due to anemia) Neurological symptoms Asterixis Signs of encephalopathy Seizures Somnolence hypotonia , peripheral neuropathy
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Hematologic symptoms
Anemia (caused by ↑ destruction of RBCs)
Leukocyte dysfunction → ↑ risk of infection
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hypertension - heart failure
pulmonary edema
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dyslipidemia
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Most complications of CKD do not manifest until at least stage 3
general treatment of CKD?
ACE / ARB
dietary protein restriction
fed infants high calorie low sodium and phosphorous
is dyslipidemia - restrict fat
restruct salt intake if hypertensive diuretics amlodipine - calcium channel blocker ======= treatment for growth failure recombinant human growth hormone therapy subcutaneously daily
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managing mineral bone disease
for stage 2
restrict dietary phosphorous , calcium carbonate or acetate which is a P binder
if hypercalcemia - aluminium hydroxide or sevelamer hydrochloride
therapeutic dose of VIt d
focus on treating hyperphophetemia
)))Secondary hyperparathyroidism
Can be treated surgically (e.g., parathyroidectomy) or with calcimimetics (e.g., cinacalcet)
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above stage 3
packed red blood cell transfusion if severe anemia
routine supplement of ron and folic acid
start oral iron 2-6mg/kg/day
do not exceed Hb >13g/dl
if refectory start
start synthetic EPO aswell
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treatmnet for acidosis
maintain serum hco3
oral bicarbonate supplement is levels below 15meq/l
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immunisation - hep b , pneumococcal vaccines , annual influenza vaccines
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dyslipideia - statins
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Children
with stage 5 CKD (ESRD) are typically treated with either dialysis or renal transplantation
.
what should be avoided in ckd?
Avoidance of nephrotoxic substances NSAIDs Antifungals (e.g., amphotericin B) Antibiotics Aminoglycosides Vancomycin
