L2: CKD Flashcards
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Introduction to CKD
- Chronic kidney disease (CKD) is a significant health threat that can progress to End-Stage Kidney Disease (ESKD)
- Leading to early death, diminished quality of life, and placing a heavy burden on healthcare systems.
Def of ESKD
Irreversible kidney dysfunction with…
▪ eGFR < 15 mL/min/1.73 m2
▪ Manifestations of uremia requiring chronic renal replacement therapy
Def of CKD
Criteria of CKD
Criteria of CKD
- General
Criteria of CKD
- Markers for Kidney Damage
Markers for Kidney Damage
- Lab Abnormalities
Criteria of CKD
- Markers of Decresed Function
Decreased GFR: < 60 mL/min per 1.73 m2
(i.e.GFR categories G3a–G5)
Criteria of CKD
- Duration
Staging of CKD
Staging of CKD
- Acc to Cause
Staging of CKD
- Acc to GFR
GFR in Staging of CKD
- G1
GFR in Staging of CKD
- G2
GFR in Staging of CKD
- G3
GFR in Staging of CKD
- G4
GFR in Staging of CKD
- G5
In the absence of evidence of kidney damage, neither GFR category ….. fulfill the criteria for CKD
G1 nor G2
Staging of CKD by Albuminuria
Staging of CKD by Albuminuria
- A1
Staging of CKD by Albuminuria
- A2
Staging of CKD by Albuminuria
- A3
CP & Complicaions of CKD
Etiology of CKD
① Diabetic nephropathy
② Hypertensive nephropathy
③ Glomerulonephritis
④ Other causes (e.g., polycystic kidney disease – analgesic misuse – amyloidosis)
⑤ Unknown causes.
Def of Uremia
Accumulation of uremic toxins due to decreased Renal excretion
Naming of Uremia
Historically, the first solute recognized to be retained in persons with kidney failure was urea, hence the terms; uremia.
Examples of Potential Uremic Toxins
Over 100 substances identified as potential uremic toxins, e.g.,
① Urea.
② Creatinine.
③ β2 microglobulin.
Significance of Uremia
- Most of CKD manifestations are due to uremic toxins.
- Examples for uremic symptoms: nausea, vomiting, hiccough, pruritis.. etc.
Uremia Symptoms Timeframe
- Patients are often asymptomatic until later stages due to the exceptional compensatory mechanisms of the kidneys.
Volume Status in CKD
Hypervolemia resulting from impairments of sodium and water handling
Def of CKD-MBD
A systemic disorder manifested by either one or a combination of the following three components:
① Abnormalities in the metabolism
② Abnormalities in bone turnover, mineralization, volume linear growth, or strength
③ Extra-skeletal calcification
CKD-MBD
- Abnormalities in the Metabolism
Po4 in CKD
Vit D in CKD
FGF23 in CKD
Ca in CKD
PTH in CKD
CKD-MBD
- Abnormalities in Bone Turnover, Mineralization, Volume Linear Growth, Strength
Renal Osteodystrophy Classified acc to Bx into:
Renal Osteodystrophy
- Low Bone Turnover
Renal Osteodystrophy
- High Bone turnover (Osteitis fibrosa cystica)
Renal Osteodystrophy
- Mixed Uremic Osteodystrophy
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Gold Standard in Dx of Renal Osteodystrophy & Its Classification
Bone biopsy
- The term “renal osteodystrophy” should be used exclusively to define alterations in bone morphology associated with CKD based upon bone biopsy, and it is only one component of the bone abnormalities of CKD-MBD
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Extra-Skeletal Manifestations of CKD MBD
Extra-Skeletal Manifestations of CKD MBD
- Vascular Calcification
For example:
- Coronary artery calcification → Increased cardiovascular risk.
- Arterioles & capillaries in the dermis & subcutaneous adipose tissue → Calciphylaxis
CVS Abnormalities in CKD
Extra-Skeletal Manifestations of CKD MBD
- Other Calcifications
Soft tissue, valvular, etc..
CVS Abnormalities in CKD
- HTN
▪ Salt & water retention.
▪ Note that: Hypertension is a cause and precipitating factor of CKD.
CVS Abnormalities in CKD
- LVH
① Volume overload
② Systolic hypertension
CVS Abnormalities in CKD
- IVD
CVS Abnormalities in CKD
- HF
① Myocardial ischemia
② Left ventricular hypertrophy
③ Frank cardiomyopathy
④ Salt and water retention
CVS Abnormalities in CKD
- Arrhythmia
① Electrolyte disturbances.
② Volume overload.
③ Sympathetic overactivity.
④ Acidosis.
CVS Abnormalities in CKD
- Pericardial Diseases
Uremic pericarditis & Pericardial effusion
What is the Leading Cause of Morbidity & Mortality in patients at every stage of CKD?
Hematological Disorders in CKD
Hematological Disorders in CKD
- Hb in Anemia
Hematological Disorders in CKD
- type of Anemia
Hematological Disorders in CKD
- Etiology of Anemia
Hematological Disorders in CKD
- WBCs
Hematological Disorders in CKD
- Platlets
Dermatologic Abnormalitis in CKD
Dermatologic Abnormalitis in CKD
- Pigmentations
- d2 failure of kidneys to excrete beta-melanocyte stimulating hormone.
Dermatologic Abnormalitis in CKD
- Pallor
d2 anemia
Dermatologic Abnormalitis in CKD
- Uremic Pruritis
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Dermatologic Abnormalitis in CKD
- Bullous Dermatosis
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Dermatologic Abnormalitis in CKD
- Calcific uremic arteriolopathy
calciphylaxis
Dermatologic Abnormalitis in CKD
- Nephrogenic systemic fibrosis
- formerly known as nephrogenic fibrosing dermopathy)
- The condition is seen in patients with CKD who have been exposed to the magnetic resonance contrast agent gadolinium
Respiratory Problems in CKD
Respiratory Problems in CKD
- Pleurisy
Due to uremia.
Respiratory Problems in CKD
- Pulmonary Edema
Multifactorial due to Hypoalbuminemia, Hypervolemia, Heart failure (LVF)
Respiratory Problems in CKD
- Pneumonia & TB
Due to impaired immunity.
Neuromuscular Abnormalities in CKD
Neuromuscular Abnormalities in CKD
- CNS
Neuromuscular Abnormalities in CKD
- PNS
Neuromuscular Abnormalities in CKD
- Muscles
Uremic Myopathy
Infections in CKD
2nd Leading Cause of Death in CKD
Infections
Infections in CKD
- Etiology
Partially due to immune dysfunction, although multiple other factors are involved.
Infections in CKD
- Types
Bacterial or viral infection
Infections in CKD
- Which type is more susceptible?
There is an increased susceptibility to bacterial infection (particularly staphylococcal)
Infections in CKD
- TB
There is an increased risk of reactivation of tuberculosis (with a negative tuberculin skin test response)
Infections in CKD
- HBV & HCV
Failure to eliminate HBV and HCV after infection may occur.
GIT Abnormalities in CKD
GIT Abnormalities in CKD
- Mouth Odour
GIT Abnormalities in CKD
- Tongue
GIT Abnormalities in CKD
- Esophagus
A. Gerd: d2 delayed gastric emptying.
B. Esophagitis.
GIT Abnormalities in CKD
- Stomach
A. Gastritis.
B. Delayed gastric emptying.
C. Peptic ulcer.
GIT Abnormalities in CKD
- Intestinal
Constipation
Nutritional Abnormalities in CKD
Nutritional Abnormalities in CKD
- Incidence
Very common problem among patients with advanced CKD and those undergoing maintenance dialysis (MD) therapy.
Nutritional Abnormalities in CKD
- Morbidity & Mortality
Associated with high morbidity & mortality.
Nutritional Abnormalities in CKD
- Contributing Factors
Glucose Metabolism in CKD
ACKD
Refers to an acute, often reversible decline in kidney function that occurs in a patient with pre-existing chronic kidney disease (CKD).
Done
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Screening & detection of CKD
- Rationale
The rationale for screening at-risk individuals for CKD is to:
① Permit earlier detection of CKD, and allowing interventions aimed at slowing CKD progression.
② Identify people who are at risk of CKD associated cardiovascular disease (CVD), morbidity and mortality.
Screening & detection of CKD
- Candidates
Screening & detection of CKD
- Methods
Screening should consist of:
① Urinalysis.
② Urine albumin or protein estimation (such as PER or ACR).
③ Measurement of serum creatinine and estimation of GFR.
Predictors of Progression of CKD
- Non-Modifiable RF
Predictors of Progression of CKD
- Modifiable RF
The most significant predictors of CKD progression are
① The degree of impaired kidney function at presentation.
② Hypertension and its control.
③ The severity of proteinuria and albuminuria
No single biomarker can identify those at risk of progression with high sensitivity and specificity.
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Investigation for CKD
- Investigations to detect functional decline
- Investigations to detect structural renal damage
- Investigations to identify underlying causes
- Other Investigations
Serum Markers Used in CKD
Creatinine & Bun in CKD
- Increased Creatinine & BUN
▪ Patients with BUN > 140 mg/dl, serum creatinine > 13.5 mg/dl, or blood urea > 300 mg/dl who appear relatively well & are still passing normal volumes of urine are much more likely to have chronic than acute kidney disease.
Cystatin C in CKD
Increased
GFR in CKD
Decreased
Methods of Estimation of GFR in CKD
Na in CKD
Na+ retention: Occurs once GFR is severely reduced, and sodium intake is unchanged.
K in CKD
Ca in CKD
Decreased
PO4 in CKD
Increased
ABG in CKD
Urinary Albumin in CKD
▪ AER ≥ 30 mg/24h
▪ ACR ≥ 30 mg/g
Urine Dipsticks in CKD
May show hematuria or proteinuria
Urine MIcroscopy in CKD
May show abnormal urine sediments (e.g., waxy casts)
Imaging in CKD
Renal US: (1st line imaging technique for the assessment of kidney structure)
Imaging in CKD
- Findings Suggestive of CKD
Imaging in CKD
- Findings Suggestive of Other Etiologies
① Ureteral or renal pelvic dilation suggests obstructive nephropathy.
② Bilaterally enlarged kidneys with multiple cysts suggest polycystic kidney disease.
In CKD, Kidneys are bilaterally shrunken EXCEPT IN ……
(DM – Polycystic kidney disease – Amyloidosis – Hydronephrosis)
Bx in CKD
Not routinely indicated - consider in either of the following:
① Rapid & unexplained decline in eGFR.
② Need for diagnostic confirmation of the underlying etiology (e.g., glomerulonephritis) prior to initiating disease-specific therapy.
Investigations for Underlying Causes of CKD
- DM
▪ Fasting plasma glucose
▪ HbA1c
Investigations for Underlying Causes of CKD
- GN
Investigations for Underlying Causes of CKD
- PCKD
APKD ( genetic testing)
Other Investigations for CKD
Managment of CKD
Managment of CKD
- TTT of Cause
E.g., Diabetes Mellites & Hypertension.
Managment of CKD
- Supportive Care
How to Manage Medications in CKD?
Managment of Volume Status in CKD
① Dietary salt restriction.
② Use of diuretics (loop diuretics, occasionally in combination with metolazone)
Managment of Electrolyte Status in CKD
Managmnet of Na in CKD
Na restriction.
Managmnet of K in CKD
- Dietary restriction of potassium.
- Use of kaliuretic diuretics. + Refer to “Potassium disorders” Lecture
- Some patients with renal dysfunction develop renal wasting of Na+ (Salt wasting nephropathy) and they are usually hypotensive and may benefit from liberalization of salt in their diet.
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Managment of Acid-Base Disturbance in CKD
Managment of Acid-Base Disturbance in CKD
- Alkali Suppmentation
Managment of Acid-Base Disturbance in CKD
- Diet
- A low-protein diet can decreased acid production.
- Base-inducing fruits & vegetables ⇢ Increase Serum [HCO3−]
Fruits & Vegetables increase risk of Hyperkalemia
Managment of MBD in CKD
Managment of MBD in CKD
- Goal
goal is to normalize phosphate, calcium, and PTH levels
Managment of MBD in CKD
- Hyperphosphatemia
Managment of MBD in CKD
- Vit D
Managment of MBD in CKD
- Avoid Hypocalcemia
① Correcting hyperphosphatemia & treating vitamin D deficiency.
② Dietary calcium should be increased to 1500 mg of elemental calcium daily.
Managment of MBD in CKD
- Avoid Hyperparathyroidism
- Correction of Ca++, P & Vit D.
- Parathyroidectomy (last-line therapy if medical ttt is failed)
Managment of HTN in CKD
Managment of HTN in CKD
- Target BP
- Target blood pressure in patients with CKD: < 130/80 “Acc. to (ACC/AHA) Recommendation”
Managment of HTN in CKD
- Aspects
- Non-pharmacological Treatment
- Pharmacological Treatment
Managment of HTN in CKD
- Non-Pharmacological TTT
① Maintaining healthy weight
② Lower salt intake (<5 gm of NaCl)
③ Regular exercise if not contraindicated
④ Stop smoking and alcohol.
Managment of HTN in CKD
- Pharmacological TTT
U-shaped curve of SBP has been reported in which very low, and very high SBP is associated with faster rates of decline in eGFR.
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Managment of Anemia in CKD
Managment of Anemia in CKD
- Rationale of TTT
Managment of Anemia in CKD
- Options of TTT
① Iron therapy.
② Check for & Treat Vit B12 & Folate deficiency.
③ Erythropoiesis-stimulating agent (The Best)
④ Blood transfusion
Managment of Anemia in CKD
- Best Option of TTT
Erythropoiesis-stimulating agent
Managment of Anemia in CKD
- Blood Transfusion
Managment of Pruritis in CKD
Managment of Glycemic Control in CKD
Managment of Glycemic Control in CKD
- Target
▪ For diabetic patient with CKD → is to keep HbA1c not exceed 7 %
▪ If the patient has limited life expectancy comorbidities or risk of hypoglycemia → It may be > 7%
Managment of Glycemic Control in CKD
- TTT Options
Managment of Glycemic Control in CKD
- Use Insulin?
- Insulin treatment should be used with caution in patients with reduced eGFR due to the increased risk of hypoglycemia.
Managment of Lifestyle in CKD
- PTN
Low protein diet 0.8 g/kg/day (unless the patients start dialysis)
Managment of Lifestyle in CKD
- Cal
High (25 – 35 Kcal/Kg IBW/day)
Managment of Lifestyle in CKD
- Salt
- Restricted (< 5 gm/day) → To correct hypervolemia & Hypertension
Managment of Lifestyle in CKD
- Fluids
Fluid balance → To avoid volume overload
Managment of Lifestyle in CKD
- K
Restricted → To correct hyperkalemia.
Managment of Lifestyle in CKD
- PO4
Restricted → To correct hyperphosphatemia.
Managment of Lifestyle in CKD
- Ca
Allowed within the dietary recommendations.
Managment of Lifestyle in CKD
- Smoking
Managment of Lifestyle in CKD
- Obesity
Managment of Lifestyle in CKD
- Dyslipidemia
Managment of CKD
- Retarding CKD Progression
Retarding CKD Progression
- Goals
① To reduce proteinuria as much as possible, ideally to less than 500 mg/day.
② Slow GFR decline as much as possible, ideally to about 1 ml/min/yr, which is the rate of GFR decline attributable to the nephropathy of aging.
Retarding CKD Progression
- Methods
By managing modifiable risk factors
RRT in CKD
RRT in CKD
- Options of Non-Operative TTT
- Hemodialysis
- Peritoneal dialysis
RRT in CKD
- Indications of Non-Operative TTT
RRT in CKD
- Operative TTT
Done
Doneeeeeee
