ChronicKidneyDisease 2
-
Upload
shanfiza92 -
Category
Documents
-
view
218 -
download
0
Transcript of ChronicKidneyDisease 2
-
7/28/2019 ChronicKidneyDisease 2
1/37
Chronic Kidney Disease
MOHAMAD S. RABABAH , MDConsultant Nephrologist , Head of Renal Unit, KAUH_Jordan
-
7/28/2019 ChronicKidneyDisease 2
2/37
Prevalence
1 in 5 diabetics
1 in 6 hypertensives
1 in 5 of all elderly > 80 without
HTN and DM
-
7/28/2019 ChronicKidneyDisease 2
3/37
Definition of CKD
Structural or functional abnormalities ofthe kidneys for >3 months, asmanifested by either:
1. Kidney damage, with or withoutdecreased GFR, as defined by
pathologic abnormalities
markers of kidney damage, includingabnormalities in the composition of the bloodor urine or abnormalities in imaging tests
2. GFR
-
7/28/2019 ChronicKidneyDisease 2
4/37
Definition
For greater than 3 months
Kidney damage
Abnormal structure by imaging
Abnormal function by urine/bloodwork
OR
GFR < 60
-
7/28/2019 ChronicKidneyDisease 2
5/37
Classification of CKD by Diagnosis
Diabetic Kidney Disease
Glomerular diseases (autoimmunediseases, systemic infections, drugs, neoplasia)
Vascular diseases (renal artery disease,hypertension, microangiopathy)
Tubulointerstitial diseases(urinary tractinfection, stones, obstruction, drug toxicity)
Cystic diseases(polycystic kidney disease)
Diseases in the transplant(Allograftnephropathy, drug toxicity, recurrent diseases,
transplant glomerulopathy)
-
7/28/2019 ChronicKidneyDisease 2
6/37
Screening
Screen all high risk and age > 55
HTN, DM, recurrent UTI
Systemic illness that affects kidney(NNS = 8.7)
Screen with
Creatinine to calculate GFR
ANDurine protein analysis
-
7/28/2019 ChronicKidneyDisease 2
7/37
Glomerular Filtration
You MUST calculate the GFR!
Use an equation MDRD or C-G
Use a 24 hr urine in special cases
-
7/28/2019 ChronicKidneyDisease 2
8/37
Prevalence of Abnormalities at each level of GFR
0
10
20
30
40
5060
70
80
90
15-29 30-59 60-89 90+
Estimated GFR (ml/min/1.73 m2)
P
roportionofpopu
lation(%)
Hypertension* Hemoglobin < 12.0 g/dL
Unable to walk 1/4 mile Serum albumin < 3.5 g/dL
Serum calcium < 8.5 mg/dL Serum phosphorus > 4.5 mg/dL
*>140/90 or antihypertensive medication p-trend < 0.001 for each abnormality
-
7/28/2019 ChronicKidneyDisease 2
9/37
Screening
Screen all high risk and age > 55
HTN, DM, recurrent UTI
Systemic illness that affects kidney
Screen with
Creatinine to calculate GFR
ANDurine protein analysis
-
7/28/2019 ChronicKidneyDisease 2
10/37
Proteinuria
Good evidence for screening withannual micro-albumin in DM
Consider screening in HTN, age> 55
WHAT to use?
- urine microalbumin- urine micro for casts
-
7/28/2019 ChronicKidneyDisease 2
11/37
Proteinuria
Protein in urine is associated with amore rapid decline in renal function
This decline can be slowed by ACE-Ior ARB even without diabetes
Can be helpful in diagnosis if not DM
-
7/28/2019 ChronicKidneyDisease 2
12/37
Causes of CKD
Diabetes
Hypertension??
Transplant
Non-diabetic
Glomerular Tubulointerstitial
Vascular
Cystic
-
7/28/2019 ChronicKidneyDisease 2
13/37
Non-DM Causes of CKD
Glomerular
Lupus or vasculitis
Hepatitis or HIV
Endocarditis Amyloidosis
Medications
Lithium
Ratio of protein:creatinine is high
Tubulointerstitial
Myeloma
Pyleonephritis
Obstruction BPH
Tumor
Chronic reflux
Sarcoidosis
-
7/28/2019 ChronicKidneyDisease 2
14/37
Non-DM Causes of CKD
Cystic and otherhereditary renaldiseases
Transplant
Chronic rejection
Medications
Chronic disease
Vascular
Hypertension
Renal artery
stenosis Renal vasculitis
Sickle cell
HUS
Low-flow states
Cirrosis, CHF, etc.
-
7/28/2019 ChronicKidneyDisease 2
15/37
CKD and no diabetes?
Medications? Family history?
Risks of HIV and Hepatitis
Rashes, joints, renal bruit Screen again for diabetes
Look at urine micro for clues
Consider ESR, SPEP, ANA, ANCA Renal ultrasound
-
7/28/2019 ChronicKidneyDisease 2
16/37
CKD Stages
Stage 1 GFR > 90
Damage but normal or elevated GFR
Stage 2 GFR 60-90
Stage 3 GFR 30-60
Stage 4 GFR 15-30
Stage 5 GFR < 15
-
7/28/2019 ChronicKidneyDisease 2
17/37
Goals of Care
1. Slow decline in renal function
2. Prevent cardiovascular disease
3. Detect and manage complications Anemia
Hyperparathyroidism
Bone disease
Electrolyte abnormalities
Vascular complications
-
7/28/2019 ChronicKidneyDisease 2
18/37
Bone Disease in Renal
Failure
-
7/28/2019 ChronicKidneyDisease 2
19/37
Resorptionosteoclasts Formationosteoblasts matrix
MineralisationQuiescence
Normal Bone
Remodelling Cycle
-
7/28/2019 ChronicKidneyDisease 2
20/37
Pathogenesis
Kidney failure disrupts systemic calciumand phosphate homeostasis and affects thebone, GIT and parathyroid glands.
In kidney failure there is decreased renalexcretion of phosphate and diminishedproduction of calcitriol (1,25-dihydroxyvitamin D) Calitriol increases serum calcium levels
The increased phosphate and reducedcalcium, feedback and lead to secondaryhyperparathyroidism, metabolic bonedisease, soft tissue calcifications and othermetabolic abnormalities
-
7/28/2019 ChronicKidneyDisease 2
21/37
GFR
PO4
1,25 DHCC
Ca
PTHCalcitriol
-
7/28/2019 ChronicKidneyDisease 2
22/37
econ aryhyperparathyroidism
In renal failure driven by
Hypocalcaemia
Decreased vitamin D
hyperphosphataemia
-
7/28/2019 ChronicKidneyDisease 2
23/37
Clinical manifestations of bonedisease
Most with CKD and mildlyelevated PTH are asymptomatic
When present classified as either1. Musculoskeletal
2. Extra-skeletal
-
7/28/2019 ChronicKidneyDisease 2
24/37
Resorptionosteoclasts Formationosteoblasts matrix
Accelerates:High PO4 or
Low Ca2+
, calcitriol,HCO3, oestrogen
Retards:Calcitriol*, Age,
Diabetes, Al3+, PTHx
Mineralisation
*Acts via
osteoblasts
Quiescence
Uraemic Bone
Remodelling
CycleVia PTH*,IL-1,6 & TNF
t
-
7/28/2019 ChronicKidneyDisease 2
25/37
g turn over onedisease
Due to excess PTH
Increased bone turnover activity(greater number of osteoclasts and
osteoblasts) and defectivemineralization.
Associated with bone pain andincreased risk of fractures.
Severe symptomatic disease iscurrently uncommon with moderntherapy.
-
7/28/2019 ChronicKidneyDisease 2
26/37
Osteomalacia
Formally linked to aluminiumtoxicity
From aluminium based phosphatebinders
From contamination of water indiasylate solutions
-
7/28/2019 ChronicKidneyDisease 2
27/37
xe uraem c onedisease
Mixture of high turn over bonedisease and osteomalacia
-
7/28/2019 ChronicKidneyDisease 2
28/37
Adynamic bone disease
Characterized by low osteoblastic activityand bone formation rates
Seen in up to 40% HD and 50% PD
May be due to excess suppression of theparathyroid gland with therapies,particularly calcium-containing phosphatebinders and vitamin D analogues.
Typically maintain a low serum intact PTH
concentration, which is frequentlyaccompanied by an elevated serum calciumlevel.
Felt to represent a state of relativehypoparathyroidism
http://www.uptodate.com/online/content/topic.do?topicKey=drug_a_k/38433&drug=truehttp://www.uptodate.com/online/content/topic.do?topicKey=drug_a_k/38433&drug=true -
7/28/2019 ChronicKidneyDisease 2
29/37
-
7/28/2019 ChronicKidneyDisease 2
30/37
To slow decline
Low salt diet (for HTN)
Low protein diet in CKD 4 & 5 Nutrition consult!
Avoid nephrotoxic agents Contrast dye, NSAIDs, gentamicin
-
7/28/2019 ChronicKidneyDisease 2
31/37
To slow decline
Diabetes control HA1c ~ 7.0 7.5
Metformin?
Glipizide v. Glyburide
Blood pressure control - < 130/80
ACE-I or ARB
Diuretics thiazide for GFR > 30
- furosemide for GFR < 30
-
7/28/2019 ChronicKidneyDisease 2
32/37
To slow decline
Prescribe an
ACE-I or ARB
for proteinuria + CKD
even in the ABSENCE of
diabetes
-
7/28/2019 ChronicKidneyDisease 2
33/37
Goals of Care
1. Slow decline in renal function
2. Prevent cardiovascular disease
3. Detect and manage complications Anemia
Hyperparathyroidism
Bone disease
Electrolyte abnormalities
Vascular complications
-
7/28/2019 ChronicKidneyDisease 2
34/37
Prevent CV disease
Most common cause of death is CV diseaseand not renal failure.
Smoking cessation
Diabetes and Blood pressure control
Lipids No evidence that tx affects renal fxn
Guidelines: ATP3 -> LDL goal < 100
-
7/28/2019 ChronicKidneyDisease 2
35/37
Goals of Care
1. Slow decline in renal function
2. Prevent cardiovascular disease
3. Detect and manage complications Anemia
Hyperparathyroidism
Bone disease
Electrolyte abnormalities
Vascular complications
-
7/28/2019 ChronicKidneyDisease 2
36/37
When to refer
Proteinuria > 3.5 gm in 24 hours
Nephritis
Hematuria, proteinuria and HTN Diabetes & CKD but no retinopathy
GFR decline of 50% in one year
Stage 3 or 4 CKD
-
7/28/2019 ChronicKidneyDisease 2
37/37
Key Points
Think about CKD and screen
Creatinine AND urine protein
Calculate the GFR!
Look for reversible cause if no DM
Get to know the KDOQI guidelines &think about the complications