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Dr Chaitanya Vemuri
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Kidney damage for >= 3months ,
as defined by structural / functional abnormalities of
kidney
with or without decreased GFR,
and manifest by either :
Pathologic abnormalities
Markers of kidney damage, including abnormalities in
composition of blood / urine or abnormalities on imaging GFR < 60 ml/min/1.73m2 for >=3 months,
with / without kidney damage
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By Radiology – USG / CT / MRI etc…
By Histology – Renal Biopsy
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Microalbuminuria
Proteinuria
Hematuria esp associated with proteinuria
Casts ( with cellular elements )
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Cockcroft-Gaul t formula
Ccr (ml/min) = (140-age) x weight *0.85 if female
72 x Scr
MDRD Study equation
GFR (ml/min/1.73 m2) = 186 x (Scr )-1.154 x (age)-.203 x
(0.742 if female) x (1.210 if African American)
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STAGE DESCRIPTION GFR ( ml/min/1.73m2 )
1 Kidney damage with
normal / increased GFR
>=90
2 Kidney damage with
mildly decreased GFR
60 – 89
3 Moderately decreased GFR 30 – 59
4 Severely decreased GFR 15 – 29
5 Kidney failure < 15 / dialysis
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STAGE ACTION PLAN
1 DIAGNOSIS AND TREATMENT
SLOW PROGRESSION
2 ESTIMATE PROGRESSION
3 EVALUATE AND TREAT
COMPLICATIONS
4 PREPARE FOR RENAL
REPLACEMENT THERAPY
5 RENAL REPLACEMENT
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Diagnosis
Measures to slow progression
Estimate Progression
Evaluation and Treatment of Complications
Preparation for Renal Replacement Therapy
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History
Physical Examination
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CLINICAL FACTORS SOCIODEMOGRAPHIC FACTORS
DIABETES MELLITUS OLDER AGE
HYPERTENSION EXPOSURE TO CERTAIN CHEMICALS
/ ENVIRONMENTAL CONDITIONS
AUTOIMMUNE DISEASES LOW INCOME / EDUCATION
SYSTEMIC INFECTIONS
URINARY TRACT INFECTIONS
URINARY STONES
LOWER URINARY TRACT
OBSTRUCTION
NEOPLASIA
FAMILY HISTORY OF CKDRECOVERY FROM AKI
REDUCTION IN KIDNEY MASS
DRUGS
LOW BIRTH WEIGHT
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Tests & Diagnostics Significance / Goal
Blood Pressure < 130 / 80 mm Hg ; Use ACEI /ARB
Serum Creatinine To estimate GFR;
Historical values assist in determining
acuity and progression of disease
Urinalysis with microscopy Presence of RBCs / RBC casts and or
Proteinuria – further work up
Serum Electrolytes ( Na+, K+ ) Useful as crude surrogate of renal disease
Help to guide antihypertensives
Help to identify patients in need of
medical nutrition education
Calcium, Phosphorus, PTH, ALP,
25-OH VITAMIN D
Assists in treatment of metabolic bone
disease
Complete Blood Count
Peripheral Blood Smear
Evaluate for anemia
TSAT , S.Ferritin Useful in evaluation of iron stores
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Tests & Diagnostics Significance / Goals
Renal Ultrasound with or without Arterial
Doppler
Characterize Kidney number and size
Echogenicity of kidneys
Rule out presence of obstruction
Rule out renovascular disease
Cholesterol panel Especially useful for patients with
nephrotic range proteinuria
Random urine protein
Random urine creatinine
Ratio approximate values obtained by
24 hour collection
Hepatitis Serology Negative Hep B testing mandates
vaccination
Serum Protein Electrophoresis
Urine Protein Electrophoresis
In adults with renal disease to rule out
Myeloma
Antinuclear antibody Warranted for adults with proteinuria /
evidence for SLE
HIV Warranted in selected population
Renal Biopsy Indicated in pts with hematuria and /
proteinuria and lack of evidence of
systemic disease
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Protein Restriction
Reducing Intraglomerular Hypertension
Reducing Proteinuria
Control of Blood Glucose
Control of Blood Pressure
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Reduces symptoms associated with uremia
Slows the rate of decline in renal function at earlier stages of renal diseases
K/DOQI clinical practice guidelines recommenddaily protein intake between 0.60 – 0.75 g / Kg per day
50 % of protein intake should be of high biological value
As patient approaches CKD Stage V,spontaneous protein intake decreases & patient enter a state of Protein – Energy Malnutrition . Recommended protein intake is0.9 g / Kg per day
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Increased intraglomerular filtration pressure & glomerular hypertrophy - a response to loss of nephron number
It promotes ongoing decline of kidney function even if the inciting process has been treated.
ACEI & ARBs
Inhibit angiotensin induced vasoconstriction of efferent arteriole
Reduces intraglomerular filtration pressure and proteinuria
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If monotherapy is not effective , combined therapy with
both ACEI & ARB can be tried
2nd line drugs : Calcium Channel Blockers
Diltiazem , Verapamil
Especially - Diabetic Nephropathy & Glomerular diseases
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Leading cause of Chronic Kidney Disease
Control of Blood Glucose : excellent glycemic control
reduces the risk of kidney disease & its progression in both Type 1 & 2 Diabetes Mellitus
Recommendations : FBS : 90 – 130 mg/dl
HbA1C < 7%
Control of Blood Pressure & Proteinuria : ACEI & ARBs
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Hypertension : sodium and water retention
renin angiotensin system activation
Control of BP : to slow progression of CKD
to prevent extrarenal complications
( cardiovascular disease / stroke )
Goal : BP < 130 / 80 mm Hg
BP < 125 / 75 mm Hg ( DM / Proteinuria > 1g/day )
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Salt Restriction
Diuretics
Loop Diuretics : Furosemide 40 mg BD
Bumetanide 1mg BD
Thiazides : less efficacious gfr < 30 – 40 ml/min
Both ameliorate hyperkalemia seen with ACEI / ARB
ACEI / ARB
Check S.Creat & S.K+ within 1 -2 weeksUpto 30 % increase in creatinine is acceptable
Beta blockers / CCB / Alpha blockers / Vasodilators
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Anemia
Bone Disorders
Dyslipidemia
Cardiovascular disease
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Defined as Hemoglobin < 13.5 g/dl in males
< 12 g/dl in females
Normocytic normochromic anemia –
as early as in Stage III CKD or universally by Stage IV CKD
Primary cause : insufficient production of Erythropoetin
Additional factors : iron deficiency
folate / vit B12 deficiencychronic inflammation
hyperparathyroidism / bm fibrosis
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Target Hb : 11 g/dl
Target Iron status : TSAT : lower limit > = 20
S.Ferritin : ng/ml
lower limit : 200 – HD CKD
100 – Non HD CKD
> 500 not routinely recommended
Check Hb monthly while on ESAs
Iron studies monthly when started on ESA
On stable ESA Therapy : Iron studies can be done 3 monthly
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Ferrous sulphate 325 mg bid – tid
IV Iron Dextran
IV Iron Sucrose
IV Sodium Ferric Gluconate Complex
Folic acid and Vitamin B 12 supplements
Erythropoetin Stimulating Agents : Epoetin alfa
Epoetin beta
Darbepoetin alfa Epoetin alfa / beta : 50 -100 IU / Kg SC per week
Darbepoetin alfa : 40 mcg SC every 2 weeks
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Osteitis Fibrosa Cystica
Osteomalacia
Adynamic bone disease
Mixed osteodystrophy
Secondary
Hyperparathyroidism
Vitamin D deficiency Acidosis
Aluminium accumulation
Osteoporosis in elderly
Osteopenia caused by
steroids
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Renal bone disease – significantly increase mortality in
CKD patients
Hyperphosphatemia – one of the most important risk
factors associated with cardiovascular disease in CKD
patients
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K/DOQI recommends :
CKD Stage III & IV : S.Phosphorus : 2.7 - 4.6 mg / dl
CKD Stage V : S.Phosphorus : 3.5 - 5.5 mg / dl
CKD STAGE GFR RANGE INTACT PTH ( pg/ml )
3 30 – 59 35 – 70
4 15 – 29 70 – 110
5 < 15 / Dialysis 150 – 300
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CKD STAGE GFR RANGE PTH LEVELS S.Calcium &
S.Phosphorus
3 30 -59 Every 12 months Every 12 months
4 15-29 Every 3 months Every 3 months
5 < 15 / dialysis Every 3 months Every month
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Reduce dietary phosphate intake
Phosphate binders : calcium carbonate
calcium acetate
aluminium hydroxide
magnesium carbonate ( rarely used )
sevelamer hydrochloride
lanthanum carbonate
The use of calcium salts is limited by development of
hypercalcemia Calcium acetate poses a less problem as less calcium is
absorbed
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Calcimimetics – Cinacalcit :
Agent that increase calcium sensitivity of the calciumsensing receptor expressed by parathyroid gland
Down regulating the parathyroid hormone secretion
Reduce hyperplasia of parathyroid gland
Calcitriol 0.25 mcg OD
Paricalcitol 1 mcg daily or 2mcg 3 times a week
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Vitamin D deficiency :
< 5 ng/ml – Ergocalciferol 50000 IU orally weekly for
12 weeks and then monthly thereafter
5 – 15 ng/ml – Ergocalciferol 50000 IU orally weekly for
4 weeks and then monthly thereafter
16 – 30 ng/ml – Monthly Ergocalciferol
Acidosis : K/DOQI – total Co2 >=22 mEq/L
Sodium bicarbonate 650 – 1300 mg bid – tid
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A major risk factor for cardiovascular morbidity &mortality
Prevalence of hyperlipidemia increases as renal functionsdiminish
All patients with CKD must be evaluated for
Dyslipidemia
Fasting lipid profile – annually
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Stage V CKD patients with dyslipidemia should always beevaluated for secondary causes :
Nephrotic syndrome
Hypothyroidism
Diabetes mellitus
Excessive alcohol consumption
Liver disease
Drugs : oral contraceptives , haart etc…
Goal : LDL – Cholesterol < 100 mg / dl
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LDL : 100 – 129 mg/dl : Lifestyle changes
Not responded : Low dose statin
LDL >= 130 mg/dl : Lifestyle changes + Statins
TG >= 200 mg/dl : Lifestyle changes + Statins
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Control BP : ACEI / ARB
Treat dyslipidemia : Lifestyle changes + Statins
Good Glycemic control
Treat anemia
Correct hyperphosphatemia
Treat hyperparathyroidism
Correct hyperkalemia
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Hepatitis B vaccination : 3 doses (0,1,2 months )
higher dose ( 40 mcg / ml )
Pneumococcal vaccination : single doseone time revaccination 5 yrs
after initial vaccination
Influenza vaccination : recommended annually for adults
> 50 yrs age
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Patients of CKD Stage IV approaching Stage V should be referredfor
Vascular access if hemodialysis is preferred
Peritoneal dialysis catheter placement if peritoneal dialysis is preferred
AVF is most preferred access for HD patients
Ideally created 6 months prior to start of HD
Non dominant upper extremity
And that arm is to be preserved – no iv lines
AVG : 3-6 weeks prior to start of HD
PD Catheter : 2 weeks prior to start of HD
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GFR not below 15 ml/min.1.73m2 but in presence of
Intractable volume overload
Hyperkalemia
Hyperphosphatemia
Hypercalcemia / Hypocalcemia
Metabolic acidosis
Anemia
Uremic encephalopathy
Uremic pericarditis
Severe hypertension , acute pulmonary edema
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