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when is world kidney day

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08 March 2012

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Progressive azotemia over months to years Symptoms and signs of uremia when nearing end-stage disease Hypertension in majority Isosthenuria and broad, waxy casts in urinary sediment are common Bilateral small kidneys on US (unless PKD)

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Essentials of Diagnosis of Chronic Kidney Disease

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`National Kidney Foundation (NKF) defines CKD as

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Evidence of renal damage Based on abnormal urinalysis [proteinuria, hematuria] or structural abnormalities found with US or GFR < 60 mL/min for 3 or more months!!!

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if you don't look for kidney failure...

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you aren't going to find it

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GFR < ___ will exhibit clinical signs & symptoms

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< 30 some can be as low as 15 before they present clinically

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what is the normal (adult) GFR

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100 - 120 ml/min

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how os GFR controlled

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control of blood flow by changing the diameter of the afferent and efferent arterioles control of glomerular surface area via contraction or relaxtion of mesangial cells

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How many stages of chronic kidney disease

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5 1 GFR >90 2 GFR 60-89 3 GFR 30-59 4 GFR 15-29 5 GFR <15 or dialysis

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what kidney situation is NOT associated with HTN

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nephrotic syndrome

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waxy casts in urinary sediment are common when there is

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a problem in the DCT

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what is the creatinine clearance formula

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Ccr= (140-age) X weight (kg)/Pcr X 72

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kidney damage w/normal GFR is seen at what GFR

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>90 (Stage 1) Dx & treat treat comorbid conditions, slow progression, CVD risk reduction

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Kidney damage w/mild decrease in GFR

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60-89 (Stage 2) estimaTE PROGRESSION

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moderate decrease in GFR

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30-59 (stage 3) evaluate and treat complications

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severe decrease in GFR

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15-29 (stage 4) perparation for kidney replacement therapy

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kidney failure

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GFR < 15 or dialysis (Stage 5) replacement if uremia present

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diabetes mellitus, hypertension, coronary vascular disease, FHx of CKD, and age > 60 yrs

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Most common risk factors for CKD

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Major outcomes of CKD include

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coronary vascular disease, progression to renal failure, and development of complications of impaired renal function, such as anemia, disorders of mineral metabolism, and secondary hyperparathyroidism

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In CKD: reduced clearance of certain solutes principally excreted by the kidney results in

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their retention in the body fluids. The solutes are end products of the metabolism of substances of exogenous origin (food) or endogenous origin (catabolism of tissue)

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is CKD revesrible?

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no the only exception is getting a kidney transplant

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Reduction in renal mass leads to hypertrophy of the remaining nephrons with hyperfiltration, and the glomerular filtration rate in these nephrons is transiently at ________ levels

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supranormal

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placing a burden on remaining nephrons, leads to

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progressive glomerular sclerosis and interstitial fibrosis, suggesting that hyperfiltration may worsen renal function

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symptoms of CKD

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develop slowly and are nonspecific

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Patients may remain asymptomatic until renal failure is far-advanced:

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(GFR < 10-15 ml/min)

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Manifestations of CKD can include

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include fatigue, malaise, weakness, pruritis GI c/o anorexia, nausea & vomiting, metallic taste and hiccups are common

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Neurologic problems of CKD include

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irritability, difficulty concentrating, insomnia, and forgetfulness

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other symptoms associated with CKD progression

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Menstrual irregularities, infertility, and loss of libido are also common as condition progresses

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Exam reveals

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chronically ill-appearing patient Look for possible underlying cause (DM, SLE) Hypertension is common

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Skin may be

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yellow, with evidence of easy bruising. May have nail changes (Mee's lines) Uremic fetor (fishy breath) may be present

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Cardiopulmonary and mental status changes are

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also frequently noted...CMDT

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Dx made by

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documenting elevations of BUN and serum creatinine concentrations

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GFR...once < 60

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refer to Nephrologist

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Persistent proteinuria is suggestive of

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CKD, regardless of GFR level

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Urinalysis:

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broad, waxy casts (evidence of LOSS of tubular concentrating ability)

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Labs May see

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see anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, and hyperkalemia...with both acute and chronic renal failur

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evaluation needed to differentiate between acute and chronic renal failure

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Evidence of previously elevated BUN and creatinine, abnormal prior urinalysis, and stable but abnormal serum creatinine on successive days is most consistent with a chronic process

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Finding of small echogenic kidneys ______ by US supports diagnosis of CKD/irreversible disease

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Finding of small echogenic kidneys (<9 cm)

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Radiological evidence of renal osteodystrophy is another helpful finding

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Check phalanges of hands Also check clavicles

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Complications (of uremia)

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Cardiovascular (over 50% of deaths in pts with ESRD) Hyperkalemia Acid-base disorders (tendency to retain hydrogen ions) Hematologic Neurologic Disorders of mineral metabolism Endocrine disorders

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________is most common complication of ESRD

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HTN

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HTN control with

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weight loss and tobacco cessation Salt intake reduced to 2g/day

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Initial RX to control HTN include

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ACE inhibitor or angiotensin II receptor blocker (ARB) If serum potassium and GFR permit (recheck 1 week)

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Goal blood pressure is

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Goal blood pressure is 1-2 g/d, goal is < 125/75 mm Hg

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BP Goal if pt has proteinuria

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for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg

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Pericarditis may develop with

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uremia Cause believed to be retention of metabolic toxins Symptoms include chest pain and fever. May have pulsus paradoxus and friction rub on exam Pericarditis is an absolute indication for initiation of hemodialysis

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_____ is an absolute indication for hemodialysis

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pericarditis

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Patients with ESRD tend toward a ___ cardiac output

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high

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CKD patients, especially those with DM, are more likely to die from

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cardiovascular disease than to progress to ESRD/dialysis! Do not focus only on the CKD...if you do, you are missing the boat Screen for and treat the C/V Dz and other risk factors present

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Potassium balance usually remains intact until

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GFR < 10-20 mL/min

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Tx of acute hyperkalemia involves

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cardiac monitoring, IV calcium chloride or gluconate, insulin with glucose, bicarbonate, and sodium polystyrene sulfonate

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Chronic hyperkalemia treated with

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dietary potassium restriction/sodium polystyrene PRN

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The resultant metabolic acidosis is primarily due to

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loss of renal mass

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Damaged kidneys are unable to excrete the ________of acid generated by metabolism of dietary proteins

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1 mEq/kg/d

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treatment for acid base d/o

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Maintain serum bicarb level at > 20 mEq/L Alkali supplements include sodium bicarb, calcium bicarb, sodium citrate Keep pH > 7.20

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anemia

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Normochromic, normocytic Due to decreased erythropoiesis and RBC survival Many patients are also iron deficient

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Recombinant erythropoietin (epoetin alfa) used in

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patients whose hematocrits are < 33% Some recommend start with iron supplement and then possibly add ESA (erythroproeitin stimulating agents..Procrit/Epogen)

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main cause of coagulopathy

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platelet dysfunction Platelet counts only mildly decreased, but bleeding time is prolonged Platelets show abnormal adhesiveness and aggregation

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Patients may present with petechiae, purpura, and increased bleeding during surgery

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CKD coagulopathy

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Tx goal of pt w/coagulopathy

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= Hematocrit increased to 30% Dialysis improves bleeding time but doesn't normalize it

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Uremic encephalopathy does not occur until GFR falls below

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10-15 mL/min Symptoms begin with difficulty concentrating and can progress to lethargy, confusion, and coma

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Earlier initiation of dialysis may prevent peripheral neuropathies

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Neuropathy found in 65% of patients on or nearing dialysis but not until GFR is 10% of normal

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Disorders of calcium, phosphorus, and bone are referred to as

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renal osteodystrophy

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Most common disorder of mineral metabolism

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is osteitis fibrosa cystica - the bony changes of secondary hyperparathyroidism...affecting 50% of patients nearing ESRD

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Radiographically, lesions most prominent in phalanges and lateral ends of clavicles Look for

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subperiostial erosions

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may cause bony pain, proximal muscle weakness, and spontaneous bone fractures

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osteomalacia or adynamic bone disease

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Tx of Disorders of mineral metabolism

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may consist of dietary phosphorus restriction, oral phosphorus-binding agents such as calcium carbonate or Renogel, and vitamin D Hyperparathyroidism treated with calcitriol or Sensipar

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Circulating insulin levels are higher because

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of decreased renal insulin clearance

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Glucose intolerance can occur in chronic renal failure when GFR is

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< 10-20 mL/min. This is mainly due to peripheral insulin resistance...

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Decreased libido and erectile dysfunction are common

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Men have decreased testosterone; women are often anovulatory

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ACE/ARB to slow progression of

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proteinuria and CVD Potentiates hyperkalemia...repeat serum creatinine & potassium in one week!!!!

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Maintain excellent diabetes control...keep HgA1C ___

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<7

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Lower cholesterol...consider

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statin agent

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Avoid fluid overload. Use diuretics such as

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Lasix PRN

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Refer patients to CKD clinics for management.... Goal of CKD clinics is to

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keep the patient OFF dialysis!

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Tx (Consult early) to

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Nephrology, Vascular/Gen Surgery

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Malnutrition very common secondary to

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anorexia, decreased intestinal absorption/digestion... Every patient should be evaluated by dietician

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Protein restriction...

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In general, protein intake should not exceed 1 g/kg/d!

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salt and water restriction

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For the nondialysis patient approaching ESRD, 2 g/d of sodium is an initial recommendation

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Once GFR has fallen below 10-20 mL/min, potassium intake should be limited to

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< 60-70 mEq/d

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Magnesium restriction No magnesium-containing .....

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laxatives or antacids

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Dialysis should be started when patient has GFR of

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10 mL/min or serum creatinine of 8 mg/dL

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when should diabetics start dialysis

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Diabetics should start when GFR reaches 15 mL/min or serum creatinine is 6 mg/dL

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indications for dialysis include

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Uremic symptoms such as pericarditis, encephalopathy, or coagulopathy Fluid overload unresponsive to diuresis Refractory hyperkalemia...>7 Severe metabolic acidosis (pH 100

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what dialysis method is the main choice for US pts

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Hemodialysis (choice for 90% of patients in US) Vascular access accomplished by an a/v fistula (preferred) or prosthetic graft

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Patients typically require hemodialysis ___ times per week...sessions

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Patients typically require hemodialysis 3 times per week...sessions last 3-5 hrs each

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Ensure patient undergoing hemodialysis getting regular labs to include

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PTH and ALK PHOS

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Peritoneal dialysis

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The peritoneal membrane is the \"dialyzer\" Semi-permeable membrane...waste products pass through, blood cells do not

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most common type of peritoneaLl dialysis is

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continuous ambulatory peritoneal dialysis (CAPD) Patients exchange dialysate 4-6 times per day Put fluid in...drain in 3-4 hrs...repeat...

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Continuous cyclic peritoneal dialysis (CCPD) utilizes

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a cycler machine to automatically perform exchanges at night

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Most common PD complication

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= peritonitis Most common pathogen = S aureus

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PD is used more commonly

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outside the US Many nephrologists believe 25-35% of pts should be on PD

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when is someone placed on a kidney transplant list

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not placed on list until GFR <15 Living donor is best option!

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One year survival rate is approximately 98% and five year survival rate is ____

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70-80%

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Expected remaining lifetime for the age group 55-64 is 22 years, whereas that of ESRD population is

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5 years

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CKD pts most common cause of death is

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cardiac

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For those who require dialysis to sustain life, but decide against it, death ensues within

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days to weeks

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dialysis numbers

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10% Dxed with ESRD 3-4 dialysis txs/week (4 is best) 150 dialysis txs/year

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Two-thirds of kidney transplants come from

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deceased donors

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Overall...medical care of CKD focuses on delaying or halting progression of CKD

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Tx underlying cause(s) Tx hypertension and diabetes Avoid nephrotoxins Tx complications Lastly...watch out for meds that are renally excreted. You will need to adjust dose in patients with renal failure!!!

Chronic Kidney Disease

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