Chronic renal Disease\failure (CKD)

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Information about Chronic renal Disease\failure (CKD)

Published on January 20, 2016

Author: deeterb


1. Chronic kidney disease (CKD) By Dr. Mujahid.A.Abbass WKUFOM

2. Definition  CKD is Impaired renal function for >3 months based on abnormal structure or function, or GFR <60mL/min/1.73m 2 for >3 months with or without evidence of kidney damage Symptoms usually only occur once stage 4 is reached (GFR <30) ESRF is defi ned as GFR <15 mL/min/1.73m 2 or need for renal replacement therapy (RRT—dialysis or transplant).

3. Major causes of CKD Glomerular diseases primary glomerular diseases Focal and segmental glomerulosclerosis Membranoproliferative glomerulonephritis IgA nephropathy Membranous nephropathy Alport syndrome (hereditary nephritis) Secondary glomerular diseases Diabetic nephropathy Amyloidosis Amyloidosis HIV-associated nephropathy Collagen-vascular diseases (eg, SLE) HCV-associated membranoproliferative glomerulonephritis

4. Tubulointerstitial nephritis Drug hypersensitivity Heavy metals Analgesic nephropathy Reflux/chronic pyelonephritis Sickle cell nephropathy Idiopathic Cystic diseases Polycystic kidney disease Medullary cystic disease Obstructive nephropathies Prostatic disease Nephrolithiasis Retroperitoneal fibrosis/tumor Congenital Vascular diseases Hypertensive nephrosclerosis Renal artery stenosis

5. Reversible causes of kidney injury

6. Classifications Stage GFR (mL/min) Notes 1 >90 Slight GFR with other evidence of renal damage* 2 60-89 Slight GFR with other evidence of renal damage* 3 A 45-59 Moderate GFR with or without evidence of other renal 3 B 30-44 damage* 4 15-20 Severe GFR with or without evidence of renal damage* 5 <15 Established renal failure

7. Screening for risky patients with: i. Diabetes mellitus ii. Hypertension iii. Cardiovascular disease (IHD, peripheral vascular disease, cerebrovascular disease) iv. Structural renal disease, known stones or BPH v. Recurrent UTIS or those with childhood history of vesicoureteric refl ux vi. Multisystem disorders which could involve the kidney, eg SLE vii. Family history of ESRF or known hereditary disease, eg APKD viii.Opportunistic detection of haematuria or proteinuria Some guidelines also suggest routine screening in those ix. Age >60yrs

8. Causes of anemia in CKD Relative defiiency of erythropoietin Diminished red blood cell survival Bleeding diathesis Iron defiiency Hyperparathyroidism/bone marrow firosis “Chronic inflmmation” Folate or vitamin B12 defiiency Hemoglobinopathy omorbid conditions: hypo/hyperthyroidism, pregnancy, HIV-associated disease, autoimmune disease, immunosuppressive drugs

9. Evaluation 1-History : •Possible cause: ask about previous UTIS, LUTS (lower urinary tract symptoms, PMH of HTN, DM, IHD, systemic disorder, renal colic. Check drug history and family history (draw tree if positive). Systems review: always be on the lookout for more than is immediately obvious, possible rare causes, symptoms suggestive of systemic disorder or malignancy. •Current state: aemic symptoms In women ask about amenorrhoea, in men impotence. Symptoms become more common with progression through CKD stages 4 and 5 but if slow onset many patients remain asymptomatic. Check for oliguria, dyspnoea, ankle swelling.

10. Symptoms and signs of uremia. Organ System Symptoms Signs General Fatigue,weakness Sallow-appearing, chronically ill Skin Pruritus, easy bruisability Pallor, ecchymoses, excoriations,edema, xerosis ENT Metallic taste in mouth, Urinous breath epistaxis Eye Pale conjunctiva Pulmonary Shortness of breath Rales, pleural effusion Cardiovascular Dyspnea on exertion,retrosternal pain on Inspiration (pericarditis) Hypertension, cardiomegaly, friction rub Gastrointestinal Anorexia, nausea, vomiting, hiccups ----------- Genitourinary Nocturia, erectile dysfunction Isosthenuria

11. Neuromuscular Restless legs, numbness and cramps in legs Neurologic Generalized irritability Stupor, asterixis, and inability to myoclonus, peripheral neuropathy concentrate, decreased libido

12. 2-Examination : You are looking for: 1Cause of ESRF/CKD, eg polycystic kidneys, signs of IHD, DM 2Current mode of renal replacement therapy (RRT) and any complications, eg transplant + skin malignancy from immunosuppression 3Previous types of RRT and any complications, eg arteriovenous fi stula + parathyroidectomy scar Periphery: Hypertension, arteriovenous fi stula (thrill, bruit, has it been recently needled?), signs of previous transplant—bruising from steroids, skin malignancy from immunosuppression.

13. Face: Pallor of anaemia, yellow tinge of uraemia, gum hypertrophy from ciclosporin, cushingoid appearance from steroids. Neck : Current or previous tunnelled line insertion (if removed, look for a small scar over internal jugular, and a larger scar in ‘breast pocket’ area from the exit site), scar from parathyroidectomy. Abdomen: PD catheter or sign of previous catheter (small midline scar just below umbilicus and small round scar to side of midline from exit site), signs of previous transplant (hockey-stick scar, palpable mass), ballotable polycystic kidneys ± liver. Elsewhere: Signs of diabetic neuropathy, retinopathy, cardiovascular or peripheral vascular disease

14. 3-Tests : i. Blood: Hb (normochromic, normocytic anaemia), ESR, U&E, glucose (DM),low Ca2+, high PO43 –, high alk phos (renal osteodystrophy).high PTH if CKD stage 3 or more ii. Urine: Dipstick, MC&S, albumin: creatinine ratio or protein : creatinine ratio

15. iii. Imaging: USS to check size, anatomy and corticomedullary dif erentiation. In CKD kidneys are usually small (<9cm) but can be enlarged in infi ltrative disorders (amyloid, myeloma), APKD and DM. If asymmetrical consider MAG3 renogram to look at contribution of each kidney to overall function iv. Histology: Consider renal biopsy if rapidly progressive disease or unclear cause and normal sized kidneys.

16. Clinical action plan Stage Descrepion GFR,mL/minPer 1.73 m2 Action 1 Kidney damage with normal or ↑ GFR ≥90 Diagnosis and treatment, treatment of comorbid conditions,slowing progression, CVD risk reduction 2 Kidney damage with mild ↓GFR 60–89 Estimating progression 3 Moderate ↓GFR 30–59 Evaluating and treating complications 4 Severe ↓ GFR 15–29 Preparation for kidney replacement therapy 5 Kidney failure <15 (or dialysis) Kidney replacement (if uremia present)

17. Essential of diagnosis: ▶ Decline in the GFR over months to years ▶ Persistent proteinuria or abnormal renal morphology may be present. ▶ Hypertension in most cases. ▶ Symptoms and signs of uremia when nearing endstage disease. ▶ Bilateral small or echogenic kidneys on ultrasound in advanced disease.

18. Treatments aim to • slowing tHe progression of CKd • reducing intraglomerular Hypertension and proteinuria • slowing progression of diabetic renal disease • Control of blood glucose • Control of blood pressure and proteinuria • protein restriction • Managing other Complections of CKD such as: Medication dose adjustment preparation for renal replacement therapy(dialysis+transplantation) patient education

19. Calciphylaxis.

20. Complications A. Cardiovascular Complications i. Hypertension ii. Coronary artery diseas iii. Heart failure iv. Pericarditis

21. B. Disorders of Mineral Metabolism i. renal osteodystrophy, ii. osteitis fibrosa cystica, iii. Adynamic bone disease iv. Osteomalacia

22. C. Hematologic Complications i- Anemia ii- Coagulopathy D. Hyperkalemia E. Acid–Base Disorders F. Neurologic Complications G. Endocrine Disorders

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