Chronic Kidney Disease
Patients may remain asymptomatic until renal failure is far-advanced:
(GFR < 10-15 ml/min)
when is world kidney day
08 March 2012
Damaged kidneys are unable to excrete the ________of acid generated by metabolism of dietary proteins
1 mEq/kg/d
Dialysis should be started when patient has GFR of
10 mL/min or serum creatinine of 8 mg/dL
dialysis numbers
10% Dxed with ESRD 3-4 dialysis txs/week (4 is best) 150 dialysis txs/year
Uremic encephalopathy does not occur until GFR falls below
10-15 mL/min Symptoms begin with difficulty concentrating and can progress to lethargy, confusion, and coma
what is the normal (adult) GFR
100 - 120 ml/min
severe decrease in GFR
15-29 (stage 4) perparation for kidney replacement therapy
moderate decrease in GFR
30-59 (stage 3) evaluate and treat complications
How many stages of chronic kidney disease
5 1 GFR >90 2 GFR 60-89 3 GFR 30-59 4 GFR 15-29 5 GFR <15 or dialysis
Expected remaining lifetime for the age group 55-64 is 22 years, whereas that of ESRD population is
5 years
Kidney damage w/mild decrease in GFR
60-89 (Stage 2) estimaTE PROGRESSION
One year survival rate is approximately 98% and five year survival rate is ____
70-80%
Glucose intolerance can occur in chronic renal failure when GFR is
< 10-20 mL/min. This is mainly due to peripheral insulin resistance...
GFR < ___ will exhibit clinical signs & symptoms
< 30 some can be as low as 15 before they present clinically
Once GFR has fallen below 10-20 mL/min, potassium intake should be limited to
< 60-70 mEq/d
Maintain excellent diabetes control...keep HgA1C ___
<7
Tx goal of pt w/coagulopathy
= Hematocrit increased to 30% Dialysis improves bleeding time but doesn't normalize it
Most common PD complication
= peritonitis Most common pathogen = S aureus
kidney damage w/normal GFR is seen at what GFR
>90 (Stage 1) Dx & treat treat comorbid conditions, slow progression, CVD risk reduction
Initial RX to control HTN include
ACE inhibitor or angiotensin II receptor blocker (ARB) If serum potassium and GFR permit (recheck 1 week)
diabetes mellitus, hypertension, coronary vascular disease, FHx of CKD, and age > 60 yrs
Most common risk factors for CKD
Tx (Consult early) to
Nephrology, Vascular/Gen Surgery
Earlier initiation of dialysis may prevent peripheral neuropathies
Neuropathy found in 65% of patients on or nearing dialysis but not until GFR is 10% of normal
anemia
Normochromic, normocytic Due to decreased erythropoiesis and RBC survival Many patients are also iron deficient
Ensure patient undergoing hemodialysis getting regular labs to include
PTH and ALK PHOS
Patients typically require hemodialysis ___ times per week...sessions
Patients typically require hemodialysis 3 times per week...sessions last 3-5 hrs each
Patients with ESRD tend toward a ___ cardiac output
high
Manifestations of CKD can include
include fatigue, malaise, weakness, pruritis GI c/o anorexia, nausea & vomiting, metallic taste and hiccups are common
Neurologic problems of CKD include
irritability, difficulty concentrating, insomnia, and forgetfulness
Most common disorder of mineral metabolism
is osteitis fibrosa cystica - the bony changes of secondary hyperparathyroidism...affecting 50% of patients nearing ESRD
Refer patients to CKD clinics for management.... Goal of CKD clinics is to
keep the patient OFF dialysis!
Magnesium restriction No magnesium-containing .....
laxatives or antacids
The resultant metabolic acidosis is primarily due to
loss of renal mass
Tx of Disorders of mineral metabolism
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
what kidney situation is NOT associated with HTN
nephrotic syndrome
is CKD revesrible?
no the only exception is getting a kidney transplant
when is someone placed on a kidney transplant list
not placed on list until GFR <15 Living donor is best option!
Circulating insulin levels are higher because
of decreased renal insulin clearance
may cause bony pain, proximal muscle weakness, and spontaneous bone fractures
osteomalacia or adynamic bone disease
PD is used more commonly
outside the US Many nephrologists believe 25-35% of pts should be on PD
Recombinant erythropoietin (epoetin alfa) used in
patients whose hematocrits are < 33% Some recommend start with iron supplement and then possibly add ESA (erythroproeitin stimulating agents..Procrit/Epogen)
_____ is an absolute indication for hemodialysis
pericarditis
main cause of coagulopathy
platelet dysfunction Platelet counts only mildly decreased, but bleeding time is prolonged Platelets show abnormal adhesiveness and aggregation
placing a burden on remaining nephrons, leads to
progressive glomerular sclerosis and interstitial fibrosis, suggesting that hyperfiltration may worsen renal function
ACE/ARB to slow progression of
proteinuria and CVD Potentiates hyperkalemia...repeat serum creatinine & potassium in one week!!!!
GFR...once < 60
refer to Nephrologist
Disorders of calcium, phosphorus, and bone are referred to as
renal osteodystrophy
Labs May see
see anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, and hyperkalemia...with both acute and chronic renal failur
Lower cholesterol...consider
statin agent
Radiographically, lesions most prominent in phalanges and lateral ends of clavicles Look for
subperiostial erosions
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
supranormal
In CKD: reduced clearance of certain solutes principally excreted by the kidney results in
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)
Pericarditis may develop with
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
HTN control with
weight loss and tobacco cessation Salt intake reduced to 2g/day
Skin may be
yellow, with evidence of easy bruising. May have nail changes (Mee's lines) Uremic fetor (fishy breath) may be present
if you don't look for kidney failure...
you aren't going to find it
Avoid fluid overload. Use diuretics such as
Lasix PRN
treatment for acid base d/o
Maintain serum bicarb level at > 20 mEq/L Alkali supplements include sodium bicarb, calcium bicarb, sodium citrate Keep pH > 7.20
Decreased libido and erectile dysfunction are common
Men have decreased testosterone; women are often anovulatory
other symptoms associated with CKD progression
Menstrual irregularities, infertility, and loss of libido are also common as condition progresses
Patients may present with petechiae, purpura, and increased bleeding during surgery
CKD coagulopathy
Persistent proteinuria is suggestive of
CKD, regardless of GFR level
Complications (of uremia)
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
what is the creatinine clearance formula
Ccr= (140-age) X weight (kg)/Pcr X 72
Radiological evidence of renal osteodystrophy is another helpful finding
Check phalanges of hands Also check clavicles
when should diabetics start dialysis
Diabetics should start when GFR reaches 15 mL/min or serum creatinine is 6 mg/dL
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)
Essentials of Diagnosis of Chronic Kidney Disease
evaluation needed to differentiate between acute and chronic renal failure
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
`National Kidney Foundation (NKF) defines CKD as
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!!!
Finding of small echogenic kidneys ______ by US supports diagnosis of CKD/irreversible disease
Finding of small echogenic kidneys (<9 cm)
salt and water restriction
For the nondialysis patient approaching ESRD, 2 g/d of sodium is an initial recommendation
Potassium balance usually remains intact until
GFR < 10-20 mL/min
kidney failure
GFR < 15 or dialysis (Stage 5) replacement if uremia present
Goal blood pressure is
Goal blood pressure is <130/80 mm Hg; for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg
________is most common complication of ESRD
HTN
what dialysis method is the main choice for US pts
Hemodialysis (choice for 90% of patients in US) Vascular access accomplished by an a/v fistula (preferred) or prosthetic graft
Protein restriction...
In general, protein intake should not exceed 1 g/kg/d!
Peritoneal dialysis
The peritoneal membrane is the "dialyzer" Semi-permeable membrane...waste products pass through, blood cells do not
Overall...medical care of CKD focuses on delaying or halting progression of CKD
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!!!
indications for dialysis include
Uremic symptoms such as pericarditis, encephalopathy, or coagulopathy Fluid overload unresponsive to diuresis Refractory hyperkalemia...>7 Severe metabolic acidosis (pH < 7.20) Neurologic symptoms such as seizures or neuropathy BUN > 100
Continuous cyclic peritoneal dialysis (CCPD) utilizes
a cycler machine to automatically perform exchanges at night
waxy casts in urinary sediment are common when there is
a problem in the DCT
Cardiopulmonary and mental status changes are
also frequently noted...CMDT
Malnutrition very common secondary to
anorexia, decreased intestinal absorption/digestion... Every patient should be evaluated by dietician
Urinalysis:
broad, waxy casts (evidence of LOSS of tubular concentrating ability)
CKD pts most common cause of death is
cardiac
Tx of acute hyperkalemia involves
cardiac monitoring, IV calcium chloride or gluconate, insulin with glucose, bicarbonate, and sodium polystyrene sulfonate
CKD patients, especially those with DM, are more likely to die from
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
Exam reveals
chronically ill-appearing patient Look for possible underlying cause (DM, SLE) Hypertension is common
most common type of peritoneaLl dialysis is
continuous ambulatory peritoneal dialysis (CAPD) Patients exchange dialysate 4-6 times per day Put fluid in...drain in 3-4 hrs...repeat...
how os GFR controlled
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
Major outcomes of CKD include
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
For those who require dialysis to sustain life, but decide against it, death ensues within
days to weeks
Two-thirds of kidney transplants come from
deceased donors
symptoms of CKD
develop slowly and are nonspecific
Chronic hyperkalemia treated with
dietary potassium restriction/sodium polystyrene PRN
Dx made by
documenting elevations of BUN and serum creatinine concentrations
BP Goal if pt has proteinuria
for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg