3. Common Clinical Features
Symptoms are often absent until renal failure
There may be long term history or hypertension, diabetes or past h/o AKI
Vague symptoms like
Loss of appetite & weight
Nausea, weakness
Hiccups
Dyspnea
Recurrent hypoglycemia
Muscle cramps, restless legs
Pruritus
Signs like Edema, Peripheral neuropathy, Hypertension
Pericardial friction rub, asterixis not attributable to other cause
4. Approach to patients of CKD
There is history of hypertension, diabetes, abnormal
urinalysis.
History of intake of drugs like NSAIDs, antimicrobials,
chemotherapeutic agents, ARVs, Lithium should be
elicited
Any family history of kidney disease with visual, auditory
or cutaneous manifestations helps in diagnosis of
heritable form of CKD
5.
6. Any acceleration in the rate of decline should prompt a search
for superimposed acute or subacute processes that may be
reversible
1. ECFV depletion,
2. Uncontrolled hypertension,
3. Urinary tract infection,
4. New obstructive uropathy,
5. Exposure to nephrotoxic agents
6. Reactivation or flare of the original disease, such as lupus or
vasculitis
9. CBC
RFT
Urine ACR
Serum Iron, Folate, Vit B12 levels
Serum calcium, phosphate, vit D and Parathyroid levels
Lipid profile
HIV, HBsAg and HCV
Autoimmune screening
Serum and urine protein electrophoresis
24 hr urine protein estimation
10.
11. Imaging studies
Renal USG
Can verify presence of two kidneys
Estimate kidney size
Symmetry
Renal masses and obstructions
Bilaterally small kidneys suggests CKD of long duration
Kidney size maybe normal in CKD due to Diabetic
nephropathy, Amyloidosis, HIV nephropathy
Polycystic kidney disease presents as enlarged kidneys with
multiple cysts
12. Diagnosis of renovascular disease can be done by Doppler
sonography, MRI.
DEXA scan to assess the severeity of metabolic bone disease.
IF suspicious of reflux nephropathy, micturating
cystourethrogram may be indicated.
Oral phosphate-containing bowel preparations should not be
used in people with a GFR <60 ml/min/1.73 m2 (GFR categories
G3a-G5)
Measures to prevent contrast induced nephropathy
IV or Intrarterial dye to be avoided.
Avoidance of hypovolemia
Minimization of dye load
Choosing least nephrotoxic dyes
13. Kidney Biopsy
Usually done by USG guided, Surgical or Laparoscopic approach
In patients with bilaterally small kidneys renal biopsy is
not advised because
Technically difficult
More chance of bleeding and other adverse effects
More scarring. So disease may not be apparent
Contraindications :
Uncontrolled hypertension
Active UTI
Bleeding diathesis
Morbid obesity
15. The medical care of patients with CKD should
focus on the following:
Delaying or halting the progression of CKD
Diagnosing and treating the pathologic
manifestations of CKD
Timely planning for long-term renal
replacement therapy
16.
17. SLOWING THE PROGRESSION OF CKD:
Reducing Intraglomerular Hypertension and Proteinuria
ARB or ACE-I be used in diabetic adults with CKD and urine albumin
excretion 30–300 mg/24 hours
ARB or ACE-I be used in both diabetic and non-diabetic adults with
CKD and urine albumin excretion >300 mg/24 hours
Target blood pressure -130/80 mmHg , 125/75 mm Hg if proteinuria
> 1 g/day
ACE inhibitors and ARBs first line agents
Adverse effects from these agents include cough and angioedema
with ACE inhibitors, anaphylaxis, and hyperkalemia,and reduced GFR
with either class
18.
19. SLOWING PROGRESSION OF DIABETIC RENAL DISEASE
Control of Blood Glucose
Optimal blood glucose control significantly reduces the risk of developing
microalbuminuria, macroalbuminuria and/or overt nephropathy in people with
Type 1 or Type 2 diabetes.
Preprandial glucose be kept in the 5.0–7.2 mmol/L, (90–130 mg/dL)
Hemoglobin A 1C should be < 7%. HbA1C may be maintained above 7% if
is having recurrent hypoglycemia.
Management
• Lifestyle modification
• Oral hypoglycemic
• Gliptins
• Incretin mimetic
• Insulin
Metformin can be continued in people with GFR >45 ml/min/1.73 m2 (GFR categories G1-
G3a); its use should be reviewed in those with GFR 30–44 ml/min/1.73 m2 (GFR category
G3b); and it should be discontinued in people with GFR <30 ml/min/1.73 m2
20. SLOWING PROGRESSION OF DIABETIC RENAL DISEASE
DIET
At least 50% of the protein intake be of high biologic value
Stage 4 & stage 5 CKD - 0.8 g/kg/day
Caloric requirement – 35cal/kg/day
Salt – 2 g of sodium equivalent to 5 g of NaCl/day except in salt
loosing nephropathies
22. Management Of Fluid, Electrolyte and Acid
– Base Disorders
Dietary salt restriction and use of loop diuretics.
Salt supplementation and sodium rich diet may be required in rare
patients of salt loosing nephropathy.
Intractable ECFV expansion despite salt restriction and diuretic therapy
maybe an indication to start renal replacement therapy.
Metabolic Acidosis
RTA with Anion Gap metabolic acidosis responds to Sodium Bicarbonate
supplementation (1 or 2 tablets BD)
Sodium Bicarbonate supplementation when serum bicarbonate level
below 20 – 23 mmol/l
23. Hyperkalemia
Dietary K+ restriction
Kaliuretic diuretics
K+ binding resins like Calcium resonium, Calcium
polystyrene sulphonate.
Cease ACE inhibitor/ARB/spironolactone if K+
persistently > 6.0 mmol/L not responding to above
therapies
Dialysis in case of intractable hyperkalemia
24. Disorders of Calcium and Phosphate Metabolism
Low phosphate diet and use of phosphate – binding agents
Calcium acetate and calcium carbonate bind to dietary phosphate in GI
tract.
Adverse effect – Hypercalcemia.
Sevelamer and Lanthanum are non calcium containing phosphate binders
that do not cause hypocalcemia.
Calcitriol suppresses PTH secretion by both direct and indirect
mechanisms.
Calcitriol also causes hypercalcemia and hyperphosphatemia.
Cinacalcet (30-90mg/day) – Calcimimetic drug that causes dose dependent
reduction in PTH and plasma calcium concentration.
25.
26. Hypertension
Goal is to prevent the extrarenal complications of HTN like
cardiovascular disease and stroke.
In CKD patients with diabetes or proteinuria > 1 g / day BP
should be reduced to below <130/80 mmHg
Salt restriction (<2 g of sodium/day)
ACE inhibitors and ARBs slow the decline in renal function
ACE inhibitors and ARBs are contraindicated in case of
renal artery stenosis and Hyperkalemia.
Can precipitate AKI on CKD
27. ACEI and ARB should be continued if reduction in GFR is less than <25%
after 2 months.
If the reduction in GFR is more than 25% below the baseline value, the
ACE inhibitor or ARB should be ceased.
Caution should be exercised if baseline K+ is≥5.5 mmol/L, as rises in
serum K+ of approximately 0.5 mmol/L are expected.
Both non-loop diuretics (e.g., thiazides) and loop diuretics (e.g.,
frusemide) are effective in all stages of CKD as adjunct antihypertensive
therapy.
Beta-blockers may be useful in people with coronary heart
disease,tachyarrhythmias and heart failure.
Calcium channel blockers may be used for people with angina, the
elderly and those with systolic hypertension
28. MANAGEMENT OF CARDIOVASCULAR DISEASE
• Lifestyle changes, including regular exercise at least 30 mins/day, 5
days a week
• Manage dyslipidemia
• If aged ≥50 years with any stage of CKD (irrespective of lipid levels):
- Statin if eGFR is > 60 mL/min/1.73 m2
- Statin or statin/ezetimibe combination if eGFR is <= 60mL/min/1.73
m2
• If aged < 50 years with any stage of CKD (irrespective of lipid levels):
- Statin if presence of one or more of:
• coronary disease
• Previous ischaemic stroke
• diabetes
• estimated 10-year incidence
of fatal or non-fatal myocardial
infarction above 10%
29. Pericardial Disease
Uremic pericarditis is an absolute indication
for urgent initiation of dialysis.
Hemodialysis should be performed without
heparin.
Pericardial drainage procedure in patients
with recurrent pericardial effusion with signs
of impending tamponade.
30. Anemia
Recombinant human erythropoietin
Iron supplementation is essential for optimal response to erythropoietin
Once ESA commenced, maintain:
Ferritin 200-500 µg/L; TSAT 20-30%
IV iron supplementation for GI intolerance or patients on hemodialysis.
B12 and Folate supplementation should be done.
Anemia resistant to ESA in presence of adequate iron stores maybe due to
Acute or chronic inflammation
Inadequate dialysis
Severe hyperparathyroidism
Chronic blood loss
31. Blood transfusions increase the risk of
Hepatitis
Iron overload
Transplant sensitization
ESA in CKD maybe associated in with an increased
risk of stroke in those with type 2 DM and an
increased risk of thromboembolic events
Target Hb must be 10 - 11.5 g/dl
32. Abnormal Hemostasis
Abnormal bleeding time and coagulopathy in patients
with renal failure may be reversed temporarily with
• desmopressin(DDAVP),
• cryoprecipitate,
• blood transfusions, and
• EPO therapy.
Optimal dialysis will usually correct a prolonged
bleeding time.
33. Muscle cramps
Encourage stretching and massaging of the affected area.
Correction of electrolyte imbalance.
Pruritus
Evening Primrose Oil, Skin emollients
If both pruritus and restless legs are present, consider gabapentin
For persistent pruritus, consider ultraviolet light B (UVB) therapy
Restless legs
Dopaminergic agents or dopamine agonists
Benzodiazepines
Sleep apnoea
Weight reduction
CPAP therapy
39. IHD SLEDD CRRT
Mechanism and molecules
removed Dialysis – mostly low MWt
Small + middle molecules
with SLEDD/F
Small + middle molecules
with CVVHDF
Use
Ambulatory CRF
Hyperkalemia
Critically ill
Hyperkalemia
Critically ill
Non-ambulatory
Efficiency High Moderate Low
Urea clearance (mL/min) 150 80 30 (CVVHDF)
Hemodynamic stability
Poor
(hypotension common) Good Good
Duration 3-4 h 3x/week 6-12 h daily Continuous (24h/filter)
Anticoagulation Not needed
Usually not needed
(if filter clots lose 150 mL
blood)
Important
(if filter clots lose 150 mL
blood)
40. Transplantation
Technique:
Source:
. Living related donor with HLA & ABO matching.
. Unrelated donor with HLA partial matching.
. Cadaveric kidney.
Operative
. Nephrectomy
. The kidney is perfused with cold solution till transplantation(cold ischemic time)
. The kidney is placed in iliac fossa & anastomosed to iliac vessels & ureter is placed in
Bladder.
Indications
All patients of ESRD without contraindications for transplantation & with available
donor.
41. Complications of transplantation
Early complications
Surgical complications
Delayed or slow graft function
Lymphocele
Allograft rejection
Hyper acute rejection (antibody-mediated rejection) : within
min. to hour of perfusion of allograft
- Due to preformed antibodies to the ABO & HLA antigens.
Acute rejection – within 3 months of transplant
Chronic rejection
43. Immunization in CKD patients
Hepatitis B Vaccine
Recombinant 40 microgram/ml IM in deltoid region at 0, 1, 2
and 6 months as earliest as possible in any stage of CKD
Anti HBs antibody titer should be assessed at 2months after
completing course and then annually. If titre below 10 mU/
ml , a booster dose should be given.
Pneumococcal vaccine
A single IM/SC dose of 0.5 ml of pneumococcal vaccine
should be administered to all dialysis patients of 2years of
age or older
Revaccination after 5 years.
44. Influenza Vaccine
Influenza vaccine should be given IM annually before beginning of
influenza season to patients who are 6 months or older and on dialysis.
Hib Conjugate Vaccine
0.5 ml IM
Hib (HbOC) – One to three doses. Booster dose given at 15 months.
Hib (PRP-OMP) – Two doses 1 month apart and booster at 12 months.
Hib (PRP) – One dose only, no booster dose required
Live Attenuated Vaccine
Usually contraindicated