Chronic Kidney Disease

Robin Maskey, MD Department of Internal Medicine

1/17/2013

A. Definitions
o

Azotemia - elevated blood urea nitrogen (BUN >28mg/dL) and creatinine (Cr>1.5mg/dL) Uremia - azotemia with symptoms or signs of renal failure End Stage Renal Disease (ESRD) - uremia requiring transplantation or dialysis

Chronic Kidney Disease (CKD) - irreversible kidney dysfunction with azotemia >3 months
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Creatinine Clearance (CCr) - the rate of filtration of creatinine by the kidney (GFR marker) Glomerular Filtration Rate (GFR) - the total rate of filtration of blood by the kidney

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Prevalence

1 in 5 diabetics 1 in 6 hypertensives 1 in 5 of all elderly > 80 without HTN and DM

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Common Underlying Causes of CRF

Diabetes: most common cause ESRD (risk 13x ) CRF associated HTN causes - 23% ESRD Glomerulonephritis accounts for ~10% Polycystic Kidney Disease - about 5% Rapidly progressive glomerulonephritis (vasculitis) - about 2% Renal (glomerular) deposition diseases Renal Vascular Disease - renal artery stenosis, atherosclerotic vs. fibromuscular

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Non-DM Causes of CKD

Glomerular

Tubulointerstitial

Lupus or vasculitis Hepatitis or HIV Endocarditis Amyloidosis Medications Lithium

Ratio of protein: creatinine is high

Myeloma Pyleonephritis Obstruction BPH Tumor Chronic reflux Sarcoidosis

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Non-DM Causes of CKD

Vascular

Hypertension Renal artery stenosis Renal vasculitis Sickle cell HUS

Cystic and other hereditary renal diseases Transplant

Low-flow states

Chronic rejection Medications Chronic disease

Cirrosis, CHF, etc.

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Clinical Approach

History Symptoms and Signs Examination Investigations Renal Biopsy

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History

Duration of symptoms Drug h/o Past medical and surgical h/o Family h/o

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Symptoms &Signs
Organ system General Skin ENT Eye Pulmonary Dyspnea CvS GIT Renal Neuromus cular Neuro
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Symptoms Fatigue, weakness Pruritus, easy brusisability Metallic taste, epistaxis

Signs Sallow appearing Pallor,edema,ecchymoses Urinous breath Pale conjunctiva Rales,Pl.effussion HTN,cardiomegaly,friction rub

Dyspnea on exertion,pericarditis Anorexia,hiccups Nocturia,impotence Restless legs,numbness Irritability,libido

Stupor,asterixis
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Examination

Short stature Pallor/hyperpigmenation/brown nails/scratch marks Signs of fluid oerload Pericardial rub Flow murmur According to etiologyDM,PD,SLEetc.
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Investigations

Urinalysis, microscopic exam, quantitation of protein in urine (protein:creatinine ratio) Calcium, phosphate, uric acid, magnesium and albumin Calculation of creatinine clearance and protein losses Complete blood count Consider complement levels, protein electrophoresis, antinuclear antibodies, ANCA

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NO MORE 24-HOUR URINES! Spot urines are adequate

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Methods of Estimating GFR

Inulin/iothalamateclearance GOLD STANDARD Creatinine Clearance (24 h urine) Equations base on serum creatinine Cockroft-Gault formula

140-age/72 xcreatnine in males or Same X0.84 in females

MDRD
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Radiographic Evaluation

Renal Ultrasound - evaluate for obstruction, stones, tumor, kideny size, chronic change Duplex ultrasound or angiography

Spiral CT scan to evaluate renal artery stenosis

MRA preferred over contrast agents

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Complications

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Anemia Bone disease Skin disease GIT complications Metabolic complications Endocrinological Muscular CNS Cardioascular

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Anemia

Erythropoietin defieciency Bone marrow toxins/fibrosis Iron,folate and B12 deficiency RBC destruction and blood loss

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Bone disease

Renal osteodystrophy Hyperparathyriodism Osteomalacia Osteoporosis Osteosclerosis

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Skin disease

Uremic pruritis Eczematous leisons Cutanea tarda

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GIT complications

GERD Peptic ulcer Acute pancreatitis Constipation in CAPD patients

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Metabolic

Gout Insulin resistance Lipid abnormalities Hypoglycemia

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Endocrine

Hyperprolactionemia Abnormal thyriod hormones LH / testosterone Abnormal GH

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CNS

Uremic encephalopathy Dialysis dementia-alumunium toxicity Seizures Restless leg symdrome Carpel tunnel syndrome Polyneuropathy

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Cardiac

Myocardial infacrtion Accelerated HTN Cardiac faliure Coronary calcification Systolic and diastolic dysfunction Uremic pericarditis Dialysis pericarditis

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Goals of Care
1.

2.
3.

Slow decline in renal function Prevent cardiovascular disease Detect and manage complications

Anemia Hyperparathyroidism Bone disease Electrolyte abnormalities Vascular complications

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To slow decline

Low salt diet (for HTN) Low protein diet in CKD 4 & 5

Nutrition consult!

Avoid nephrotoxic agents

Contrast dye, NSAIDs, gentamicin

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To slow decline

Diabetes control HA1c ~ 7.0 7.5

Metformin? Glipizide v. Glyburide Insulin

Blood pressure control - < 130/80

ACE-I or ARB Diuretics thiazide for GFR > 30 - furosemide for GFR < 30
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To slow decline
Prescribe an ACE-I or ARB for proteinuria + CKD even in the ABSENCE of diabetes
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Goals of Care
1.

2.
3.

Slow decline in renal function Prevent cardiovascular disease Detect and manage complications

Anemia Hyperparathyroidism Bone disease Electrolyte abnormalities Vascular complications

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Prevent CV disease
Most common cause of death is CV disease and not renal failure.

Smoking cessation Diabetes and Blood pressure control Lipids

No evidence that tx affects renal fxn Guidelines: ATP3 -> LDL goal < 100

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Renal replacement therapy

Hemodialysis Peritoneal dialysis CAPD Renal transplantation

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Indications of HD
H-Severe Hyperkalemia U-Uremia - azotemia with symptoms and/or signs

M-Metabolic acidosis
P- Volume Overload - usually with congestive heart failure (pulmonary edema) Periccariditis S- serum creatnine >6 mg/dl

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When to refer

Proteinuria > 3.5 gm in 24 hours Nephritis

Hematuria, proteinuria and HTN

Diabetes & CKD but no retinopathy GFR decline of 50% in one year Stage 3 or 4 CKD

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Chronic Hemodialysis Medications

Anti-hypertensives - labetolol, CCB, ACE inhibitors Eythropoietin - for anemia in ~80% dialysis pts Vitamin D Analogs - calcitriol given oral Calcium carbonate or acetate to phosphate and PTH RenaGel, a non-adsorbed phosphate binder, is being developed for hyperphosphatemia DDAVP may be effective for patients with symptomatic platelet problems
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Key Points

Think about CKD and screen

Creatinine AND urine protein

Calculate the GFR! Look for reversible cause if no DM Get to know the KDOQI guidelines & think about the complications
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Thank you

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