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Chronic Kidney Disease

Dr.G.Sridhar MD,DM(Nephro) AWARE GLOBAL HOSPITAL L.B.Nagar,Hyderabad.

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Definition
Kidney damage > 3 months as defined by structural or functional abnormalities of kidney, with or without GFR manifest by either. GFR < 60 ml / mt / 1.73 m2 for > 3 months with or without kidney damage
K Doqi Guideline 2002

Staging of CKD NKFNKF-DOQI CKD is divided in to 5 stages according to GFR

Stage Description At risk 1 Kidney damage with N or GFR GFR (ml/min/1.73 m2) > 90 (with CKD risk factor) > 90 Action Screening CKD risk reduction

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Diagnosis & treatment Treatment Co-morbidity CoSlowing progression CVD risk reduction Estimate progression Evaluation & treatment of complications Prepare for RRT Replacement

2 3 4 5

Kidney damage mild GFR Moderate GFR Severe GFR Kidney failure

60 - 89 30 - 59 15 - 29 < 15

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Chronic kidney disease

Patients with a GFR > 60 ml/min not considerd as CKD unless evidence of kidney damage Proteinuria hematuria Structure abnormalities (abnormal renal imaging) Genetic disease (APKD) Histological proven disease

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GFR
Normal  Males 110 135ml/mt(Av.125ml/min/1.73m2)  Females 90 -120ml/mt(Av.110ml/min/) GFR decreases with age at 80 yrs 80ml/min/1.73m2

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HOW TO CALCULATE e-GFR

1.Cockroft and Gault formula Cr.Cl = (140 age) x weight (kgs) S.creatinine X 72
Creatinine 1. 1.5 2. 1.5 3. 1.5 Age 50 50 70 Weight 50 Kg 40 Kg 45 Kg eGFR CKD 69ml no ckd or ckd II 39ml ckd III 29 ml ckd IV.

2./MDRD FORMULA

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Common cause of ESRD

Diabetes (43 %) Hypertension (25 %) Glomerulonephritis (21%) Intersitial nephritis /pylonephritis (5 % ) Polycystic kidney and hereditary disease(7%)

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Etiology of ESRD in India

Disease % Chronic glomerulonephritis Diabetic nephropathy Chronic interstitial nephritis Hypertensive nephrosclerosis Obstructive nephropathy ADPKD Unknown Miscellaneous Center A 28.6 23.2 16.5 4.1 6.4 2.0 16.2 3.0 Center B 36.64 23.84 14.35 13.47 3.53 3.76 4.3 Center C 18.20 26.76 27.05 10.06 1.22 2.07 -

Kher Neph. Forum KI July 2002

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Diagnosing CKD Why to identify patient at CKD

Predisposes to increased cardio vascular risk . Some patient benefit from further evaluation (Biopsy) It is possible to slow progression to ESRD . Complications of CKD like anemia & bone disease identified & treated early. Preparation for transplantation & dialysis .

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Whom to Screen ?
Family H/o renal disease Diabetes Hypertension Stones Recovered ARF Persistent UTI Renal mass - Solitary kidney. Unexplained edema CHF Atherosclerotic disease Multisystem disease

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How to Screen ?
GFR annually 140 - Age x Body wt. (kgs) S. Creat. x 72 Proteinuria
Dipstick (early morning) Urine Prot. / creatinine ratio 24hrs urinary protein

(Cockroft &Gault &Gault formula)

Urine
Sediment Microscopy Imaging

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WHY PROTEINURIA SO IMPORTANT ?

Marker of chronic kidney damage Prognostic value in the progression of CKD It self causes progression of CKD Good surrogate treatment target. Independent CV risk factor

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Clinical Presentation
GENERAL NERVOUS Dehydration Twitching Saline depletion Convulsions Hyperkalemia Neuropathy Metab. Acidosis Coma Water intoxication Susce. to infection GI Anorexia Hiccoughs Vomittings Polydipsia GENITOURINARY Oliguria/ Polyuria Nocturia Impotence CVS HTN CAD Pulm.edema Pericarditis Arrhythmias

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HEMAT. Anemia Pla.dysfn

SKIN Pigmentation Pruritus SKELETAL Frost Renal osteodys. Purpura Metastatic calcn Dwarfism Cramps Loss of strength

When to refer ?
Screen patients at high risk:
Age >60 Diabetes Hypertension Family history of renal disease

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Refer to nephrologist if stable or rising S.Creatinine >1.5 -female, >2.0 -male Proteinuria > 1 gm/day even if GFR is normal

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Benefits of early referral

Those referred to nephrologists more than a year prior to dialysis have reduced mortality in the first year of dialysis Those with late referral more likely to be sicker at the time of first dialysis more likely to need emergency dialysis

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Early referral
Aim :
To make early diagnosis if necessary renal biopsy To identify and manage complications To retard progression of disease To reduce morbidity and mortality To prepare patient for maintenance dialysis To prepare for preemptive transplantation

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Does pre dialysis nephrology care influence patient survival after initiation of dialysis ?
Early referral > 3 months Late referral 1-3 months 1Ultra late < 1 month Study of 109321 pts - < 50 % have nephrology care in 6 months before initiation of dialysis Better nephrology care 6 months before initiation of dialysis reduces mortality
*Kidney International March 2005

C.K.D Renal function preservation - Primary health care Vs Nephrology

Early referral of diabetic nephropathy pts - Better renal function preservation - Better BP control - Increased use of ACEi / ARBs / statins - Decreased use of NSAIDs *AJKD,Jan 2006

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Reasons for non referral

Unavailability Holding back for non medical reasons Misdiagnosis - Persistent hematuria/proteinuria and pyuria always treated as UTI - Unreliability of serum creatinine as a measure of renal function gives a false sense of security - Serum creatinine is with in normal limits despite significant loss of renal functions

Cost of ESRD Therapy : India

A - V Fistula HD EPO CAPD Transplant Immuno suppression Rs. 5,000 - 8,000 Rs. 12,000 per month Rs. 10,000 per month Rs. 20,000 per month Rs. 50,000 Govt. Setup Rs. 2 to 3 lakhs Private Rs. 1,50,000 1st yr Rs. 60,000 from 2nd yr

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Kher Neph. Forum KI July 2002

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PREVENTING PROGRESSION OF CKD

Factors influencing progression of CRF . NONMODIFIABLE

Underlying cause of CKD Race Blood glucose control Blood pressure Level of proteinuria Plus Nephrotoxic agents Underlying disease acitivity Further renal insults (obstruction , UTI hypovolemia ) Dislipdemia Hyperphosphatemia Metabolic acidosis Anaemia smoking

MODIFIABLE FACTORS

Staging of CKD NKFNKF-DOQI CKD is divided in to 5 stages according to GFR

Stage Description At risk 1 Kidney damage with N or GFR GFR (ml/min/1.73 m2) > 90 (with CKD risk factor) > 90 Action Screening CKD risk reduction

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Diagnosis & treatment Treatment Co-morbidity CoSlowing progression CVD risk reduction Estimate progression Evaluation & treatment of complications Prepare for RRT Replacement

2 3 4 5

Kidney damage mild GFR Moderate GFR Severe GFR Kidney failure

60 - 89 30 - 59 15 - 29 < 15

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Secondary Prevention
Proteinuria ACE inhibitors ARBS Glycemic control Diet, insulin, OHA HbA1C 2000) < 6.5 (ADA
Lipid control S. Triglycerides < 100 mg% S. LDL < 150 mg% (NCEP) Treatment of Anaemia Treatment of Hypoalbuminemia Cessation of smoking

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Conservative Treatment
Blood pressure targets in CKD
o Without proteinuria
-Treat at 140/90 -Target at 130/80

o With proteinuria
-Treat at 130/80
-Target

120/75

o Diabetes mellitus
-Target 120/75

o What drug? Suggested batting order

-ACEI -Loop diuretic -Add ARB -Calcium - channel blockers -B- Blockers -Centrally acting alpha blockers

Management of CKD

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Conservative Replacement Diet Salt / fluid Transplantation Dialysis restriction Rx of anaemia HD PD Rx of HTN Rx of bone disease Institute Home Rx of infection Rx of acidosis CAPD CCPD Rx of hyperkalemia Live Cadaver LRD LURD

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Conservative Treatment
Diet Protein CHO Fat Calories Salt / H2O Potassium Vitamins Trace-elements Trace Fibre - 0.6 - 0.8 gm /Kg /day - 14-20 gm EAA 14- At least 100 gm - 15-20% of calories 15- ~ 35 kcal / kg basal

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Conservative Treatment
Hyperkalemia
Insulin Soda bicarb K- exchange resins Calcium Gluconate Dialysis

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Conservative Treatment
Acidosis
Normal acid production Bicarb. replacement -1mmol/kg/day - pH<7.3 - S.bicarb. < 15mmol/L

Judicious use in oliguric patients (1mmol of HCO3 gives 1mmol of Na+)

pH < 7.2 - dialysis

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Conservative Treatment
Anemia
< 12.0 gm% - Males / post menopausal < 11.0 gm % - Pre-menopausal Pre Epo - supplement Epo (50-100 IU/kg/week) (50 Iron-def - Iron - supplement Iron(Blood loss) (If S.Fe <100 mg/dl & TSAT <20%)

Blood - Tx ?? Vit - B12, Vit - C

* Ramp - Renal anemia management programme

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Conservative Treatment
Renal osteodystrophy
Hypocalcaemia Ca supplements - Ca carbonate Vit D analogues Hyperphosphatemia Aluminium hydroxide Calcium based-carbonate acetate based Sevalamer HCL Lanthanum salts Parathyroidectomy * Prevent Ca x P product

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Conservative Treatment
Infections
No drug absolutely contra-indicated contra Dose - adjustment as per GFR Avoid combination of Nephrotoxic agents Close - monitoring of renal functions * Risk factors - Elderly, dehydration, prepreexisting renal disease

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Reversible - Factors
Acute on Chronic Kidney Disease Volume - depletion Accelerated hypertension Infection Obstruction Drugs - ACE-I, Amino glycosides, ACENSAIDS and Contrast drugs

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Prevention of complications
Early recognition and treatment of cardio vascular events Helping in planning Angiographic studies , avoid contrast nephrotoxicity Judicious use of antibiotics Avoiding NSAIDs and nephrotoxic drugs Plan nutrition

Renal Replacement Therapy



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Dialysis
Home Peritoneal dialysis (CAPD) Institutional Hemodialysis


Transplantation Kidney Tx

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Hemodialysis Access when ?

Educate patients to Save Their Veins Save If GFR is 25 ml/mt and in Diabetics < 30-40 ml/mt 30 AV fistula to be created 6 months to 1 year prior to dialysis to allow for maturation time. Avoid temporary hemodialysis catheter whenever possible Placement of CAPD catheter to be planned 6 8 weeks prior to commencement of dialysis

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Dialysis
Absolute Indications
Severe azotemia Acute LVF Pericarditis Hyperkalaemia Metabolic acidosis Uraemic encephalopathy

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Renal Transplantation
Live - related Live - unrelated Cadaver

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Conclusions
CKD on the rise - especially in young Monitoring of at - risk group Measures to retard progression Identify & treat reversible factors

As RRT is beyond reach of many

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Start early & Reach safely (To ESRD)

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Better to be late on earth (to nephrologist) than early to heaven

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Thank you

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