CHRONIC KIDNEY DISEASE (CKD)

Transcription

1 CHRONIC KIDNEY DISEASE (CKD)

2 CKD implies longstanding (more than 3 months), and usually progressive, impairment in renal function. In many instances, no effective means are available to reverse the primary disease process. Exceptions include correction of urinary tract obstruction, immuno suppressive therapy for systemic vasculitis and Goodpasture s syndrome, treatment of accelerated hypertension, and correction of critical narrowing of renal arteries causing CKD. The rate of deterioration in renal function can, however, be slowed.

3 Causes Congenital and inherited disease Polycystickidneydisease(adultandinfantileforms) Medullary cystic disease Tuberous sclerosis Oxalosis Cystinosis Congenital obstructive uropathy Glomerular disease Primary glomerulonephritides including focal glomerulosclerosis Secondary glomerular disease(systemic lupus, polyangiitis,wegener s granulomatosis,amyloidosis, diabetic glomerulosclerosis,accelerated hypertension, haemolytic uraemic syndrome,thrombotic thrombocytopenic purpura,systemic sclerosis,sickle cell disease) Vascular disease Hypertensive nephrosclerosis(common in black Africans) Renovascular disease Small and medium-sized vessel vasculitis

4 Tubulointerstitial disease Tubulo interstitial nephritis idiopathic, due to drugs (especially nephrotoxic analgesics), immunologically mediated Reflux nephropathy Tuberculosis Schistosomiasis Nephrocalcinosis Multiplemyeloma (myeloma kidney) Balkan nephropathy Renal papillary necrosis(diabetes,sickle cell disease and trait, analgesic nephropathy) Chinese herb nephropathy Urinary tract obstruction Calculus disease Prostatic disease Pelvic tumours Retroperitoneal fibrosis Schistosomiasis

5

6 Symptoms Malaise, loss of energy Lossofappetite Insomnia Nocturia and polyuria due to impaired concentrating ability Itching Nausea,vomiting and diarrhoea Paraesthesiae due to polyneuropathy Restlesslegs syndrome(overwhelming need to frequently alter position of lower limbs) Bone pain due to metabolic bone disease Paraesthesiae and tetany due to hypocalcaemia Symptoms due to salt and water retention peripheral or pulmonary oedema Symptoms due to anaemia Amenorrhoea in women; erectile dysfunction in men. In more advanced uraemia CKD stage 5,these symptoms become more severe and CNS symptoms are common Mental slowing,clouding of consciousness and seizures Myoclonictwitching.

7 Signs and symptoms

8 Investigations Urinalysis 1. Hematuria 2. proteinuria 3. Urine culture Urine microscopy 1. WBC 2. Eosinophiluria 3. Casts 4. Red cells in the urine Urine biochemistry 1. Measurements of urinary electrolytes, Urine osmolality, Urine electrophoresis and immunofixation Serum biochemistry 1. Ureaandcreatinine 2. CalculationofeGFR 3. Electrophoresis and immunofixation for myeloma 4. Elevations of creatine kinase and a disproportionate elevation in serum creatinine and potassium compared with urea suggest rhabdomyolysis.

9 Haematology 1. Eosinophilia 2. Markedly raised blood viscosity 3. Fragmented red cells and/or thrombocytopenia 4. Tests for sickle cell disease Immunology 1. Complement components 2. autoantibody Screening 3. Cryoglobulin 4. Antibodies to streptococcal antigens 5. Antibodies to hepatitis B and C 6. Antibodies to HIV Radiological investigation 1. Ultra sound 2. CT 3. MRI 4. Renal biopsy

10 Complications of CKD Complicatiin Anemia Bone disease Skin disease Gastrointestinal complications Metabolic abnormalities - Gout - Modestly impaired glucose tolerance Endocrine abnormalities(anterior pituitary gland) Muscle dysfunction Depressed cerebral functions Causes Erythropoietin deficiency, Bone marrow toxins, Bone marrow fibrosis, Haematinic deficiency, Increased red-cell destruction, Abnormal red-cell membranes, Increased blood loss(hemodialysis), ACE inhibitors. 1α-hydroxylase deficiency, Reduced activation of vitamin D receptors, Phosphate retention. Retention of nitrogenous waste, hypercalcaemia, hyperphosphataemia, hyperparathyroidism. continuous ambulatory peritoneal dialysis(capd). Urate retention end-organ resistance to insulin Altered protein binding Uraemia, Decreased physical fitness Severe uraemia.

11

12 Treatment Hypocalcaemia and hyperphosphataemia should be treated aggressively, preferably with regular (e.g.3 monthly) measurements of serum PTH to assess how effectively hyperparathyroidism is being suppressed. Suppression of PTH levels to below two or three times the upper limit of normal carries a high risk of development of a dynamic bone disease. Eg:- Gut phosphate binders Nicotinamide Calcitriol (1,25-dihydroxycholecalciferol) or a vitamin D analogue Calcimimetic agents Drug therapy should be minimized in patients with CKD. Tetracyclines (with the possible exception of doxycycline) should be avoided in view of their anti-anabolic effect and tendency to worsen uraemia. Drugs excreted by the kidneys, such as gentamicin, should be prescribed only in the absence of any alternative and drug levels monitored if feasible. Non-steroidal antiinflammatory drugs(nsaids) should be avoided. Potassium-sparing agents, such as spironolactone and amiloride, pose particular dangers, as do artificial salt substitutes, all of which contain potassium. Bardoxolone,an antioxidant inflammatory modulator, has shown a reduction in GFR in diabetic CKD.

13 Dialysis Haemodialysis Peritoneal dialysis Haemofiltration

14 Kidney Transplantation This mode of renal replacement therapy has significant survival advantage compared to dialysis patients on transplant waiting lists. It allows freedom from dietary and fluid restriction; anaemia and infertility are corrected; and the need for parathyroidectomy is reduced.

15