Chronic Kidney Disease Presence of kidney damage or decreased kidney function for three or more months, - necessary to distinguish CKD from acute kidney disease. Ascertained either by kidney biopsy or markers of kidney damage such as; Proteinuria, abnormal urinary sediment, abnormalities on imaging Usually asymptomatic in early stages, Silent Disease Small or mild declines in kidney function as much as 30 to 40 percent would rarely be noticeable.
ESKD CAUSES (end stage kidney disease) The two most common causes of kidney disease are DIABETES and HIGH BLOOD PRESSURE. Screened Annually for CKD Nephrotoxic Drugs (ongoing) NSAIDS, Lithium. Regular Aspirin risk V benefit Inherited and Congenital Kidney Diseases PKD - Polycystic kidney disease Abnormalities of the urinary tract Solitary kidney status
Other Causes of CKD Ageing Kidneys Obstructive Uropathy Glomerulonephritis IgA Nephropathy Chronic Pyelonephritis Vascular diseases renal artery stenosis
Main Function remove waste & excess water from blood The kidneys produce certain hormones that have important functions in the body, including the following: Calcitriol Active form of vitamin D ( or 1,25 dihydroxy-vitamin D), which regulates absorption of calcium and phosphorus from foods, promoting formation of strong bone. Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells. Renin, which regulates blood volume and blood pressure
CKD Complications CKD complications include increased risks for; systemic drug toxicity cardiovascular disease; early CKD more likely to die from CVD than reach ESKD cognitive impairment and impaired physical function Hormonal & metabolic A history of diabetes, hypertension, or cardiovascular disease confers the highest risk for developing CKD, and individuals who have such a history should be screened
I GFR> 90 Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease II GFR 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease IIIA GFR 45-59 Moderately reduced kidney function IIIB GFR 30-44 IV GFR 15-30 Severely reduced kidney function V GFR <15Very severe, or end stage kidney disease
Estimating egfr glomerular filtration rate CG - Cockroft Gault formula, not widely used, need weight Schwartz 1-17yrs MDRD Modification of diet in renal disease. Validated in Caucasians and African-American 18 70yrs. Not Valid in; children, very elderly (some natural reduction in renal function), pregnant women, nutritional states or AKI or in ethnic minority groups. extremes of muscle mass, body mass e.g. amputees, bodybuilders, paraplegics, eating a vegetarian diet, muscle wasting disease.
Stage MONITORING MANAGEMENT I >90 Annual BP, Urinary ACR, Urinalysis, Serum Creatinine & egfr II 60-89 As Stage I As Stage I Excellent BP & Blood Sugar Control. CVD risk factors, Lipid Profiling, Alcohol, Smoking cessation, BMI, Exercise, Sodium restriction. Both stages require other evidence of kidney disease, namely; A Persistent finding laboratory confirmed ; 2wks & 90days (3) 1. Microalbuminuria or Proteinuria 2. Microscopic Haematuria or recurrent macroscopic haematuria B Structural abnormalities of the kidneys demonstrated on imaging C Biopsy-proven Glomerulonephritis
ACR 70mg/mmol, approximately equal to 1g of protein per 24h Unlike haematuria, Proteinuria almost always has a renal origin. Early 1 st sign of glomerulopathies in strenuous exercise, high protein diet, pregnancy, UTI s, 1 ST EARLY MORNING URINE SAMPLE Strongly associated with adverse cardiovascular outcomes. ACR has greater sensitivity than PCR for low levels of Proteinuria. ACR is the recommended method for people with diabetes
Blood Pressure Targets in CKD Blood Pressure together with Proteinuria represents one of the most important factors in the progression of CKD. Antihypertensive therapy is beneficial to slow this progression no matter what the underlying cause of CKD including the following; Developing hypertension under 55 years With diabetes of either type With higher levels of Proteinuria (urine ACR>70mg/mmol) Proteinuria low: ACR<70 or PCR<100 - Target blood pressure <140/90 Proteinuria high: ACR>70 or PCR>100: - Target blood pressure <130/80
RENOPROTECTIVE DRUGS & CVD angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs)- Renoprotective Drugs -to treat high blood pressure can also slow or delay the progression of diabetic kidney disease. Proteinuria is associated with cardiovascular and renal disease and is a predictor of end organ damage in patients with hypertension. More likely to die of CVD than reach ESKD and require dialysis. CKD patient highest risk group for CVD
Starting & Monitoring therapy with ACE inhibitors or ARBs 1. Check serum Creatinine and Potassium Before starting therapy (do not start if K+ above normal range) After 1-2 weeks After subsequent dose increases 2. If Creatinine rises >30% or GFR fall >25%, repeat tests, stop drug and consider other causes. Do not discontinue for lesser changes in egfr/creatinine, some change is expected. 3. If K>6, stop drugs that may be contributing, If hyperkalaemia persists the ACE inhibitor or ARB should be stopped.
ASSESSMENT Subjective Objective Medication review Urine Tests Imaging/Investigations Rapid assessment for deteriorating renal function? AKI MANAGEMENT CVS Risk screen for CKD Serum tests 6-12mthly Drug Nephrotoxicity, NSAIDS Urinary Protein as per guide Blood Pressure as per guide Anaemia; rule out non renal cause Health promotion in all stages; BMI, Smoking cessation, Exercise, Dyslipidaemia, Sodium restriction
As per stage III management plus; Renal Diet assessment Fluid volume status, salt/water imbalance Treat mineral bone disorder Treat Iron deficiency anaemia Treat metabolic imbalances Timely Vascular/Peritoneal access provision Pre emptive Transplant work up & screening Counsel & Educate RRT treatment options Immunise Hep B, Flu, Pneumococcal 2-3mthly review - serum & Uraemic symptoms
Appetite loss, taste changes, aversions to foods Weight loss without trying to lose weight General ill feeling and fatigue Headaches Itching (pruritus) and dry skin Nausea with dry retching/vomiting, often in the morning Abnormally dark or light skin Bone pain Drowsiness or problems concentrating or thinking Numbness or swelling in the hands and feet Muscle twitching or cramps particularly at night in bed Breath odour Easy bruising Excessive thirst Problems with sexual function Menstrual periods stop (amenorrhea) Shortness of breath Sleep disturbances
Hgb target >10.0g/dl & <12g/dl Iron stores TSAT, Iron, Ferritin Erythropoietin (EPO) injections s/c IV Iron infusion (Ferinject) Blood Transfusion only in emergency Monitoring of response to EPO & Iron Improves; exercise tolerance, cardiovascular outcomes, mortality, QOL
Calcium, PTH, Phosphate balance with active Vitamin D, Phosphate binder agents that may be calcium or non calcium containing May need to introduce Calcicimetic agents Regular Dietary review
Metabolic Imbalances & Fluid Volumes Salt & water retention fluid/salt restrict, diuretics, CCB Potassium and Bicarbonate levels acidosis hyperkalaemia Dietitian review vital Medication management ACEI/ARB, Antibiotics, Analgesia, Biphosphonates, oral hypoglycaemics
Pre Emptive Transplantation
AIM to maintain/improve QOL Haemodialysis in centre/home therapies Peritoneal Dialysis Live related/unrelated Transplantation Cadaveric Transplantation Palliative Care pathway Conservative management
Haemodialysis; Arteriovenous Fistula for permanent access. PRESERVE ARM PermCath as temporary access Tenchkoff Catheter for Peritoneal Dialysis
Assessment of stage of CKD Treat BP, Proteinuria, CVS risks Exclude other causes of Anaemia Investigate persistent Haematuria Medication management, Nephrotoxicity Treat renal anaemia and renal bone (MBD) Educate, Explore RRT options, Immunise Timely RRT Access acquisition Pre emptive Transplant work up Transfer care to HD, PD, Community
Educational Resources The majority of people with early stage CKD can be effectively managed in primary care and there are clear guidelines from NICE and britishrenal.org to support this http://www.britishrenal.org, Go To: CKDSG, Early CKD: Management Resources for Primary Care and Renal Teams and educational resources http://www.ckdonline.org chronic kidney disease, a guide for Primary care
GLOBAL CKD GUIDELINES KDIGO RENAL.ORG/BRITISHRENAL KDOQI NICE SIGN CARI WWW.IKA.IE
Thank you