CHRONIC KIDNEY
DISEASE – CKD
A Silent Killer
Dr R V S N Sarma M D
Consultant Physician
Tiruvallur 602 001
Cell 93805 21221
Now we know
why the titanic sank !!
< 0.5 %
5- 10%
This is not what we want !!
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Pedal, ankle, facial oedema
Urine output decreased (romba)
Lasix is the only weapon
At best order for bl. urea or creatinine
We cannot handle it
Immediately pack off to Dr. RENAL
KIDNEY / DISEASE OUTCOMES
QUALITY INITIATIVE
The K/DOQI
Practice Guidelines of CKD
The National Kidney Foundation (NKF)
National Kidney Diseases Education Program
The NKDEP
Why this CME on CKD ?
• CKD is a major global pandemic like DM
• DM and HT make CKD burden very high
• CKD predicts CVD – the major threat
• Testing and therapy are inadequately used
• Knowledge on CKD is at best sketchy
• Testing and early therapy are economical
• Most of the progression is preventable
Do we care about CKD ?
1. Doctors do not realize that CKD is hidden in their
patients of DM, HT and in elderly people
2. Most doctors screen less than 10% of their clinic
patients for CKD in its early stages
3. Patients are referred very late to nephrologists
especially after the CKD is irreversible
4. Only < 1/4 of people with identified CKD get an
ACE Inhibitor – All are true - all over the globe
Filtration, Reabsorption
and Secretion
Normal GFR 120 ml/min/1.73m2
In a day 210 L of water is filtered
Only 20% nephrons work at a time
2 L /day of urine is excreted
Prevalence of CKD
What is the role of GPs ?
1. Recognize who is at risk of CKD
2. Consider all DM and HT as potential CKD pt.
3. Evaluate all at risk cases; treat hypertension
4. Understand eGFR, Albuminuria, MAU
5. Stage the CKD and manage appropriately
6. Must start patients on ACEi or ARB early
Some useful Definitions
1. Azotemia - Elevated blood urea nitrogen - Biochemical
(BUN >28 mg/dl) and creatinine (Cr >1.5mg/dl)2. Uremia is Azotemia + symptoms or signs of renal failure
3. End Stage Renal Disease (ESRD) - Uremia requiring
transplantation or dialysis (Renal replacement therapy)
4. Chronic Renal Failure (CRF) - Irreversible kidney
dysfunction with azotemia >3 months – now not used
5. Creatinine Clearance (CCr) - The rate of filtration of
creatinine by the kidney (a marker of GFR)
6. Glomerular Filtration Rate (GFR) - The total rate of
filtration of fluid from blood by the kidney
Clinical Features – CKD 3-5
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Unintentional weight loss
Nausea, vomiting General ill feeling
Fatigue; Headache; Frequent hiccups
Generalized itching (pruritus)
Increased or decreased urine output
Need to urinate at night, polyuria
Easy bruising or bleeding
Clinical Features – CKD 3-5
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Blood in the vomit or in stools
Decreased alertness; Muscle cramps
Seizures; Agitation; Hypertension
Peripheral sensory neuropathy
Breath fetor; Loss of appetite;
Uremic frost on the skin
Uremic pericarditis, CHF
Who are at Risk for CKD
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Diabetes
Hypertension
Age , Family H/o Kidney Disease
Systemic Infections
Recurrent UTI
Urinary Stone Disease
Loss of Renal mass
Neoplasia of any part
Nephrotoxic Drugs (NSAIDs)
Risk of CKD is not uniform
Racial differences in CKD
Caucasians (Whites)
1.0
Asians (Indians)
1.3 X
Hispanics (Spanish)
1.5 X
Native Americans
2.0 X
Africans (Blacks)
3.8 X
Etiology of CKD
1.
Diabetes - most common cause ESRD (risk 13 x )
2.
Over 30% cases ESRD are primarily due to diabetes
3.
CKD associated HTN causes @ 23% ESRD cases
4.
Glomerulonephritis accounts for ~10% cases
5.
Polycystic Kidney Disease - about 5% of cases
6.
Rapidly progressive glomerulonephritis (vasculitis) about 2% of cases; Drug induced Tubulo-interstitial
7.
Renal Vascular Disease - renal artery stenosis
(ARAS), atherosclerotic vs. fibromuscular
The Two Most
Common Causes of CKD
Other
10%
Diabetes
50.1%
Glomerulonephritis
13%
Hypertension
27%
Primary Diagnosis for Patients Who Start on Dialysis
Causes of CKD
CKD Predicts CVD
40
Cadio-vascular events
per 1000 person years
36.6
35
30
25
21.8
20
15
11.29
10
5
2.11
3.65
0
≥ 60
45-59
30-44
15-29
< 15
Estimated GFR (ml/min/1.73 m2)
Definition of CKD
1. Either GFR < 60 ml/min/1.73m2 for  3 mon or
2. Kidney damage for  3 mon as manifested by
a. Persistent microalbuminuria / macroproteinuria
b. Biochemical abnormalities in RFT
c. Persistent non-urological hematuria
d. Structural renal abnormalities by USG
e. Biopsy proven Glomerulonephritis (rarely needed)
(Any one of the above evidences)
CKD Clinical Stages
Stage Description
GFR
(ml/min/1.73 m2)
1
Kidney damage with normal or ↑ GFR
 90
2
Kidney damage with mild  GFR
60-89
3
Kidney damage with moderate  GFR
30-59
4
Severe  GFR
15-29
5
Kidney Failure (ESRD)
< 15 (or dialysis)
Chronic Kidney Disease - Stages
CKD Prevalence
K/DOQI CKD Staging
CKD Features – Stage wise
CKD
eGFR
B.P
ACR
Urine Edema Anemia Ca x P
SHPT
Stage
1
>90
N
MAU
N
No
No
N
No
Stage
2
60+
↑
MAU
↑
No

N
No
Stage
3
30 +
↑
ALB
↑
No

N

Stage
4
15+
↑
ALB
↑↓


↑
↑
Stage
5
<15
↑↑
ALB
↓


↑
↑
GP and Nephrologist in CKD
Who is to be tested for CKD ?
Regular testing of people for CKD a must for
1. All Diabetics whether Type 2 or Type 1
2. All Hypertension patients – SHT or DHT
3. Patients having a relative with kidney problem
4. All patients of Cardiovascular disease
5. Pts of Obesity, Metabolic syndrome, smokers
Investigating CKD
1
• Risk factors – CVD, DM, HT, Met. Syndro.
• Age, Smoking, F H/o CKD, BMI, NSAID
2
• Serum Creatinine, eGFR
• Proteinuria, MAU, U.Cr, ACR
3
• Urine for RBC, Casts, Crystals, Na, Sp.Gr.
• Serum Electrolytes, Ca, Ph, iPTH, FENa
4
• USG, Renal Angio only in select cases
Blood Urea v/s Sr. Creatinine
Parameter
Blood Urea (BUN)
Serum Creatinine
As measure of GFR
Only half the GFR
Nearly 95%
Calculation of eGFR
Not useful
It is the parameter
Day to day variance
More
Less
Pred. of improvement
Changes late
Changes soon
Affect of meat diet
Yes; affected
Yes; affected
Volume status of pt.
Affects very much
Not so much
Upper GI bleeding
Increases it
Not affected
Corticosteroid Rx
Increases it
Not affected
The Two Imp. Tests for CKD ?
1. Test serum creatinine; Note age and gender
2. Estimate GFR from serum creatinine (MDRD)
3. Standard dipstick for urine protein – if negative
4. Spot urine Albumin to Creatinine Ratio (ACR)
5. 24 hour urine collections are NOT needed.
6. Diabetics should be tested at least once a yr.
7. Others at risk to be tested once in 2 years
Today’s Watch Word
At what level of Serum Creatinine
would you diagnose CKD?
• In a 65 years old lady of 50 kgs with DM and HT
• 87% of doctors said Creatinine > 1.5 mg /dl
If Serum Creatinine is 1.5 mg %,
The eGFR = 37 ml/min/1.73 m2
Creatinine clearance is 35 ml/min
If Sr. Creatinine is 1.0 mg%
The eGFR will be 59 ml/min/1.73 m2
Methods of GFR Estimation
• Inulin / I125-Iothalamate clearance is
the “Gold Standard’
• Creatinine Clearance (24 h urine)
• Equations based on serum creatinine
– MDRD (age, sex, ethnicity)
– Cockroft-Gault (need weight also)
Why eGFR ? Why not Creatinine ?
Age
Gender
Race
SCr
(mg/dL)
(ml/min/1.73 m2)
CKD
Stage
20
M
B
1.3
91
1
20
M
W
1.3
75
2
55
M
W
1.3
61
2
20
F
W
1.3
56
3
55
F
B
1.3
55
3
85
F
W
1.3
41
3
eGFR
CCr and eGFR Correlation
eGFR calculation
Don’t be afraid – we have help
Albuminuria and
Microalbuminuria
How to test for MAU ?
Albumin Creatinine Ratio (ACR)
Spot urine only (no 24 hour urine)
Urine Microalbumin in mg/liter
Urine creatinine in mg/deciliter
ACR calculation :
Urine MAU in mg/l
Urine creatinine mg/dl
X 100 =
60
120
X 100
= 50
Interpretation of Albuminuria
Spot Urine only
(No 24 hr urine please)
Albumin : Creatinine Ratio (ACR)
(Urine albumin in mg per liter ÷
Urine creatinine in mg/dl) x 100
No Albuminuria
Less than 30 mg/g
Micro Albuminuria
30 to 300 mg/g
Macro Albuminuria
More than 300 mg/g
Nephrotic Proteinuria
More than 3000 mg/g
MICRAL Test II Strips for MAU
Roche
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RDT – Bed side
Sensitivity 95 %
Specificity 85 %
PPV 89%
NPV 92%
Sp. Gr. Correction
Cost Rs.84/- strip
Simple reliable
Imp. of Albuminuria in CKD
1. Marker of CKD
• Spot ACR > 30 mg/g for more
than 3 months (MAU)
ACR > 500 mg/g indicates
2. Clue to Dx. CKD • Spot
DKD, Glomer, Transplant GP
proteinuria - severe CKD
3. Prognostic Index • Higher
and higher CV risk indicator
4. Modified by Rx.
• B.P control, use of ACEi / ARBs
slow CKD predict improvement
5. Surrogate Goal
• Validated as the marker for CKD
and is the goal of therapy
Treatment of CKD (contd..)
1. Renal diet with adequate protein, salt, H20
2. Consult a nephrologist early (from stage 3)
3. Team with the nephrologist for care if
eGFR is less than 30 ml/min/1.73 m2
4. Monitor hemoglobin and sr. phosphorous
5. Treat cardiovascular risk factors, especially
smoking & hypercholesterolemia
Metabolic Effects of CKD 3-5
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9.
Hyperkalemia
Mixed Metabolic acidosis
Fluid loss/ Fluid over load (Stage 5)
Hyponatremia or Hypernatrimia
Normocytic normochromic anaemia
Increased Ph, ↓ Calcium
↓ Vitamin D formation
Secondary ↑ in PTH
Renal Osteodystophy
How to handle CKD ?
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B
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A1c < 6.5, ACEi, ARBs
Blood pressure < 125/75
Cholesterol LDL < 100
Drugs – avoid nephrotoxicity
Diet – Moderate in protein
Na, K, Ph, Fluids, Cal
CKD – Management Goals
1. Blood pressure < 125/75
–
HT is both a cause and consequence
2. Glycemic control – Hb A1c < 6.5
3. Hemoglobin level > 11 g%
4. Calcium x Phosphorous product < 50
Normal values :
GFR 120 to 150 ml/min/1.73m2
Ca 9 to10.5mg%, Ph 3 to 4.5mg%, Ca x Ph < 50
iPTH 150 to 300 pg/ml
Early treatment makes
a difference in CKD
Brenner, et al., 2001
B.P. Treatment in CKD
1. Maintain B.P. less than 125/75 mmHg
2. Use ACE Inhibitor or ARB early enough
3. More than one drug is usually required
4. Diuretic should be part of the regimen
5. Achieve best possible glycemic control
in Diabetics
The Renal Injury (CKD) Triad
Angiotensin II
Hypertension
Proteinuria
ACEIs, ARBs, and Combination
RX. in Non-diabetic Nephropathy
ACEI (n = 86)
Losartan (n = 89)
ACEI + ARB (n = 88)
P = 0.02
*Primary end point: doubling of SCr or kidney failure.
Nakao et al. Lancet. 2003;361:117-124.
© 2005 The Johns Hopkins University School of Medicine.
Importance of control of DM
DM and Proteinuria
Stages in Progression of Chronic Kidney
Disease and Therapeutic Strategies
Complications
Normal
Screening
for CKD
risk factors
Increased
risk
CKD risk
reduction;
Screening for
CKD
Damage
Diagnosis
& treatment;
Rx. comorbid
conditions;
↓ progression
 GFR
Kidney
failure
Estimate
Replacement
progression;
by dialysis
Rx. complications; & transplant
Prepare for
replacement
CKD
death
Stage-wise management of CKD
Stage 0
Test for CKD, Management of Risk Factors
Stage 1
Manage co-morbidity, Rx. of CVD and RF
Stage 2
Slow rate of loss of Kidney function - ACEi
Stage 3
Prevent Anemia, Bone effects, Ca x Ph
Stage 4
Preparation for RRT; refer to nephrology
Stage 5
RRT – PD, HD or RT – Donor / Cadavre
Effects of Good Glycemic Control
Reduces Complications
Type of
Results of Clinical Trial
Complication
DCCT
A1C: (9  7%)
N = 1441
Kumamoto
(9  7%)
N = 110
UKPDS
(8  7%)
N = 5102
Retinopathy
 76%
 69%
 17-21%
Nephropathy
 54%
 70%
 24-33%
Neuropathy
 60%
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DCCT = The Diabetes Control and Complications Trial.
DCCT Study Group. N Engl J Med. 1993;329:977-986; Ohkubo. Diabetes Res
Clin Prac. 1995;28:103-117; UKPDS Study Group. Lancet. 1998;352:837-853.
© 2005 The Johns Hopkins University School of Medicine.
Recommendations for BP and
RAS Management in CKD
Patient
Group
Goal BP
(mm Hg)
First Line
Adjunctive Drugs
+ Diabetes
<125/75
ACE-I or ARB
Diuretics then CCB or BB
 Diabetes
+ Proteinuria
<125/75
ACE-I or ARB
Diuretics then CCB or BB
 Diabetes
 Proteinuria
<130/80
No specific preference:
Diuretics then ACE-I, ARB, CCB, or BB
Expect the need to use 3+ agents to chieve B.P. goals
Recommendations largely consistent across JNC 7, ADA, and K/DOQI
© 2005 The Johns Hopkins University School of Medicine.
Macroalbuminuria in T2DM
Heralds Rapid Decline in GFR
Time
1
1.5
2
years
2.5
3
3.5
4
Change in GFR ml/min
0
-10
-20
-30
Microalbuminuria
-40
-50
Macroalbuminuria
Nelson RG. et al NEJM, 1996
Diabetics with MAU are more likely
to CV death than develop ESRD
The United Kingdom Prospective Diabetes Study (approx. 5000 Type 2 Diabetics)
Newly diagnosed, predominantly white, medically treated
No albuminruia
2.0%
1.4%
3.0%
C
V
Microalbuminruia
2.8%
4.6%
Macroalbuminruia
2.3%
Elevated Serum Creatinine
Adler et al. Kid Int, 2003
19%
D
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A
T
H
Diabetic Nephropathy
CVE
• Prevention
• Management
ESRD
• Early
Detection
• Prevent
Progression
Diabetic
Nephropathy
Diabetic Nephropathy
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Lower blood pressure < 125 / 75 mmHg
Reducing Proteinuria
Combination of ACEi + ARB
Multiple risk factor intervention
– Glycemia
– Dyslipidemia
– Physical activity
– Aspirin
– Smoking cessation
Adverse Renal and CV
Effects of Aldosterone
Aldosterone
Glomerulosclerosis
Interstitial Fibrosis
Proteinuria
Renal Failure
LVH
Endothelial dysfunction
Cardiac Fibrosis Inflammation
LV Dysfunction Oxidative Stress
Heart Failure
MRA – Eplerenone
Brand name: Eplirestat
Dual Blockade of the RAAS
in Diabetic Nephropathy
Ang I
Non-ACE
Pathways
ACE
ACEi
Ang II
ARB
+
AT1 Receptor
Aldosterone
+
Renal Injury
and Proteinuria
MRA
Progressive Diabetic Nephropathy
Baseline Hemoglobin Predicts ESRD in
Type 2 Diabetics with Nephropathy:
RENAAL Trial (N=1513)
End-stage renal disease, %
60
50
Hb < 11.3*
Hb g/dl
Adjusted
HR*
P
value
< 11.3
1.99
0.001
40
Hb 11.4-12.5*
30
20
Hb 12.5-13.8*
10
11.3-12.5 1.61
0.02
12.5-13.8 1.85
0.002
> 13.8
-
1.00
Hb > 13.8
0
1
2
3
4
* Age, gender, GFR, Race, Proteinuria,
CV disease, A1c, lipids, BP, Ca, P, albumin
Time, in years
Mohanram et al. Kid. Int. Sept 2004
Diabetic Nephropathy
Some Novel Therapies
1. Pirfenidone –antifibrotic agent
2. Aliskerin – an anti-renin agent
3. Robuxistaurin- Protein Kinase C
Beta-1 antagonist (PKCB1-A)
4. Advanced Glycation End product
(AGE) antagonists
Diabetic Nephropathy
Management Summary
BLOOD PRESSURE TARGET 125 / 75
ACEi + ARB
MRA
GLYCEMIA CONTROL TARGET Hb A1c < 6.5
TZDs, ? Metformin,
Insulin (early)
LDL CHOLESTEROL < 100 (70) mg%
Early Statin Rx
Ezetemebe, Others
ANAEMIA Rx. TARGET HB > 11 g
Erythropoetin
Iron supplementation
ENDOTHELIAL DYSFUNCTION
Aspirin 150 mg o.d
Smoking cessation
Anemia is an Important
CV Risk Factor in CKD
Chronic Kidney
Disease
Cardiovascular
disease
Anemia
Anemia in CKD
• Decreased production
– Low EPO (RF)
– Nutritional
• (Iron, B12, Folate)
– inflammation
– Infection, Ca
• Blood Loss
• Serum Erythropoietin
levels not indicated
• Reticulocyte count
• Red Blood Cell
indices: MCV, RDW
• Iron Parameters
– TIBC
– Serum Ferritin
• Vitamins:
– Folate\B12 levels
• Stools for occult blood
Principles of Anemia Rx.
• Erythropoietin
– Epoetinalfa - Procrit® , Epogen®
– Darbepoietin Alpha - ARANESP ®
• Targets
– Hb
– PCV
11 to 12 g/dl
33% to 36%
• Iron supplimentation to maintain
– TSAT of >20%,
– Serum ferritin level of >100 ng/ml
Feedback Loops in SHPT
Decreased Vitamin D Receptors
and Ca-Sensing Receptors
 PTH
 PTH
 Ca++
Bone Disease
Fractures
Bone pain
Marrow fibrosis
Erythropoietin resistance
 Serum P
1,25D
Calcitriol
Systemic Toxicity
CVD
Hypertension
Inflammation
Calcification
Immunological
25D
Renal Failure
Ca = calcium; CVD = cardiovascular disease;
P = phosphorus. Courtesy of Kevin Martin, MB, BCh.
Vitamin D and PTH in CKD
Calcium & Phosphorus Balance
• AIM - To Normalize
– Serum calcium
– Serum Phosphorus
– PTH levels
• Methods
– Oral Calcium; Vitamin D analogs
– Phosphate binders (sevelamer-Renagel®)
– Calcimimetics (cinacalcet-Sensipar®)
Phosphate Control
• Dietary restriction of phosphorous
• Phosphate binders to ↓↓ absorption
– CaCo3 ( BoneStat)
– Ca acetate (PhosLo)
– Sevelamer (RenaGel)
– Al hydroxide, Al carbonate
– PhosRenal (Lanthanum Carbonate)
• Removal of Ph by dialysis - poor
Phosphate: Restriction
Special Treatment in CKD
 Calcium acetate (PhosLo)
1334 mg PO with each meal
 Calcium Crabonate
Sandocal, Bonestat, Oyestercal, Cipcal
1-2 g bid with each main meal
 Calcitriol (Vitamin D), Paricalcitriol
0.25 mcg PO once a day
 Doxercalciferol (Vitamin D analog)
10 mcg PO x 3 times a week
Special Treatment in CKD
 Sevelamer (RenaGel) –
800 to 1600 mg PO with meal
 Calcimimetics – Cinacalcet - ↓ PTH
Sensipar orally with meal
30 mg PO once day – up to 120 mg
PTH target of 150 to 300 pg/ml
 Eplerenone (Selective MRA)
 Eplaristat
 Lanthenum Carbonate (FosRenal)
250 to 500 mg tid to be chewed
Fluids in CKD – Wet?
High Energy Foods: Yes
Protein 0.6 g per kg
Some Simple Salt Rules
• Do not add salt to your food at the table.
• Do not use flavoured salts, e.g. garlic salt or sea salt.
• Use only a small amount of salt in cooking or none.
• Do not use salt substitutes, e.g. Lo Salt or LONA
• Use herbs, spices and other flavorings agents
• Pickles, tinned foods, tinned juices, chips, savories,
papads, salted fish, sea foods are rich in sodium
• Recommended salt in take is less than 2 grams /day
Na: 1.5 to 2.5g (4.5 to 6)
Potassium Liberal
Low Potassium Diet !
Low Potassium Diet
Food type
HIGH POTASSIUM
LOW POTASSIUM
Drink
Fruits, Vegetable juices,
Coffee, Alcohol
Fizzy drinks, Squash, Tea,
Fruit tea
Fruits
Dry fruits, Banana, mango,
grapes, pineapple, grape fru
Apple, pears, tinned fruits,
non-juicy fruits
Vegetables
Tomato, Beetroot, spinach
sweet corn, plantains
Boiled veg. onion,
cucumber, carrot ,
cauliflower, cabbage
Sweets
Chocolate, toffees, deep fat
fried sweets
Jam, honey, boiled sweets,
syrups, fruit pastels
Snacks
All nuts, potato crisps
Wheat, corn, rice made
savories, popcorn
Staple food
Baked or roasted potatoes
Boiled potatoes, rice, pasta,
bread, noodles
Important Guidelines
Interventions to slow
progression of CKD
To be avoided to prevent
acute reduction in GFR
1. Glycemic control in DM 1. Volume depletion
2. BP control ACEI / ARB
2. Radiographic contrast
3. Protein restriction
3. Antibiotics / NSAIDS
4. Lipid lowering therapy
4. Cyclosporine / tacrolimus
5. Weight reduction
5. ACEI / ARB if Cr > 3.5mg
6. Anemia Rx, Smoking
6. Obstructive uropathy
Preparation for RRT
•
•
•
•
Choice of Renal Replacement
Timely Access Surgery
Timely Dialysis initiation
When GFR < 25ml/min
– Renal transplant is the first choice
– Workup living donors
– If no donors available
– List patient on cadavre transplant list
– Place A-V fistula if HD preferred
Peritoneal Dialysis
•
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•
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CAPD – Continuous Ambulatory PD
CCPD – Continuous Cycling PD
PD catheter placement by LAP
URR – Urea Reduction Ratio – 65%
Kt/V (Kay tee over vee) – at least 1.2
Tests done monthly
Peritoneal Dialysis (PD)
A-V Fistula Access
Hemodialysis
Indications for Hemodialysis
Absolute indications (Chronic)
• GFR < 15 ml – Stage 5
• Creatinine > 8, BUN >100
• K > 7.0 meq persistently
• Refractory CHF, Diuretic F
• Accelerated Hypertension
• Uremic pericarditis
• Uremic encephalopathy
• Uremic Bleeding, Vomiting
•
•
•
•
•
•
•
Acute indications
Poisoning - dialysable
Drug over dosage
ARF > 48 hours
GFR < 30 ml
Metabolic acidosis
Hyperkalemia
Hyperphosphatemia
Nephrotoxic Drugs
• Which drug is (not) nephrotoxic?
– Antibiotics
• Aminiglycosides, Indinavir, Amphotericin
• Penicillin / -lactums, Tetracyclines
• Fluoroquinolones, Sulphas, Ketoconozole gr.
– NSAIDS/ COX2 inhibitors, Indometh. Nimesulide
– Cancer: MTX, Cisplatin, Acyclovir, Pentamidine
– Heavy metals: Hg, Pb, Ar, Bi, Lithium
– IV Contrast dyes
– ACEi / ARBs if Serum creatinine > 3.5
Mechanism of Nephrotoxicity
• Mechanisms of renal toxicity
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
Direct injury to PCT, Glomeruli
Allergic interstitial nephritis
Crystallization in renal tubules
Fluid over load on the kidney
Renal papillary necrosis
Metabolites may be toxic
Side effects may increase in renal failure
Adequate fluid intake is essential
Dehydration must be avoided
Reducing the dosage or avoiding the drug
Let this not happen please!
Normal
ESRD
Polycystic Kidney Disease
Contracted Kidneys
Contracted smooth kidney
Scarred kidney –cut section
End Stage Renal Disease
PCKD with ESRD
Chronic Contracted Kidney
My dear Doctors - Remember
Please Remember
Web links for CKD
1.
2.
3.
4.
5.
6.
7.
8.
www.kidney.org
http://nkdep.nih.gov
www.kdoqi.nih.gov
www.kidney.org.au
www.renal.org/eGFR
www.nephron.com
www.medicalc.com
www.edren.org
1.
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NKF – USA
NKDEP – USA
K/DOQI Guidelines
Kidney Health- Au
eGFR calculators
Kidney resources
Medical calculators
Diet in CKD
Take Home Messages
• CKD is a silent killer – we need to uncover it
• CKD progression is preventable – Stage it & treat
• DM most common cause of ESRD all over globe
• CKD - more likely CV death than progress to ESRD
• Multi-risk factor intervention is critical, Hb A1c goal
• Lowering blood pressure with RAAS blockade
• Combinations of ACEi + ARB ± MRA
• Prevent cardiovascular morbidity and mortality