Chronic kidney disease

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Chronic kidney disease

• M.Mokrejšová

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Definition of chronic kidney disease (CKD)

• The presence of markers of kidney damage for more
  than 3 months
• a/ structural or functional
  abnormalities of kidney
• b/ decreased glomerular filtration rate
  (GFR)lt60ml/min/1,73 m2
• c/ abnormalities in the composition of blood
  or urine or in imaging tests

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Classification of CKD

1. stage 1 normal GFR and persistant albuminuria
2. stage 2 GFR between 60-89 ml/min/1,73m2 and
   persistant proteinuria
3. stage 3 GFR between 30-59 ml/min/1,73m2
4. stage 4 GFR between 15-29 ml/min/1,73m2
5. stage 5 GFR of less than 15 ml/min/1,73m2

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Incidence of CKD

• The Framingham Offspring study (1223 men and 1362
  women initially free of preexisting kidney
  disease)
• after follow-up of 18,5 years
• 244 participants (9,4 ) had developed CKD GFR
  of less than 60ml/min/1/73m2
• associated with increased age, diabetes,
  hypertension, smoking, obesity

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End-stage renal disease

• GFR less than 15 ml/min)
• Renal replacement therapy (RRT)
• a/ hemodialysis
• b/ peritoneal dialysis
• c/ kidney transplant

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Risk factors for CKD

• History of diabetes, cardiovascular disease,
  hypertension, hyperlipidemia, obesity, metabolic
  syndrome, smoking
• Family history of kidney disease
• Treatment with potentially nephrotoxic drugs

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Screening for CKD - methods

• Urine test for albumin in a first morning or a
  random spot urine sample
• Blood test for creatinine to estimate GFR
• Screening for hematuria with a urinalysis (in
  patients at increase risk for glomerulonephritis)

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Management of CKD - A

• Treatment of reversible causes of renal
  dysfunction
• 1/ decreased renal perfusion hypovolemia,
  hypotension, infection
• 2/ administration of nephrotoxic drugs
  aminoglycoside antibiotics, nonsteroidal
  antiinflammatory drugs, radiographic contrast
  material
• 3/ Urinary tract obstruction

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Management of CKD - B

• Slowing the progression of renal disease -
  lowering of intraglomerular hypertension and
  glomerular hypertrophy leading to glomerular
  scarring (glomerulosclerosis) - administration of
  ACEI and ARB, low-protein diet
• - therapy of hyperlipidemia, metabolic acidosis
  and tubulointerstitial disease
• -smoking cessation

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Management of CKD - C

• Treatment of the complications of renal
  dysfunction (fluid and electrolyte balance
  volume overload, hyperkalemia, metabolic
  acidosis, hyperphosphatemia), hypertension,
  anemia, bone disease
• Identification and preparation of the patient in
  whom renal replacement therapy will be required

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Indication for renal replacement therapy the
uremic syndrome

• 1/ Pericarditis or pleuritis (urgent indication)
• 2/ Progressive uremic encephalopathy or
  neuropathy (confusion, myoclonus, seizures)
• 3/ Bleeding diathesis attributable to uremia
• 4/ Persistant nausea and vomiting

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Uremic syndrome

• Deterioration of biochemical and physiological
  functions
• in parallel with progressive renal failure,
• thereby resulting in complex but variable
  symptomatology

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Uremic toxins

• A/ small, water-soluble such as urea (low
  degree of toxicity), ADMA (asymmetric
  dimethylarginine)
• B/ small, lipid-soluble such as the phenols
  (p-cresol and p-cresylsulfate)
• C/ larger, so-called middle-molecules (in excess
  of 500 D) such as beta2-microglobulin, PTH, AGE
  products

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Symptomatology of uremic syndrome

• Uremic pericarditis and pleuritis
• Uremic encephalopathy and polyneuropathy
• Uremic gastroenteritis
• Uremic thrombocytopathy
• Uremic pruritus
• Reproductive and sexual dysfunction

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Uremic pericarditis

• Exudative aseptic inflammation (fibrin and
  leucocytes do not penetrate the myocardium, no ST
  elevation on ECG)
• An increase in the vascularity, blood vessels
  break, serosanguinous effusion
• The exact etiology remains to elucidated

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Uremic pericarditis

• Clinical features
• chest pain and radiation to the neck and
  shoulders
• cough and dyspnea
• weight loss
• pericardial friction rub
• pericardial effusion PERICARDIAL TAMPONADE

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Uremic pericarditis

• Diagnosis
• the chest radiograph
• the transthoracic echocardiography

• Management
• intensive hemodialysis daily for 10-14 days
• NO GLUCOCORTICOIDS
• If tamponade pericardial centesis

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Mineral bone disease

• Retention of phosphates - loss of GFR
• Insufficient production of active alfa 1
  calcitriol in kidney
• Low calcemia
• Increased production of parathormone

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Renal osteodystrophy

• bone abnormilities in renal patients
• 1/ high-turnover bone disease
• osteitis fibrosa
  
• 2/ low-turnover osteomalacia
• 3/ adynamic bone
• 4/ mixed uremic osteodystrophy (focuses 1 2)

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Examination

• Ca, P
• Parathormon (PTH)
• Tc-MIBI (radioisotope of technetium longest
  persists in hyperractive tissue of parathyroid
  gland)
• Bone biopsy

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Therapy

• Diet
• Phosphorus binders
• Active vitamine D
• Inhibitor of Ca-sensing receptors in parathyroid
  gland
• Parathyreidectomy

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Diet

• Restriction of
• dairy produce (especially cheese)
• chocolate
• fish and seafood
• Coca-cola

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Parathyreidectomy

• Total PTE removing of all parathyroid glands
  (one of them is implant in the forearm)
• Partial PTE not all paratyroid glands are found
• Sklerotisation - alcohol is instillated into the
  parathyroid gland

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Metabolic acidosis (MAC) in renal disease

• Decrease in blood pH
• Decrease in bicarbonate
• Decrease in pCO2
• Normochloremic MAC high anion gap (accumulation
  of anorganic and organic acids)

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Therapy of renal acidosis, benefits

• Bicarbonate orally Vitar soda (the level of
  bicarbonate is under 18 mmol/l)
• Benefits restriction of bone resorption (bone
  buffering of the excess hydrogen ions releases of
  calcium and phosphate from bone)
• restriction of skeletal muscle
  breakdown leading to loss of lean body mass and
  muscle weakness

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Protein dietary intake in CKD patients

• Dietary protein restriction protects against the
  progression of CKD by
• 1/ hemodynamically mediated reduction in
  intraglomerular pressure
• 2/ changes in cytokine expression (TGF, PDGF)
• 3/ matrix synthesis

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Safety of a low protein diet

• Moderate protein restriction
• 0,6-0,8 g/kg per day
• Dietary protein of high biological value
• Well tolerated, safe
• Does not lead to malnutrition
• (MDRD study 1989-2000 12 years)

• Very low protein diet
• 0,4-0,6 g/kg per day
• Diminished energy intake
• Declines in body weight and arm muscle area
• Increased mortality

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Recommended dietary intake for CKD (ESRD) patients
CKD Maintenance HD
Protein 0,8-1 g/kg per day 1,2-1,3 g/kg per day
Energy 35 kcal/kg per day 35 kcal/kg per day
Fat ( of total energy intake) 30 to 40 30 to 40
Potassium (mmol/day) 40 to 70 40 to 70
Phosphorus (mg/day) 600 to 800 600 to 800
Water (ml/day) Up to 3000 Usually 750 to 1500