Slow Progression in CRF

1
Chronic Kidney Disease (CKD)
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2
Renal Anatomy
3
Renal Anatomy
4
Renal Anatomy
5
Renal Function

• Excretory Regulatory
• Solute electrolyte non-electrolyte
• Solvent water
• Synthetic
• Erythropoietin ? RBC stimulation
• 1,25-(OH)2 Vitamin D3 (Calcitriol)
• Etc.

6
Renal Function
GFR (90 ml/min./1.73 m2)
7
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????????????? (???????????????)
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• ????????????
• ????????????????????

• ??
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• ??????????????

• SLE
• IgA Nephropathy
• etc.

8
RENAL FAILURE

• Definition ? Renal function
• ? GFR (Glomerular filtration rate)
• ? ? Uremic toxin excretion
• ? ? Serum BUN, Cr

9
GFR Measurement

• 1. Direct clearance of substance
• Inulin Gold standard
• Radioisotope - 99mTc EDTA, 125I Iothalamate
• Creatinine practical
• CCr (Cr Clearance) GFR
• CCr (ml/min.) UCr x V (urine volume)
• PCr

10
GFR Measurement

• 2. Formula
• Cockcroft-Gault
• CCr (ml/min)
• (140 - Age) x Body weight x (0.85 if
  Female)
• 72 x SCr
• MDRD
• eGFR (ml/min/1.73m2)
• 186 x (SCr)-1.154 x (Age)-0.203 x (0.742 if
  Female)
• x (1.210 if African-American)

11
GFR Measurement

• 2. Formula
• CKD-EPI Recommended formula

Serum Cr eGFR (ml/min/1.73m2)
Female 0.7 144 (Scr/0.7)-0.329 (0.993)Age
Female gt 0.7 144 (Scr/0.7)-1.209 (0.993)Age
Male 0.9 141 (Scr/0.9)-0.411 (0.993)Age
Male gt 0.9 141 (Scr/0.9)-1.209 (0.993)Age
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GFR Measurement

• http//www.nephron.com/MDRD_GFR.cgi

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RENAL FAILURE

• ARF (Acute Renal Failure)
• ? Renal function in hours to days
• CRF (Chronic Renal Failure)
• ? Renal function in gt 3 months

• AKI (Acute Kidney Injury)

• CKD (Chronic Kidney Disease)

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Reversible !
ARF
CRF
Irreversible
15
Clues in Diagnosis of CKD (from AKI)

• Uremia gt 3 months
• Previous high serum BUN, Cr
• Clinical nausea, edema, hematuria, nocturia
• Small size kidneys lt 9 cm
• Anemia
• Renal osteodystrophy

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Chronic Kidney Disease (CKD)

• Definition duration 3 months
• 1. Kidney damage
• Pathology
• Structure Stone, Cyst, Mass, etc.
• Function Proteinuria, Albuminuria
• Hematuria, Abnormal Cast
• And / Or
• 2. GFR lt 60 ml/min/1.73 m2

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Stages of CKD
Stage Description GFR Action
0 At increased risk 90 Screening, CKD risk reduction
1 Kidney damage with normal GFR 90 Dx Rx, Rx of comorbid condition, Slowing progression, CVD risk reduction
2 Kidney damage with mild ? GFR 60-89 Estimating progression
3 Moderate ? GFR 30-59 Assess Rx complication
4 Severe ? GFR 15-29 Praparation for RRT
5 Kidney failure lt 15 Renal replacement
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Stages of CKD
Stage Description GFR Action
0 At increased risk 90 Screening, CKD risk reduction
1 Kidney damage with normal GFR 90 Dx Rx, Rx of comorbid condition, Slowing progression, CVD risk reduction
2 Kidney damage with mild ? GFR 60-89 Estimating progression
3 Moderate ? GFR 30-59 Assess Rx complication
4 Severe ? GFR 15-29 Praparation for RRT
5 Kidney failure lt 15 Renal replacement
CRF
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• Male, BW 60 Kg, Age 60

Serum Cr CKD-EPI Cockcroft-Gault CKD stage
1.3 59 51 3
2.5 27 27 4
5.0 12 13 5
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Stages of CKD
Stage Description GFR Prevalence in THAILAND 2550
0 At increased risk 90
1 Kidney damage with normal GFR 90
2 Kidney damage with mild ? GFR 60-89
3 Moderate ? GFR 30-59
4 Severe ? GFR 15-29
5 Kidney failure lt 15
8.9
8.7
(4,500,000 Thai)
(120,000 ChiangMai)
21
Signs Symptoms

• Uremic symptoms (????????????? ????????
  ??????????)
• Anemia (????????), Fatigue (???????????
  ?????????)
• Dysuria (??????????), Nocturia (??????????????????
  ???), Hematuria (??????????????)
• Edema (???), ?????????????
• ??????? ??????
• ???????????????, ??????????

CKD stage 1-2 ? Asymptomatic !
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How to approach CKD Patients

• Work up cause Correction
• Slow progression of CKD
• Comorbidity treatment
• Counseling Patient education
• Cost
• Mode of Renal replacement therapy HD, CAPD,
  Kidney transplantation
• Nutrition
• Vascular access (in HD)
• Renal replacement therapy

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Causes of CKD

• DM most common ( 30-40 )
• Chronic glomerulonephritis (CGN)
• Vascular disease HT
• Tubulointerstitial Stones, NSAIDs, Gout
• Others Polycystic kidney, etc.

24
Initial investigation for CKD

• U/A proteinuria, sediment
• Proteinuria trace repeat in 3-6 m.
• 1 repeat in 3-6 m.
• or urine
  protein-creatinine ratio (UPCR)
• gt 2 urine
  protein-creatinine ratio (UPCR)
• Abnormal UPCR gt 0.2 (or urine protein gt 0.3
  g/day)
• Serum creatinine, eGFR
• Plain KUB (or ultrasound)
• Others (depend on patient)

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Slow Progression in CKD

• Control BP
• ACEI, ARB
• Low Protein, Low Salt Diet
• Control Blood Sugar
• Control Lipid Level (?)
• Avoid Smoking
• Avoid Nephrotoxic Agents

26
Control BP

• Goal 130/80 140/90 mmHg
• Lifestyle modifications
• Weight reduction BMI 19-23
• Diet Low Salt
• Low Fat (saturated)
• Exercise (30 min. x 5 / week)
• Moderate Alcohol consumption (Beer 720 cc, Wine
  300 cc, Whisky 90 cc)

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Control BP

• Medication ACEI, ARB
• ACEI (Angiotensin Converting Enzyme Inhibitor)
• Enaril (Enalapril)
• Coversil (Perindopril)
• Tritace (Ramipril)

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Control BP

• Medication
• ARB (Angiotensin II Receptor Blocker)
• Cozaar (Losartan)
• Diovan (Valsartan)
• Micardis (Telmisartan)
• Aprovel (Irbesartan)

29
Control BP

• Medication
• Ca2-channel blocker
• Amlodipine
• Adalat (Nifedipine)
• Madiplot (Manidipine)
• Zanidip (Lercanidipine)
• Isoptin (Verapamil)
• Herbesser (Diltiazem)

30
Control BP

• Medication
• Diuretics
• Lasix (Furosemide)
• HCTZ (Hydrochlorothiazide)
• Aldactone (Spironolactone)
• Beta-blocker
• Metoprolol
• Atenolol
• Propranolol

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Control BP

• Medication
• Alpha-blocker
• Cardura, Pencor (Doxazosin)
• Minipress (Prazosin)
• Centrally acting agent
• Aldomet (Methyldopa)
• Direct vasodilator
• Apresoline (Hydralazine)
• Minoxidil

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RAAS (Renin-Angiotensin-Aldosterone System)
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Diet

• Protein
• GFR lt 30 ml/min/1.73 m2 (stage 3)
• 0.8 g/kg/day
• CKD at risk of progression
• avoid high protein (1.3 g/kg/day)
• Salt
• lt 2 g/day of Na (5 g of NaCl, ???????? 1
  ??????, ?????? 2 ????????)

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Control Blood Sugar

• Goal
• Fasting 80-120 mg/dl
• Post-prandial 80-160 mg/dl
• HbA1C 7
• Precaution of Hypoglycemia

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Control Lipid Level

• Goal
• Total Cholesterol lt 200 mg/dl
• Triglyceride lt 200 mg/dl
• HDL gt 45 mg/dl
• LDL lt 100 mg/dl

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Nephrotoxic Agents

• NSAIDs Diclofenac, Ibuprofen, Mefenamic acid
  (Ponstan), Indomethacin, Naproxen, etc.
• Aminoglycoside Gentamicin, Amikin
• Herb medicine

• ACEI, ARB stop, if ? Cr gt 25 or Hyperkalemia

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Treatment of CKD
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Treatment

• Medication
• Anti-hypertensive
• Diuretics
• Phosphate binder CaCO3, Al(OH)3
• Alkaline NaHCO3
• Rx of Anemia EPO (erythropoietin), PRC
  transfusion, Ferrous
• Goal Hb 10-12 g/dL (Hct 30-36)
• Vitamin Bco, C, Folic
• Others DM, IHD, Dyslipidemia, Hyper K

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Treatment

• Diet Control
• Low Protein
• Low Salt
• Low K
• Low Phosphate
• Low Fat
• Restricted Fluid Intake

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• Fat (?????)
• ?????? Unsaturated fat (???????????????)
  ????????????????, ????????????, ????????,
  ???????????
• ????????? Saturated fat (????????????)
  ??????????, ?????????, ?????????,??????,
  ?????????, ???????????, ?????????????, ????,
  ?????????

41

• ???, ?????
• ???????? ???????, ??????? ????????????
  (???????)
• ??? ?????????? (Potassium, K)

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• Potassium (K)

??? ??????? ????
??????, ????????????, ??????, ??????,???????????, ??????, ???????, ?????, ?????????? ??????, ????????, ?????????, ?????????, ????????, ??????????, ?????????? ??????????, ?????? (???????), ??????????, ?????????
???????, ????, ????? ???, ???????, ?????, ????, ??????, ?????, ???????, ????, ?????? ?????
43

• Phosphate (P)
• ?????????? P ???
• ????
• ??
• ??????
• ???????? (????)

44

• Water
• ????????????????/??? ?????????????/??? 500
  ml.
• Vitamin
• ????????? A, E
• ?????? B, C, D

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Treatment

• Correct Volume Status
• Dehydration
• Volume replacement
• Avoid diuretics
• Volume overload
• Restrict fluid intake
• Diuretics
• Dialysis HD, PD

46
Treatment

• Renal Replacement Therapy
• Indications for Dialysis in CKD (ESRD)
• GFR 6 ml/min./1.73 m2
• (Serum Cr 10 mg/dl)
• Volume overload, Uncontrolled BP
• Hyper K, Hyper P
• Uremic encephalopathy
• Uremic pericarditis, pleuritis
• Protein-Energy Malnutrition

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Treatment

• Mode of Dialysis
• Hemodialysis (HD)
• Intermittent
• Continuous (CRRT, Continuous Renal Replacement
  Therapy) CVVH(F), CAVH(F), CVVHD, CVVHDF, etc.
• Peritoneal Dialysis (PD)
• Intermittent
• Continuous CAPD (Continuous Ambulatory PD),
  etc.

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Convection
49
Hemodialysis
Ultrafiltrate (UF)
Diffusion
M E M B R A N E
Blood
Dialysate
Uremic toxins Water
Convection
50
Peritoneal Dialysis
Ultrafiltrate (UF)
Diffusion
M E M B R A N E
Blood
Peritoneal Cavity
Uremic toxins Water
Dialysate
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Nutrition
Daily Requirement in HD patients
Energy 3035 kcal/kg
Protein 1.2 g/kg
High biological value gt 50
Na 3 g
K 3 g
Phosphate 1.2 g
Water 5001000 ml Urine output
???????????????? essential amino acid ???????
??????????????????? ?????? ?????????? ??? ??
52
Kidney Transplantation

• Living-related KT
• Cadaveric KT

53
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????? 1. ?????????????????????????????????????????????? ??????????????????????? 2. ??????????????????????????????? 1. ???????????????, ?????????????????????????????? 2. ????????????????????????????????? ????????????????????????????????3. ??????????????????????????????????? 4. ???????????????????? ?????????????? 1. ????????????????????????????????????????? ????????????????
??????? 1. ??????????????????????????? 2. ?????????????????????????? ????????? 2-3 ?????3. ???????????????????????? ???? ??????????????? ???????? ?????? ??? 1. ??????????????????????????2. ????????????????????????????????????? 1. ?????????????????????? ????????????????????????????????????? 2. ???????????????????
54
??????????????????????????????? (ESRD)
?????????????? CAPD
??
?????
CAPD
?? CAPD ?????????
??????
???
HD
CAPD
KT
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Pitfall

• ??????? CKD ?????????????????????????? ? ???????
  ???????????????? Diuretics ??????
• ??????? CKD ??????????????????? HD ? ???????????
• ???????????? HD ???? ? ???????????????????

56

• ??????
• ?????????????
• ????????????????????????

???????
?????????????
57
????????? ????????

• ?????????????????????????
• ???????????????
• ???????????
• ????????? ??????? BUN, Cr
• ???????????????
• ???????????????????????
• ????????????????? ???????????? 6 8 ??.
• ?????????????????????? ????? 6 8 ????

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????????? ????????

• ??????????????? (???)
• ??????????? ????????? 30 ????, 5 ?????/???????
• ????????????????
• ??????????? (Body Mass Index, BMI)
• ??????? (??.) / ??????? (????) 2
• ?????????? 23 ?????? ????
• ????????????????
• ?????????????????????????????

59
????????? ????????

• ??????????????????????????????????????
• ????????????? ???????? gt 50 ???? !
• ??????????
• ???
• ????????????????????????
• ???????? ????? ??????? (NSAIDs)
• ??????????, ??????? ???????
• ???

60
????????? ????????

• ????????????????? ????????????
• ??????????
• ?????????????????????
• ??????????????
• ??????? ???????
• ??????? ??????

61
Continuous Ambulatory Peritoneal Dialysis (CAPD)
??.???????? ?????????? ??., ??.???????????,
??.????????????????
62
Continuous Ambulatory Peritoneal Dialysis (CAPD)
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Peritoneal Dialysis
Ultrafiltrate (UF)
Diffusion
M E M B R A N E
Blood
Peritoneal Cavity
Uremic toxins Water
Dialysate
64
Mode of PD

• Continuous
• Continuous Ambulatory PD (CAPD)
• Continuous Cyclic PD
• Intermittent
• Day-time Ambulatory PD
• Nightly Intermittent PD
• Manual / Automated
• ???????
• Prescription
• Complication

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Mode of PD
Auto mated PD
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PD Prescription

• Mode CAPD
• Peritoneal Dialysate Fluid
• 1.5, 2.5, 4.25 Dextrose
• 2 Litre / bag
• 4 - 6 cycles / day
• Adequacy
• Weekly Kt/V gt 1.7
• Weekly nCCr gt 50 Litre / 1.73 m2

67
Complications

• Infection
• Volume overload
• Catheter malfunction
• Metabolic HypoK, Hyperglycemia
• Anemia
• Cardiovascular
• Malnutrition
• Inadequacy

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Complications

• Infection
• Exit site infection Tunnel infection
• - common cause staph. aureus
• - Empirical Rx of exit site infection
• Dicloxacillin, oral, 14 d

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Complications

• Infection
• Exit site infection Tunnel infection
• - common cause staph. aureus
• - Empirical Rx of exit site infection
• Dicloxacillin, oral, 14 d

Acute Exit Site Infection
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Complications

• Infection
• Exit site infection Tunnel infection
• - common cause staph. aureus
• - Empirical Rx of exit site infection
• Dicloxacillin, oral, 14 d

Chronic Exit Site Infection
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Equivocal Exit Site Infection

• Infection
• Exit site infection Tunnel infection
• - common cause staph. aureus
• - Empirical Rx of exit site infection
• Dicloxacillin, oral, 14 d

Chronic Exit Site Infection
72
Tunnel Infection
73
Complications

• Infection
• Peritonitis
• - common cause staph. epidermidis
• - PDF WBC gt 100 /mL, gt 50 PMNs
• - PDF 10 ml in hemoculture media ? yield
• - Empirical Rx Cefazolin 1 gm, IP, od
• Ceftazidime 1 gm, IP, od
• or specific Rx ? 14 d

74
(No Transcript)
75
Complications

• Infection
• Peritonitis
• - Heparin, 500 u/L, prevent occlusion of the
  catheter by fibrin
• - Indications for Catheter Removal
• Refractory peritonitis
• Relapsing peritonitis
• Refractory exit-site and tunnel infection
• Fungal peritonitis

76
Complications

• Infection
• Peritonitis

lt 4 weeks gt 4 weeks
Same organism Relapsing Repeat
New organism Recurrent
Refractory failure of the effluent to clear
after 5 days of appropriate ABO
77
Complications

• Infection
• Peritonitis

lt 4 weeks gt 4 weeks
Same organism Relapsing Repeat
New organism Recurrent
Refractory failure of the effluent to clear
after 5 days of appropriate ABO
78
Complications

• Volume overload

Edema

• I/O, Salt Water Diet
• Compliance
• Residual renal function

False UF Failure
True UF Failure
PET study
High
Low
High Av/Low Av

• Catheter malfunction
• - Leakage

• Peritonitis
• - Large vascular area

• Adhesion
• - SEP

• Aquaporin def.
• - ? Lymphatic absorption

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Complications

• Infection
• Catheter malfunction
• Volume overload
• Metabolic HypoK, Hyperglycemia
• Anemia
• Cardiovascular
• Malnutrition
• Inadequacy

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