CKDMMM 150717231019 Lva1 App6892 PDF

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Chronic Kidney

Disease

Dr. Kevin T John


Medicine PG (PIMS)
DEFINITION OF CKD

• CKD is defined as abnormalities of


kidney structure or function,
present for >3 months, with
implications for health.
Classification of
CKD
Evaluation of CKD
EVALUATION OF CKD
• In people with GFR <60 ml/min/1.73m2
(GFRcategories G3a-G5)
• markers of kidney damage
• review past history
• previous measurements to determine
duration of kidney disease
• duration is >3 months

• CKD IS CONFIRMED
EVALUATION OF CKD
• urinalysis to detect hematuria or pyuria ,
urine microscopy to detect RBC casts or
WBC casts.
• Ultrasound to assess kidney structure for
kidney shape,size, symmetry and
evidence of obstruction
• Serum and urine electrolytes to assess
renal tubular disorders
DEFINITION AND IDENTIFICATION
OF CKD
PROGRESSION

• Define CKD progression based on one of


more of the following
• drop in GFR category accompanied by a
25% or greater drop in eGFR from
baseline
• Rapid progression is defined as a
sustained decline in eGFR of more than
5 ml/min/1.73 m2/year
• confidence in assessing progression is
increased with increasing number of
serum creatinine measurements and
duration of follow-up.
FOLLOWUP
• Assess GFR and albuminuria at least
annually in people with CKD. Assess GFR
and albuminuria more often for individuals
at higher risk of progression
• The AER is one of the best indicators of
diabetic nephropathy risk in both type 1
and type 2 diabetes
Management
of CKD
PREVENTION OF CKD PROGRESSION

• BLOOD PRESSURE
• diabetic and non diabetic adults with
CKD and urine albumin excretion <
30mg/24 hours treated with BP-
lowering drugs to maintain a BP that is
consistently<140mm and diastolic <90.
• CKD and with urine albumin excretion of
>30mg/24 hours maintain a BP
<130/80mmhg
• Use of ARB or ACE-I in both diabetic and
non-diabetic adults with CKD and urine
albumin excretion >300 mg/24 hours
• If diabetic, albuminuria 30-300mg /24 hrs
is indicated for ACE/ARBI
• electrolyte disorders, acute deterioration in
kidney function, orthostatic hypotension
and drug side effects has be given close
attention in CKD to prevent adverse effects
of antihypertensive therapy.
CKD and risk of AKI
• All CKD patients are at risk for AKI
• All reversible precipitating factors has to
be avoided
Protein intake in CKD
• protein intake restriction to 0.8
g/kg/day in adults with diabetes or
without diabetes and GFR <30 ml/min/
1.73 m2.
• avoid high protein intake (1.3 g/kg/day)
in adults with CKD at risk of progression
Diabetic control
• Glycemic control improves outcomes in people
with diabetes with or without CKD
• In people with CKD and diabetes, glycemic
control should be part of a multifactorial
intervention
• Blood pressure control and cardiovascular risk,
ACE-I,ARBS,Statins and antiplatelet therapy to
be used where clinically indicated
• Recommended target (HbA1c)at 7.0% and not
less to prevent hypoglycaemia and to delay
progression of the microvascular complications
of diabetes, including diabetic kidney disease
Salt intake
• Salt lowering intake to <2 g per day of
sodium (corresponding to 5 g of sodium
chloride) in adults, unless
contraindicated.
• Individuals with CKD should receive
expert dietary advice and information as
a education program, based on severity
of CKD and the need to intervene on
salt,phosphate, potassium, and protein
intake where indicated.
• Patients with CKD be encouraged to
undertake physical activity compatible
with cardiovascular health and tolerance
(aiming for at least 30minutes 5 times
per week),
• BMI - 20 to 25, and
• Stop smoking
COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY
FUNCTION

• CKD are prone to develop a variety of complications which


reflect loss of endocrine or exocrine function of the kidney.
Anaemia
 Diagnose anemia in adults and children >15 years
when the Hb concentration is
• <13.0 g/dl in males
• <12.0 g/dl in females.

 Blood Hb monitoring in CKD


• when clinically indicated in people with GFR
>60 ml/min/1.73 m2
• at least annually in people with GFR 30-59 ml/min/1.73 m2
• at least twice per year in people with GFR<30 ml/min/1.73
m2
Anaemia (Cont)
• Work-up for anemia in CKD
• Iron replacement therapy if indicated
• ESA therapy is not recommended in those
with active malignancy
• ESAs should not be used to increase the
Hb concentration above 11.5g/dl
CKD METABOLIC BONE DISEASE
• Changes in bone mineral metabolism and
alterations in calcium and phosphate
homeostasis occur early in the course of CKD
and progress as kidney function decline
• serum levels of calcium,phosphate, PTH, and
alkaline phosphatase activity at least once in
adults with GFR o45 ml/min/1.73 m2.
• Aluminium hydroxide, Calcium citrate,
Magnesium carbonate,calcium acetate phosphrus
binders are used
Vit D hypovitaminosois
• As CKD progresses, levels of 1,25(OH)2D
progressively fall
• Deficiency of 25(OH)D increases fracture
risk and is associated with increased
mortality
• In vitamin D-deficient subjects
supplementation with vitamin D increases
BMD and muscle strength, reduces risk for
fractures reduces, and reduces PTH.
Acidosis
• Severity of metabolic acidosis in people with
CKD progressively rises as GFR falls.
• Chronic metabolic acidosis is associated with
increased protein catabolism, uremic bone
disease, muscle wasting, chronic
inflammation, impaired glucose homeostasis,
impaired cardiac function, progression of CKD,
and increased mortality
• In CKD with serum bicarbonate
concentrations <22 mmol/l ,oral bicarbonate
supplementation be given to maintain serum
bicarbonate within the normal range
Cardiovascular disease
• Heart Outcomes Prevention
• Evaluation (HOPE) study demonstrated
that any degree of albuminuria is a risk
factor for cardiovascular events in
individuals with or without diabetes
• 1. Smoking cessation
• 2. Exercise
• 3. Weight reduction to optimal targets
• 4. Lipid modification recognizing that the risk reduction
associated with statin therapy in adults with CKD
• 5. Optimal diabetes control HbA1C o7% (53 mmol/mol)
• 6. Optimal BP control to o140/90 mm Hg or o130/80
• mm Hg in those with CKD and depending on the degree
• of proteinuria (see Recommendations 3.1.4 and 3.1.5)
• 7. Aspirin is indicated for secondary prevention but not
• primary prevention
• 8. Correction of anemia to individualized targets
Peripheral arterial disease

• CKD patients are at high risk of developing PAD


• Regularly examined for signs of peripheral arterial
disease
• Patients with CKD and diabetes are offered regular
podiatric assessment
MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD
• All adults with CKD should be
annually vaccinated with
influenza vaccine,unless
contraindicated.
• They should receive
vaccination with polyvalent
pneumococcal vaccine and
hepatitis B.
TIMING THE
INITIATION OF RRT
Dialysis be initiated when one or
more of the following are
present:
• serositis, pericarditis
• acidbase or electrolyte
abnormalities
• Pruritus
• Inability to control volume
status or blood pressure
• a progressive deterioration in
nutritional status refractory to
dietary intervention
• cognitive impairment
TIMING THE
INITIATION OF RRT
• Living donor preemptive
renal transplantation in
adults
• GFR is <20 ml/min/1.73
m2,
• evidence of progressive
and irreversible CKD over
the preceding 6-12 months
THANK YOU

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