Chronic Kidney Disease

Definition Processes Promoting Progressive Kidney Failure

Kidney damage ≥ 3 months Partial Loss of
Structural, Functional abnormalities of kidney Function
With/ without ↓ GFR
Manifest by Fibrosis Compensatory Renin AII Afferent
Pathological abnormalities apoptosis Growth Activation vasodilation
Markers of Kidney Damage
(including abnormal composition of Blood, Urine, imaging studies) Release of ↑ Wall Tension Systemic Glomerular
GFR < 60mL/min/1.73m2 for ≥ 3 months, with/ without Kidney Damage Cytokines, Hypertension hypertension
Process of continuing significant Irreversible ↓ in Nephron number Growth Factors
Corresponds to CKD stages 3-5
End-Stage Renal Disease (ESRD) Capillary Injury Proteinuria
CKD + Uremic Syndrome = Stage 5 CKD
Angiotensin II in Promoting Progressive CKD
Markers of Kidney Damage Release of
Pathological Abnormalities Abnormal Blood, Urine Cytokines
Kidney stones Hypokalaemia (RTA) Growth Factors
Polycystic kidneys Urine – Haematruia, Proteinuria
↑ Protein Filtration Angiotensin II Hyperplasia
Hydronephrosis
Hypertrophy
Stages of Chronic Kidney Disease
Systemic, Glomerular
1 2 3 4 5
Hypertension
GFR (mL/min/1.73m2) > 90 60-89 30-59 15-29 < 15
CRF CRF ESRF Declining Renal Function & Development of Uraemic Symptoms

Estimation of GFR
Inulin, 125I-Iothalamate, 99mTc-DTPA, Iohexol, 51Cr-EDTA
24-hour clearance, Serum Ceratinine
Adult Children
MDRD Study Schwartz Formula
Cockcroft-Gault Formula Counahan-Barratt Equations

Causes of Chronic Renal Failure

Diabetes Mellitus
DM Nephropathy
(Microvascular complication)
(eg. Glomerular damage, Arteriolosclerosis, Pyelonephritis)
Hypertension Development of Uraemic symptoms
Hyaline, Arteriolosclerosis as Serum Creatinine ↑with ↓ Renal Function
(eg. Ischaemia, Fibrosis, Glomerular Damage) Approximately 50% of Glomerular Filtration is lost,
Polycystic Disease before Serum Creatinine exceeds the upper-limit of Normal
Glomerulonephritis
Toxic Nephropathy Detection of Chronic Kidney Disease
Obstructive Nephropathy Urine Examination
SLE Microalbuminuria, Proteinuria, Red Blood Cell, White Blood Cell, Casts
Blood Examination
1° Renal Disease in Paediatric eGFR calculation using Cockcroft-Gault, MDRD formula
Unknown (47.2%) Kidney Biopsy
Glomerulonephritis (21.9%) Kidney Imaging
Ultrasound
Focal Segmental Glomerulosclerosis (FSGS) (7.5%)
Reflux Nephropathy (4.3%)
Clinical Features
SLE (6.1%)
Anaemia
Obstructive Uropathy (4.9%)
Pallor, Lethargy, Breathlessness on exercise
Renal Dysplasia (2.4%)
Platelet Abnormality
Hereditary Nephritis (2.2%)
Epistaxis, Bruising
Cystic Kidney Disease (1.6%)
Skin
Drug Induced Nephropathy (1.0%) Pigmentation, Pruritus
Metabolic (0.1%) GI Tract
Anorexia, Nausea, Vomiting, Diarrhoea
Pathophysiology Endocrine/ Gonads
Intraglomerular Hypertension, Glomerular Hypertrophy Amenorrhoea, Erectile impotence, Infertility
Compensatory response to Nephron loss in attempt to maintain total GFR Polyneuropathy
1° Renal Vasodilatation, occurs in Diabetes Mellitus, leading to Hyperfiltration CNS
Compensatory Adaptation Confusion, Coma, Fits (severe uraemia)
(to ↓ in permeability of glomerular capillary wall to small solutes, water) CVS
↑ Intraglomerular Pressure (to minimize ↓ GFR) Uraemic Pericarditis, Hypertension, Peripheral Vascular Disease, Heart Failure
Mediated by ↓ flow to Macula Densa Renal
Activation of Tubuloglomerular Feedback
Nocturia, Polyuria, Salt & Water Retention, Edema
Renal Osteodystrophy
Other 2° Causes Osteomalacia, Muscle Weakness, Bone Pain, Hyperparathyroidism,
Proteinuria Osteosclerosis
Podocyte Injury/ loss
Tubulointerstitial disease (Fibrosis) Laboratory Results
Calcium Phosphate deposition Creatinine > 100 umol/L
Metabolic acidosis Glomerular Filtration Rate (GFR/ Creatinine Clearance) < 60ml/min/1.73m2
Hyperlipidaemia
Complications Renal Replacement Therapy
Fluid, Electrolyte Dialysis
Fluid Retention, Hyperkalemia, Hyperphosphatemia Haemodialysis Peritoneal Dialysis
Endocrine Metabolic Continuous Ambulatory Peritoneal Dialysis (CAPD)
Metabolic Acidosis, Renal Osteodystrophy Continuous Cyclic Peritoneal Dialysis (CCPD)
Neuromuscular Criteria
Fatigue, Drowsiness, Asterixis, Muscle Cramps, Myopathy Presence of Uremic Symptoms
Hematologic, Immunologic Hyperkalaemia
Anaemia, Bleeding, Susceptible to Infection Persistent Extracellular Volume Expansion
Cardiovascular, Pulmonary Creatinine Clearance/ Estimated GFR < 10mL/min/1.73m2
Uraemic Pericarditis, Renovascular Hypertension Acidosis
Dermatologic Bleeding Diathesis
Hyperpigmentation (due to Urobilin) Choosing Type of Dialysis (Psychosocial Factors)
Pruritus Preference, Motivation
Gastrointestinal Body Image (young adults)
Anorexia, Nausea & Vomiting, Gastroenteritis, PUD, Peritonitis Occupation
Anaemia, Malnutrition, Bone Growth Economic considerations
Home, Workplace Environment
Management Family Support
Complication Management Distance from nearest HD center
Anaemia Erythropoietin
IV Ferritin
Renal Bone Disease Phosphate Binder
Vitamin D
Hypertension Strict BP Control < 130/80
ACEI / ARB < 125/75
Diabetes Strict Glycaemic Control (HbA1c < 7%)
Fluid Overload Salt, Water Restriction
↑ Dose Loop Diuretics

Estimating Time to Kidney Failure

Renal Transplantation
Treatment of choice (for advanced chronic renal failure) – Best quality of Life
Transplant centres in Malaysia
KL Hospital
HUKM
UMMC
Selayang Hospital
Recipient Selection
Thorough Risk-Versus-Benefit Evaluation
Donors
Deceased
Volunteer Living Donors
Benefits
Better quality of Life, Survival
Contraindications
Elderly age group (> 65 y/o)
HIV Infection, Diabetes with MOF, Psychosis, Malignancy, Severe CVD,
Chronic Active Hepatitis, Cirrhosis
Active Substance Abuse
Complications
Rejection
Infections
HPT
Post-Transplant DM
Immuno-suppressive agents side effects (eg. Cancer)