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C.K.D
Definition
Kidney damage > 3 months as defined by structural or functional abnormalities of kidney, with or without GFR manifest by either. GFR < 60 ml / mt / 1.73 m2 for > 3 months with or without kidney damage
K Doqi Guideline 2002
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Diagnosis & treatment Treatment Co-morbidity CoSlowing progression CVD risk reduction Estimate progression Evaluation & treatment of complications Prepare for RRT Replacement
2 3 4 5
Kidney damage mild GFR Moderate GFR Severe GFR Kidney failure
60 - 89 30 - 59 15 - 29 < 15
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Patients with a GFR > 60 ml/min not considerd as CKD unless evidence of kidney damage Proteinuria hematuria Structure abnormalities (abnormal renal imaging) Genetic disease (APKD) Histological proven disease
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GFR
Normal Males 110 135ml/mt(Av.125ml/min/1.73m2) Females 90 -120ml/mt(Av.110ml/min/) GFR decreases with age at 80 yrs 80ml/min/1.73m2
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2./MDRD FORMULA
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Whom to Screen ?
Family H/o renal disease Diabetes Hypertension Stones Recovered ARF Persistent UTI Renal mass - Solitary kidney. Unexplained edema CHF Atherosclerotic disease Multisystem disease
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How to Screen ?
GFR annually 140 - Age x Body wt. (kgs) S. Creat. x 72 Proteinuria
Dipstick (early morning) Urine Prot. / creatinine ratio 24hrs urinary protein
Urine
Sediment Microscopy Imaging
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Clinical Presentation
GENERAL NERVOUS Dehydration Twitching Saline depletion Convulsions Hyperkalemia Neuropathy Metab. Acidosis Coma Water intoxication Susce. to infection GI Anorexia Hiccoughs Vomittings Polydipsia GENITOURINARY Oliguria/ Polyuria Nocturia Impotence CVS HTN CAD Pulm.edema Pericarditis Arrhythmias
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SKIN Pigmentation Pruritus SKELETAL Frost Renal osteodys. Purpura Metastatic calcn Dwarfism Cramps Loss of strength
When to refer ?
Screen patients at high risk:
Age >60 Diabetes Hypertension Family history of renal disease
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Refer to nephrologist if stable or rising S.Creatinine >1.5 -female, >2.0 -male Proteinuria > 1 gm/day even if GFR is normal
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Early referral
Aim :
To make early diagnosis if necessary renal biopsy To identify and manage complications To retard progression of disease To reduce morbidity and mortality To prepare patient for maintenance dialysis To prepare for preemptive transplantation
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Does pre dialysis nephrology care influence patient survival after initiation of dialysis ?
Early referral > 3 months Late referral 1-3 months 1Ultra late < 1 month Study of 109321 pts - < 50 % have nephrology care in 6 months before initiation of dialysis Better nephrology care 6 months before initiation of dialysis reduces mortality
*Kidney International March 2005
Early referral of diabetic nephropathy pts - Better renal function preservation - Better BP control - Increased use of ACEi / ARBs / statins - Decreased use of NSAIDs *AJKD,Jan 2006
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MODIFIABLE FACTORS
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Diagnosis & treatment Treatment Co-morbidity CoSlowing progression CVD risk reduction Estimate progression Evaluation & treatment of complications Prepare for RRT Replacement
2 3 4 5
Kidney damage mild GFR Moderate GFR Severe GFR Kidney failure
60 - 89 30 - 59 15 - 29 < 15
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Secondary Prevention
Proteinuria ACE inhibitors ARBS Glycemic control Diet, insulin, OHA HbA1C 2000) < 6.5 (ADA
Lipid control S. Triglycerides < 100 mg% S. LDL < 150 mg% (NCEP) Treatment of Anaemia Treatment of Hypoalbuminemia Cessation of smoking
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Conservative Treatment
Blood pressure targets in CKD
o Without proteinuria
-Treat at 140/90 -Target at 130/80
o With proteinuria
-Treat at 130/80
-Target
120/75
o Diabetes mellitus
-Target 120/75
Management of CKD
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Conservative Replacement Diet Salt / fluid Transplantation Dialysis restriction Rx of anaemia HD PD Rx of HTN Rx of bone disease Institute Home Rx of infection Rx of acidosis CAPD CCPD Rx of hyperkalemia Live Cadaver LRD LURD
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Conservative Treatment
Diet Protein CHO Fat Calories Salt / H2O Potassium Vitamins Trace-elements Trace Fibre - 0.6 - 0.8 gm /Kg /day - 14-20 gm EAA 14- At least 100 gm - 15-20% of calories 15- ~ 35 kcal / kg basal
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Conservative Treatment
Hyperkalemia
Insulin Soda bicarb K- exchange resins Calcium Gluconate Dialysis
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Conservative Treatment
Acidosis
Normal acid production Bicarb. replacement -1mmol/kg/day - pH<7.3 - S.bicarb. < 15mmol/L
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Conservative Treatment
Anemia
< 12.0 gm% - Males / post menopausal < 11.0 gm % - Pre-menopausal Pre Epo - supplement Epo (50-100 IU/kg/week) (50 Iron-def - Iron - supplement Iron(Blood loss) (If S.Fe <100 mg/dl & TSAT <20%)
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Conservative Treatment
Renal osteodystrophy
Hypocalcaemia Ca supplements - Ca carbonate Vit D analogues Hyperphosphatemia Aluminium hydroxide Calcium based-carbonate acetate based Sevalamer HCL Lanthanum salts Parathyroidectomy * Prevent Ca x P product
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Conservative Treatment
Infections
No drug absolutely contra-indicated contra Dose - adjustment as per GFR Avoid combination of Nephrotoxic agents Close - monitoring of renal functions * Risk factors - Elderly, dehydration, prepreexisting renal disease
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Reversible - Factors
Acute on Chronic Kidney Disease Volume - depletion Accelerated hypertension Infection Obstruction Drugs - ACE-I, Amino glycosides, ACENSAIDS and Contrast drugs
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Prevention of complications
Early recognition and treatment of cardio vascular events Helping in planning Angiographic studies , avoid contrast nephrotoxicity Judicious use of antibiotics Avoiding NSAIDs and nephrotoxic drugs Plan nutrition
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Dialysis
Home Peritoneal dialysis (CAPD) Institutional Hemodialysis
Transplantation Kidney Tx
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Dialysis
Absolute Indications
Severe azotemia Acute LVF Pericarditis Hyperkalaemia Metabolic acidosis Uraemic encephalopathy
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Renal Transplantation
Live - related Live - unrelated Cadaver
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Conclusions
CKD on the rise - especially in young Monitoring of at - risk group Measures to retard progression Identify & treat reversible factors
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Thank you
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A ny Q
sti ns?