CKD and ESRD - Clin Med

What does this refer to

• Kidneys are damaged and can't filter blood the way they should

• Encompasses all degrees of decreased renal function

• Chronic = progressive functional decline > months

Chronic Kidney Disease

What does this refer to

• More prevalent in the elderly significantly increases with age

• Stable kidney disease 30% of patients > 65yo

• Younger patients have progressive loss of kidney function

• Overall AA > Caucasian (4 : 1)

• Peds → M > F

  • Posterior urethral valves (MC birth defect) found only in boys

EpidemiologyChronic Kidney Disease

What does this refer to

• Risk factors for developing kidney disease

  • Diabetes

  • HTN

  • CAD

  • Family history of kidney failure

Risk factors of Chronic Kidney Disease

What does this refer to

• Diabetic kidney disease

• Hypertension

• Vascular disease

• Glomerular disease (primary or secondary)

• Cystic kidney diseases

• Tubulointerstitial disease

• Urinary tract obstruction or dysfunction

• Recurrent kidney stone disease

• Congenital (birth) defects of the kidney or bladder

• Unrecovered acute kidney injury

EtiologyCauses of ckd

What does this refer to

• Renal artery stenosis

• Cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA)–positive and perinuclear pattern antineutrophil cytoplasmic antibody (P-ANCA)–positive vasculitides

• ANCA-negative vasculitides

• Atheroemboli

• Hypertensive nephrosclerosis

• Renal vein thrombosis

Etiologyvascular

What does this refer to

• Membranous nephropathy

• Alport syndrome

• Immunoglobulin A (IgA) nephropathy

• Focal and segmental glomerulosclerosis (FSGS)

• Minimal change disease

• Membranoproliferative glomerulonephritis (MPGN)

• Complement-related diseases (e.g., atypical hemolytic-uremic syndrome [HUS], dense deposit disease)

• Rapidly progressive (crescentic) glomerulonephritis

Etiologyprimary glomerular disease

What does this refer to

Etiology of Secondary Glomerular Diseas

What does this refer to

Etiologycauses of Tubulointerstitial disease

What does this refer to

• Benign prostatic hypertrophy

• Urolithiasis (kidney stones)

• Urethral stricture

• Tumors

• Neurogenic bladder

• Congenital (birth) defects of the kidney or bladder

• Retroperitoneal fibrosis

Etiologyurinary tract obstruction

What does this refer to

• CKD stages 1-3 may be asx

• Usually sx with stage 4

• Metabolic Acidosis

• Peripheral edema

• Pulmonary edema

• HTN

• Anemia due ↓ renal synthesis of erythropoietin

  • Fatigue

  • Reduced exercise capacity

• New onset HF, worsening of HF & ↑ risk of CV disease

Clinical History Chronic Kidney Disease

What does this refer to

• Pericarditis

• Encephalopathy

• Peripheral Neuropathy

• RLS

• GI sx → N/V/D/loss of appetite

• Skin – dry, pruritic, ecchymosis

• Malnutrition

• Platelet dysfunction ( ↑ bleeding)

• ED/decreased libido/amenorrhea

Less common Clinical historyChronic Kidney Disease

What does this refer to

How to detect chronic kidney disease

What does this refer to

• Findings characteristic of disease that cause CKD

  • Lupus, severe arteriosclerosis, HTN

• Peripheral edema

• Pulmonary edema

• HTN

• Dry, pruritic skin +/- ecchymosis

Clinical Presentation Chronic Kidney Disease

What does this refer to

• Findings characteristic of disease that cause CKD

  • Lupus, severe arteriosclerosis, HTN

• Peripheral edema

• Pulmonary edema

• HTN

• Dry, pruritic skin +/- ecchymosis

Clinical PresentationChronic Kidney Disease

What does this refer to

• AKI

• Alport Syndrome

• Antiglomerular Basement Membrane Disease

• Chronic Glomerulonephritis

• Diabetic Nephropathy

• Multiple Myeloma

• Nephrolithiasis

• Rapidly Progressive Glomerulonephritis

Differential DiagnosisChronic Kidney Disease

What does this refer to

• Proteinuria

• Abnormal urine sediment

• Abnormal serum/urine chemistries

• Abnormal imaging studies

• Inability to buffer pH

• Inability to make urine

• Inability to excrete nitrogen waste

• ↓ synthesis of vitamin D/erythropoietin

CharacteristicsChronic Kidney Disease

What does this refer to

WorkupChronic Kidney Disease

What does this refer to

• Serum Cr 1 mg/dL is normal GFR

• Serum Cr 2 mg/dL 50% ↓ in GFR

• Serum Cr 4 mg/dL 70-85% ↓ in GFR

• Serum Cr 8 mg/dL 90-95% in ↓ GFR

Workup (Cr and GFR Correlation)Chronic Kidney Disease

What does this refer to

• What is creatinine clearance?

• Creatinine Clearance

  • Approximation of residual renal fxn in all patients with CKD

  • CrCl (male) = ([140-age in years] × weight in kg)/(serum creatinine × 72)

  • CrCl (female) = CrCl (male) × 0.85

• eGFR

  • Included on the CMP

Workup - renal function studiesChronic Kidney Disease

What does this refer to

• Renal US

  • Hydronephrosis

  • Retroperitoneal involvement in fibrosis tumor or diffuse adenopathy

  • Initial imaging study of choice for pediatric patients

• CT/MRI/Radionuclide scans can better define renal masses/cysts on US

• CT most sensitive for renal stones (NO CONTRAST)

• MRI

• MRA – renal artery stenosis

• US guided transcutaneous renal bx (if imaging unclear + massive proteinuria)

Workup – imagingChronic Kidney Disease

What does this refer to

• Low protein

• Low salt

• Phosphate restriction

• Potassium restriction

• Plant based diet

• DASH diet (HTN)

Clinical intervention – dietChronic Kidney Disease

What does this refer to

• Treat underlying disease(s)

• Aggressive BP control

• Glycemic control A1C < 7%

• Avoidance of nephrotoxic meds

• Monitor urine protein

• Treat fluid/electrolyte & endocrine imbalances

• Hyperlipidemia goals

  • LDL < 100mg/dL

  • TG < 150mg/dL

  • HDL > 50mg/dL

Clinical managementChronic Kidney Disease

What does this refer to

Know this (u can change this slide later)

What does this refer to

• Indications for dialysis (non-diabetic)

  • GFR < 10mL/min

  • Serum creatinine > 8mg/dL

• Indications for dialysis (diabetic)

  • GFR < 15mL/min

  • Serum creatinine > 6mg/dL

Clinical managementChronic Kidney Disease

What does this refer to

• At initiation of dialysis → MH screening

  • Depression

  • Sleep disturbance

  • Fatigue

  • Anorexia—that can coexist with chronic disease symptoms

• Do not screen for CKD in asx adults without CKD risk factors

PreventionChronic Kidney Disease

What does this refer to

• Consult/referral Nephrology

• Renal dietitian

• Surgery for permanent vascular access or peritoneal catheter placement

• Referral to renal transplant center

ConsultsChronic Kidney Disease

What does this refer to

• Progressive loss of renal function ↑ risk for ESRD

• Rate of progression depends on age & underlying ds

• Lower eGFR ↑ Albuminuria younger age & male sex = faster progression of kidney failure

• Lower serum albumin, calcium, and bicarbonate level and a higher serum phosphate level predict an ↑ risk of kidney failure

• Adjusted mortality rate for stage 4-5 CKD mortality is 76%

Prognosis Chronic Kidney Disease

What does this refer to

• Last stage (5) of chronic kidney disease

• Kidney failure

  • Dialysis

  • Renal transplant

• eGFR < 15mL/min (diabetics)

• eGFR < 10mL/min (non-diabetics)

End Stage Renal Disease (ESRD)

What does this refer to

• Glomerular filtration rate (GFR) - flow rate of filtered fluid through the kidney

• eGFR → estimate of renal function

• Creatinine clearance → estimate of actual GFR

WorkupEnd Stage Renal Disease (ESRD)

What does this refer to

• Dialysis

• Renal transplant

Treatment of End Stage Renal Disease (ERSD)

Whats the left box

Hemodialysis

Whats the right box

Peritoneal Dialysis