7.1 Chronic Kidney Injury.pdf.pdf

Chronic Kidney Injury (CKI) https://youtu.be/fv53QZRk4hs  Objectives ØDefinition. ØPathophysiology. : ØCauses ØPresentation. ØComplications and Treatment. ØPrevention  Definition months > 3 M...

Chronic Kidney Injury (CKI) https://youtu.be/fv53QZRk4hs  Objectives ØDefinition. ØPathophysiology. : ØCauses ØPresentation. ØComplications and Treatment. ØPrevention  Definition months > 3 M ØChronic kidney disease (CKD) refers to an irreversible deterioration in renal function which classically develops over a period of years. Initially, it is manifest only as a biochemical abnormality (Azotemia). Ø Eventually, loss of the excretory, metabolic and endocrine functions of the kidney leads to the clinical symptoms and signs of renal failure, which are referred to as Uraemia.  Ø The term chronic renal failure applies to the process of continuing significant irreversible reduction in nephron number, and typically corresponds to CKD stages 3–5. Ø The dispiriting term end-stage renal disease represents a stage 5 of CKD where the accumulation of toxins, fluid, and electrolytes normally excreted by the kidneys results in the uremic syndrome. Ø The normal annual mean decline in GFR with age from the peak GFR (~120 mL/min per 1.73 m2) attained during the f third decade of life is ~1 mL/min per year per 1.73 m2, reaching a mean value of 70 mL/min per 1.73 m2 at age 70. 20 at age  Classification of Chronic Kidney Disease (CKD) Stage Description GFR (ml/min/1.73m2 0 no kidney damage , Risk factors Present ceg DM ) ≥90a 1 Kidney damage with normal or high GFR > 90b 2 Kidney damage with slightly low GFR 60–89 3 Moderately low GFR 30–59 4 Severe low GFR 15–29 5 Kidney failure ESRD 40 years or there are risk factors for cardiac disease 9. Renal artery imaging: if renovascular disease is suspected 10. Tissue typing HLA antigens for transplantation ,. 11. Cytomegalovirus, Epstein-Barr virus, varicella zoster virus tested before transplantation , bcz immunosuppression would 9 risk of infections Urinalysis and quantification of proteinuria: Haematuria and proteinuria may indicate glomerular disease and need for biopsy. Proteinuria indicates risk of progressive CKD requiring preventive ACE inhibitor or ARB therapy Albumin: Low albumin: consider malnutrition, inflammation, nephrotic syndrome  Retarding the progression of CRF ØOnce the plasma creatinine exceeds about 300 μmol/l (3.4 mg/dl), there is usually progressive deterioration in renal function, irrespective of aetiology. The rate of deterioration is very variable between patients but is relatively constant for an individual patient.  Fits,” also known as seizures, are sudden, uncontrolled electrical disturbances in the brain systems uremic encephalopathy all the are affected → { tiny, yellow-white urea crystals deposit on the skin, resulting in a frosted a appearance as sweat evaporates. any → colour → cause & complication (activation of RAAS ) → uremic syndrome ✓ ↑ urea causes platelet ← dysfunction → anemia or pulmonary edema many mechanisms { 1. ← uremic myopathy Bethel osteo dystrophy uremic neuropathy either due to toxic effects of fluid retention ( Possibly hypoalbumimemia wren or underlying also ) cause CEJ DM) Signs and symptoms of chronic renal failure  Yellow complexion ( Earthy colour] Jugular venous pressure Pallor Anemia raised in fluid overload or pericardial tamponade Dual-lumen central venous catheter for dialysis access (right or left)* Pericardial friction rub ( Pericarditis) Pulsus paradoxus in pericardial tamponade Arteriovenous fistulae for dialysis access* Transplanted kidney (right or left) Tenckhoff catheter for peritoneal with overlying scar* dialysis (right or left)* ‘Brown line’ pigmentation of nails krussmawl respiration Increased respiratory Excoriation of pruritus rate and depth in metabolic acidosis → this effort is also called air hunger. respiratory Compensation of Bruising easily. renal induced acidosis Peripheral neuropathy Absent reflexes Reduced sensation Paraesthesia ‘Restless legs’ Fig. 15.22 Physical signs in advanced chronic kidney disease. (*Features of renal replacement therapy)  General Considerations Ø Blood pressure control: maximum target 130/80 mmHg, reduced to 125/75 mmHg in diabetes mellitus, and anyone with an elevated PCR or ACR protein : creatinine Ø Use of ACE inhibitors or ARBs in those with Albumin Ratio : creatinine proteinuria Having proteinuria is a risk factor for progressive CKD, and ACEi / ARBs 2 reduces proteinuria in general Ø Lipid management Caggressive metabolic control ) Ø Lifestyle advice: smoking, exercise, diet and weight e.g. 'Restriction of dietary protein intake delays the progression of chronic renal failure.  Complications and treatment Fluid, Electrolyte and Acid-Base Disorders 1. Sodium and Water Homeostasis: Hyponatremia is not commonly seen in CKD patients but, when present, can respond to water restriction. Thiazide diuretics have limited utility in stages 3–5 CKD, such that administration of loop diuretics, including furosemide, bumetanide, or torsemide, may also be needed. The combination of loop diuretics with metolazone, can help effect renal salt excretion. 1. diuretic Thiazid like  Fluid, Electrolyte and Acid-Base Disorders 2. Potassium Homeostasis: hyperkalemia may be precipitated in certain settings. These include increased dietary potassium intake, protein catabolism, hemolysis, hemorrhage, transfusion of stored red blood cells, and metabolic acidosis, (ACE) (ARBs), and spironolactone and other potassium- sparing. & NSAIDs +1-1/1 6-9 is art level week indication for dialysis. 3-4 times per persistent urea > too " d " be W hours of dialysis - regarded as indication. at least resistant K+> 5.2 hyperkalemia K Plus risk factors ' > s s - or are required Per week. for arrhythmia  Flow Scheme Hemodialysis thrombosis ttepcrrin to prevent , Blood Pump y like heart Dialyzer Anti-Coagulation artificial kidney Blood to the Patient vein like a Fresh Dialysate Used Dialysate Blood from the Patient like an artery  Haemofiltration ØThis may be either intermittent, with 15-30 litres of plasma ultrafiltrate exchanged for replacement fluid over 3-5 hours (high- volume haemofiltration), or continuous with 1-2 litres/hour of filtrate replaced (equivalent to a GFR of 15-30 ml/min); higher rates of filtration may be of benefit in patients with sepsis and multi-organ failure.  Peritoneal dialysis In ARF, this technique is rarely used. It is less efficient than haemodialysis, and seldom achieves adequate biochemical control in catabolic patients. It requires an intact peritoneal cavity and is not feasible after recent abdominal surgery  Peritoneal dialysis Ø In peritoneal dialysis, 1.5–3 L of a dextrose-containing solution is infused into the peritoneal cavity and allowed to dwell for a set period of time, usually 2–4 h. The rate of peritoneal solute transport varies from patient to patient and may be altered by the presence of infection (peritonitis), drugs, and physical factors such as position and exercise. Ø Continuous ambulatory peritoneal dialysis (CAPD), continuous cyclic peritoneal dialysis (CCPD), or a combination of both. CAPD used during the day and exchanged three to five times daily. In CCPD, exchanges are performed in an automated fashion, usually at night. While the patient is sleeping  Peritoneal dialysis Haemodialysis Less efficient Efficient Four exchanges per day usually required, each 4 hours three times per week usually adequate taking 30-60 minutes (continuous ambulatory peritoneal dialysis) or 8-10 hours each night (automated peritoneal dialysis) A few hours between treatments 2-3 days between treatments Performed at home Requires visits to hospital (although home treatment possible for some patients) Requires an intact peritoneal cavity without major Requires adequate venous circulation for vascular scarring from previous surgery access Diet and fluid less restricted Careful compliance with diet and fluid restrictions required between treatments Slow continuous fluid removal, usually Fluid removal compressed into treatment periods; asymptomatic may cause symptoms and haemodynamic instability Peritonitis and catheter-related infections may Infections related to vascular access may occur occur Patients can take full responsibility for their Patients are to some extent dependent on others treatment for children & elderly , bet this less likely to blood volume in these ayes ) cause hypotension Chow  Complications during Hemodialysis 1. Hypotension:. Numerous factors appear to increase the risk of hypotension, including excessive ultrafiltration with inadequate compensatory vascular filling, impaired vasoactive or autonomic responses, osmolar shifts, overzealous use of antihypertensive agents, and reduced cardiac reserve. 2. Muscle cramps : common complication of the procedure use of low-sodium–containing dialysate. 3. Anaphylactoid reactions to the dialyzer. 4. Headache. 5. Haemorrhage Anticoagulation & venous needle disconnection - 6. Cardiac arrhythmias CK & acid base shift ) -1 -  Complications during Peritoneal Dialysis 1. Peritonitis. infection 2. Hypoproteinemia. peritoneum permeable is to Proteins 3. Hyperglycemia and weight gain. 4. 4. Complications of insulin resistance, including hypertriglyceridemia. ' ' and n here the dialyserte contains high glucose it may lead to uncontrolled DM  Renal Transplantation Ø Renal transplantation offers the best chance of long-term survival in patients with end-stage renal disease. It can ESRD restore normal kidney function and correct all the with - metabolic abnormalities of CRF. All patients should be considered for transplantation unless there are active contraindications. Ø Kidney grafts may be taken from a cadaver or from a living donor. ↳ not allowed here every unfortunately ) Ø ABO (blood group) compatibility between donor and recipient is essential, and the degree of matching for major histocompatability (MHC) antigens-particularly HLA-DR- influences the incidence of rejection. Renal Transplantation  CONTRAINDICATIONS TO RENAL TRANSPLANTATION Ø Absolute: high rate of the transplanted recurrence need to 1. Active Malignancy → very and attacking kidney so , no be transplanted 2. Active vasculitis or anti-GBM disease, with positive serology-at %t least 1 year of remission is recommended prior to transplantation 3. Severe IHD 4. Severe occlusive aorto-iliac vascular disease. bcz the renal external artery is anastomosed to Ø Relative artery iliac 1. Age: not routinely offered to very young children (< 1 year) or older people (> 75 years) 2. High risk of disease recurrence in the transplant kidney. 3. Disease of the lower urinary tract-in patients with impaired bladder ok function, an ileal conduit may be considered 4. Significant comorbidity.  Renal Transplantation Ø All transplant patients require regular life-long clinic follow-up to monitor renal function and immunosuppression. Ø Immunosuppressive therapy is required to prevent rejection. Different therapeutic regimens are used; a I commonly used one is triple therapy consisting of prednisolone, plus ciclosporin or tacrolimus and azathioprine. Newer immunosuppressive drugs such as mycophenolate mofetil and rapamycin are increasing in use. ccycwsporineortacioi.im# Glucocorticoid cpvednisolone ) £ calcineurin inhibitor drugs 3 , for life ! Anti proliferative ( mycofenolerte mofetil , Azathioprine or sirolimus ) Thanks for Listening