Chronic kidney disease

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chronic renal failure


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Chronic Kidney disease:

Chronic Kidney disease What is the definition? Kidney damage > 3 months of duration (evidenced by hitopathology or by markers), or GFR < 60 ml/min for > 3 months.


Causes? 40 Diabetes (type 1 ~ 15%, type 2 ~ 25%) HTN (30%) Glomerulopathies (10%) Others: TIN, heriditary , congenital, tumors, idiopathic, obstruction…

What are the stages? :

What are the stages? Stage 1 – normal GFR > Stage 5 – GFR < 15. Or 1-diminished renal reserve, asymptomatic. (GFR 120 > 50), (Cr 1.5-2 mg\dl) 2- Renal insufficiency, symptoms begin. (GFR ~ 10), (Cr ~ 2-5) 3- Renal failure, requires medical management. ( GFR ~ 5), (Cr >8) 4- Uremia, all systems affected. (GFR <5), (Cr >12)


Pathophysiology Toxin accumulation. Neurosymptoms , insulin resistance, vit.D deficiency,… PTH overactivity . Cardiomyopathy, bone disease, calciphylaxis ,… Fluid and electrolyte imbalances. HTN, Arrhythmias, Acidosis.


Symptoms Initially asymptomatic. Non specific symptoms. Nausea, vomiting, malaise, pruritus, diarrhea, seizures, Insulin resistance > impaired glucose tolerance, hypertriglyceridemia. Complications. Bone pain, anemia, sensory/motor neuropathy, coagulopathy. Mortality: #1 from IHD #2 from infections. Vascular access complications.

Bone disease:

Bone disease Renal Osteodystrophy Adynamic bone disease Osteomalacia Osteoporosis.

Renal Osteodystrophy:

Renal Osteodystrophy In stage 3 disease, Related to accumulation of phosphorus ► Stimulates iPTH Chelates Calcium ► ↓ Calcium ► ↑ PTH ↓ Vit . D at this GFR also contributes. Ca-Po4 complex cause vascular calcification. iPTH ↑↑ ► bone turnover increases too much, calcium rises, bone symptoms appear.

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Osteitis fibrosa cystica Replacement with fibrous tissue (brown tumors) Pain, tenderness, fractures, deformity. iPTH ↑ Po4 ↑ Ca ↓ Vit.D ↓ Treatment: Phsphate binders Vit.D Calcium Calcimimetics . ( Cinacalcet )

Adynamic bone disease::

Adynamic bone disease: More common type of bone disorder in patients on dialysis. A decreased Bone turnover from overtreatment of Renal Osteodystrophy . Causes : Ca dependent phosphate binders > ►> Hypercalcemia Symptomatic, fractures, calciphylaxis ( vascular calcification, thrombosis and skin  necrosis). iPTH ↓ Po4 ↑ or normal Ca ↑ or normal Vit.D ↓

How to treat bone disease?:

How to treat bone disease? Follow iPTH Patients not on dialysis: Start with Ca based phosphate binders with iPTH high and Ca 8.5-9.5 Switch to non Ca based binders when Ca > 9.5 or iPTH <100 pg /dl. Correct Vit.D deficiency.

Anemia: :

Anemia: Normochromic normocytis Responds to EPO treatment ( SubC 3 times/week) HTN in 20% Make sure to correct any Iron/B12/ folate deficiency. Start at HCT 30% Target: HCT ~ 35%, 11-12 gm /dl, or less?


Neuropathy: Snesory is reversible with dialysis. Motor neuropathy reversible only with kidney implantation. Platelet dysfunction: Reversible with dialysis. Vessel calcification: Reversible only with kidney implant.

Uremic patient: what will you find? :

Uremic patient: what will you find? General appearance? Mental Respiration Complexion Hydration


Hands? Flapping tremor Pallor Tarry’s nails in 1/3 patients. AV fistula Scratch marks Bruises Uremic frost. Arms?

Face, trunk?:

Face, trunk? Anemia Uremic fetor Pericardial rub Pulmonary edema, pneumonia Kidneys might be enlarged, Or polycystic. Bruit.

Back, Legs?:

Back, Legs? Tender bone, edema, tender kidneys Scratch marks Sensory neuropathy Absent reflexes. Manifestations of DM or HTN.

Next.. Investigations.. I’m sure you know those, right?:

Next.. Investigations.. I’m sure you know those, right?


Investigations… U&E Electrolytes Urine analysis US Biopsy Radionuclide studies


Treatment… Diet Aggressive management of comorbidities Avoidance of nephrotoxins Dialysis Renal translplant .


Diet Protein restricion : <1 gm /kg/day in CKD, <0.8 in dialysis (except….?) K+ restricion : very low GFR, hyperkalemia Phosphorus restriction. Never reduce intake of calcium in hypercalcemic patients.

Aggressive management of comorbidities:

Aggressive management of comorbidities ACE/ARBs DM/HTN control Hyperlipidemia Acidosis/electrolyte imbalance Stop smoking.

Avoidance of nephrotoxins:

Avoidance of nephrotoxins Contrast agents Gadolinium and systemic fibrosis. NSAIDs Aminoglycosides


Dialysis… Any uremic symptoms with GFR <15 ml/min Friction rub Refractory Hyper K+ Volume overload Ph <7.2 Seizures, encephalopathy, coagulopathy Prepare access month prior to need Drug dose alterations before and after dialysis. Peritoneal dialysis.

Renal transplant…:

Renal transplant…

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