Kidney Disease

Dr. Abdul Halim bin Abdul Gafor Associate Professor and Consultant Nephrologist Nephrology Unit, Medical Department Universiti Kebangsaan Malaysia Medical Centre

Contents
Page 3 4-5 6-12 13-22 23 24-25 26

1. 2. 3. 4. 5. 6. 7.

Kidney functions Renal syndromes Acute kidney injury Chronic kidney disease Acute on chronic renal failure End stage renal disease Summary

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Normal Renal Functions

1. 2. 3. 4. 5. Excretion of both endogenously produced and exogenously ingested waste product, Excretion of excess acid ( H+) or base ( HCO3-) - regulate bodys pH Control of body fluid/volume Control and metabolism of electrolytes eg Na+, K+, P04, Mg, As an endocrine organ secretion of a. Renin b. Erythropoietin c. Activated vitamin D d. Prostaglandin

As kidney function deteriorates, clinical problems related to the above functions become more apparent.
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Renal Syndromes Helpful for organizing diagnostic plan

Acute kidney injury (AKI): Definition: sudden decline of kidney functions Causes: pre-renal, renal, and post-renal causes Importance: reversible; high mortality Chronic kidney disease (CKD): Definition: slow decline of renal functions; Causes: diabetes mellitus, hypertension, glomerulonephritis Importance: irreversible ; high cardiovascular events Acute on Chronic renal failure End-stage renal disease (ESRD): requires dialysis or renal transplant to maintain life.

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Acute RF
90-120 ml/min

Renal Function (GFR)

Acute on Chronic

CKD

ESRD

Time
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Acute Kidney Injury (AKI)

Causes
Causes can be divided to Pre-renal renal failure
Due to reduced blood supply/volume to kidneys eg bleeding, hypotension, septic shock

Intrinsic renal failure

Due to an acute glomerulonephritis, interstitial nephritis or toxin

Post renal failure

Due to obstruction to urine flow eg renal calculi and benign prostate hyperplasia

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Clinical features of AKI

Symptoms:
Uraemic symptoms: nausea, vomiting, pruritus, unable to sleep,lethargy,confusion Fluid overload symptoms: ankle swelling, difficulty in breathing, orthopnoea, chest pain etc

Signs:
Tachypnoeic Disorientated Body swelling (oedema) Raised jugular venous pressure Cardiomegaly Lungs-crepitation, pleural effusion
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Imaging Studies
Plain film of abdomen good screen for calcium containing stones Ultrasound Kidney ureter bladder (KUB) Screen for size and obstruction All patients with AKI of unknown cause should have one CT scan MRI/MRA (gold standard for Renal Vein Thrombosis) Renal arteriography/venography Radionuclide scans (eg DTPA/DMSA) Voiding cystourethrogram Retrograde pyelography Intravenous pyelogram
CT scan: Computed tomogram scan MRI: Magnetic Resonance Imaging MRA: Magnetic Resonance Angiogram 9
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Role of Kidney Biopsy in AKI

Most patients with AKI dont need one Indication usually in
acute glomerulonephritis, intrinsic cause other than ischemic or toxic acute tubular necrosis (ATN) cases where the diagnosis and treatment are uncertain.

We have to rule out pre-renal and post-renal causes first In renal transplantation, renal biopsy more commonly done for evaluation of acute transplant dysfunction

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Treatment of AKI
Treat the underlying cause Hydration with iv fluid and N-acethycysteine (NAC) in the prevention of contrast induced nephropathy (CIN) in high risk patients. Saline, urinary alkalinization, and diuresis are helpful in myoglobinuria or hemoglobinuria Blood purification therapy
Eg haemodialysis and peritoneal dialysis

Indications for blood purification therapy include

Fluid overload Hyperkalemia Metabolic acidosis Uremic symptoms or symptoms

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AKI
90-120 ml/min
Renal Function (GFR)

Degree of recovery depends on the insult

Although renal functions will recover, the degree of recovery depends on the intensity of the cause/insult
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Chronic Kidney disease (CKD)

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Definition of CKD
Kidney damage at least for 3/12 with or without decreased glomerular filtration rate (GFR).
Structural damage : based on pathological Functional damage: based on markers (blood or urine)

GFR < 60ml/min at least 3/12 with or without kidney damage

Diagnosis of CKD is often delayed due to insidious signs and symptoms.

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Stages of CKD

National Kidney Foundation K/DOQI: Am J Kidney Disease. 2002; 39(2):S1-S200

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Early detection
Renal disease is often progressive once GFR < 25% of normal. Early detection is important to prevent further injury and progression of CKD.

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Important causes
Diabetes Mellitus (DM) Hypertension (HPT) Obstructive uropathy Drugs especially NSAIDs and traditional medications Autoimmune disease eg Systemic Lupus Erythematosus

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Progression factors
1. 2. 3. 4. 5. 6. 7. 8. 9. These are factors that cause progressive decline in renal functions Persistent activity of underlying disease Persistent proteinuria Elevated blood pressure Elevated blood glucose in diabetic patients High protein/phosphate diet Dyslipidaemia Anaemia Cardiovascular disease Smoking
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Reversible causes
1. 2. 3. 4.

These are potential reversible causes for worsening renal functions Effective circulatory volume depletion,thus cause persistent hypotension Uncontrolled hypertension Obstructive uropathy Toxic causes:
Contrast induced nephropathy , Nephrotoxic drugs

5.

Autoimmune diseases and vasculitis. eg systemic lupus erythematosus(SLE)

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Clinical features
1.

Signs and symptoms that due to excretory failure of the kidneys

Uraemic: nausea, vomiting, pruritus, unable to sleep, lethargy, confusion etc Fluid overload: ankle oedema, difficulty in breathing, orthopnoea,chest pain etc

2.

Signs and symptoms that due to the failure of kidneys endocrine functions.
Anaemia Renal bone disease

3.

Signs and symptoms that due to increase risk of cardiovascular disease.

Chest pain Reduced effort tolerance
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Diagnosis
Renal functions
Serum creatinine Estimated GFR

Ultrasound KUB CT scan Investigations targeting the underlying cause

DM: FBS, HbA1c Hypertension: secondary causes if indicated SLE: LAI

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Treatment
Depends on the underlying cause. Correct the progression factors and reversible causes. DM
Glucose control, HbAIC < 7% BP < 125/75mmHg Low protein diet ACE-I/ARB irrespective of blood pressure Control dyslipidaemia Healthy life style

Hypertension
Target BP BP < 130/85mmHg in all CKD BP< 125/75 mmHg in proteinuric CKD Anti-HPT choice ACE-I/ARB Non-dihydropyridine CCB

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Acute and Chronic renal failure

Patients with CKD are at increase risk of developing acute kidney injury (AKI) Recurrent AKIs in CKD patients can expedite the progression of CKD Thus it is important to prevent AKI episode in CKD patients

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End stage renal failure

Definition : CKD stage 5 The patient has to be on renal replacement therapy (RRT) RRT is the therapy that we initiate once the kidneys functions are too low to support life. There are 3 types of renal replacement therapy Haemodialysis Peritoneal dialysis Renal transplantation

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Preparing patient for RRT

Patients should be referred early to nephrologist Should received comprehensive care
Control of the risk factors Hb and Ca/PO4 control Permanent access creation eg arteriovenous fistula RRT options

Patient starting dialysis early has

less malnutrition, less morbidity less mortality.

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Summary
AKI is a potential reversible condition, thus early and correct management is very important. Patients with CKD have excretory failure, endocrine failure and very high risk of developing cardiovascular disease. Management are geared to retard the progression of CKD. CKD patients also are more prone to develop AKI ( acute on chronic renal failure) Renal replacement therapy must be initiate once patient reached end stage renal disease ( stage 5 CKD)
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