Updates in management of CKD new updates and practical guidlines
- 1. Management of chronic kidney disease(CKD ) Dr Saja Mahmood Mohammed Senior Specialist Nephrologist Department of Medicine /Renalunit SQUH 2024
- 2. Outline • Function of the kidney • Definition Of CKD • Classification of CKD • Burden of the CKD • Management of CKD • Renal replacement therapy • Indication of dialysis
- 3. Introduction • Chronic kidney disease is highly prevalent (10-13% of the population). • Irreversible, progressive, and associated with higher cardiovascular risk. • Patients remain asymptomatic most of the time. • The CKD complications appear only in more advanced stages. • CKD of unknown etiology (CKDu), which compromises our understanding of the burden, severity, and natural history of these conditions.
- 4. Function of the kidney • The kidneys remove waste and excess fluid from the blood through structures called nephrons. • Each nephron contains a filter called a glomerulus that has a network of tiny blood vessels called capillaries. • When blood flows into a glomerulus, small molecules, water, essential minerals, nutrients, and wastes will pass through the capillary walls. Large molecules, such as proteins and red blood cells, do not. • The filtered solution then passes into another part of the nephron called the tubule. • The water, nutrients, and minerals that the body needs are transferred back to the bloodstream. • The excess water and waste become urine that flows to the bladder.
- 5. Oman: burden of CKD • According to the latest WHO data published in 2020 Kidney Disease Deaths in Oman reached 312 or 2.10% of total deaths. • The age-adjusted Death Rate is 18.16 per 100,000 population ranks Oman 113 in the world. • The Ministry of Health is facing a challenge with increased noncommunicable diseases including CKD. • The annual incidence of ESKD is estimated to be approximately 120 per million in Oman.
- 10. Progression risk
- 11. Screening for CKD in adults • History • Diabetes, Hypertension, cardiovascular disease (CVD) • Human immunodeficiency virus (HIV) or hepatitis C virus infection. • Malignancy • Autoimmune diseases • Nephrolithiasis, or recurrent urinary tract infections. • Drug history • Family history of renal disease.
- 12. Etiology of CKD • Diabetes • Hypertension • Chronic glomerulonephritis • Chronic pyelonephritis • Chronic use of anti-inflammatory medication • Autoimmune diseases. • polycystic kidney disease • Alport disease • Congenital malformations • Prolonged acute renal disease.
- 13. Referral to the Nephrologist • GFR <30 mL/min/1.73 m2. • A decrease greater than or equal to 25% in the GFR. • Progression of the CKD with a sustained decrease in the GRF of more than 5 ml/min per year. • A consistent finding of significant albuminuria. • Persistent unexplained hematuria. • Secondary hyperparathyroidism, persistent metabolic acidosis, and anemia due to an erythropoietin deficiency.
- 14. Referral to the Nephrologist • Hypertension resistant to treatment with four or more antihypertensive agents. • Persistent abnormalities of serum potassium. • Recurrent or extensive nephrolithiasis. • Hereditary kidney disease or unknown cause of CKD.
- 15. Potentially reversible causes of worsening renal function • Volume depletion: • Obstruction • Uncontrolled hypertension • Toxic causes:
- 17. The strategies used to reduce the progression of CKD: • use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with proteinuria above 500 mg/24 hours. • Target blood pressure below 130×80 mmHg. • Glycated hemoglobin lower than 7% for diabetic patients. • Protein restriction indicated and managed by a nutritionist; • Correction of metabolic acidosis. • Smoking cessation, Avoid NSAID .
- 18. Treatment options : • Conservative medical therapy aiming to slow the progression OF CKD • Renal replacement therapy (RRT) • Hemodialysis(HD) • Peritoneal dialysis(PD) • kidney transplantation.
- 19. Objective of medical treatment of CKD • Slow down the progression of kidney dysfunction • Treat complications • Anemia • Bone diseases • Cardiovascular diseases • Vaccination for hepatitis B, and preparation for kidney replacement therapy. • Nutritional support • Psychosocial support
- 21. Renal replacement therapy • Hemodialysis (MHD ) • Need for vascular access AVF , AVG , tunnel permcath • Peritoneal access and social support • Transplantation • Donor • Long-term use of immunosuppression
- 26. Principle of hemodialysis and hemofiltration
- 27. Case 1: A 68-year-old male presents with generalized body ache, lethargy with anorexia, and repeated vomiting of food content for 2 weeks also noted worsening leg swelling and SOB for two days with decreased UOP. Background of longstanding DM, with poor glycemic control, HB AIC > 8. High BP 160/100 Urine albumin/creatinine ratio 70mg /mmol.(normal<2.5 male ,<3.5.female) Serum creatinine 680umol/l , GFR 12ml/min/1.73m2 Serum potassium 5.8 mmol/l
- 28. Further work up • ABG, FBC, Iron profile, bone profile, PTH • Abd US Indication for RRT
- 29. Case2: • A 40-year-old Omani male • Persistent microscopical hematuria since 2006, presumed he is stone former never seen by a nephrologist • In Nov 2022, he developed headaches then he was found to have severe HTN 170/110 • UDS RBC +++, Prots ++, urine/c ratio 170-180 • Elevated serum creatinine 120-177 Umol/L ,started on oral medication • No hearing loss or eye problems • Negative FH of CKD
- 30. Further work up • Abdominal US • Normal size kidneys with increased cortical echogenicity, no obstruction • Autoimmune serology all negative • Normal c3,c4 • Chronic viral screens all were negative • MM workup was negative
- 32. •Thank you