Definition
- What is CKD?
- What is chronic renal failure (CRF)? Hl
- What is ESRD? A
- What is acute renal failure? A
- What is renal osteodystrophy? A
- What are the components of renal osteodystrophy? Hl
- What do you mean by renal replacement therapy (RRT)? Hl
- What are the types of renal replacement therapy? H108
- What is dialysis? Hl
- What are the types of dialysis? hl
Epidemiology
- Q
Etiology and Pathophysiology
- What are the causes of acute renal failure? A
- What are the causes of CKD? A / What are the causes of chronic kidney disease/chronic renal failure? Hl
- What is the most common cause of CRF in developing countries? Hl
- What are the common causes of CKD worldwide? Hl
- What are the stages of CKD? A, h96
- What are the causes of anemia in CKD? A, hl
- What are the mechanisms of renal osteodystrophy? A
- What are the reversible factors in CKD? A
- What are the common renal diseases causing hypertension? H100
- What are the inherited causes of chronic kidney disease? H111
Clinical manifestations
- What is difference between CKD and CRF? Hl
- What are the clinical manifestations of CKD? A
- How does a patient of CKD usually present? H98
- What are the stigmata of chronic kidney disease? H99
- What are the different features due to involvement of different systems of the body? A
Examinations
- Q
Investigations
- What investigations do you suggest in CKD? A, hl
- What may be the findings of renal ultrasonography in chronic renal failure? Hl
- What are the causes of CRF with normal or enlarged kidney size? hl
Diagnosis
- Why do you consider this diagnosis? Hl
- Why is this not CCF? Hl
- Why is this not acute renal failure? Hl
- What are the features favoring chronic over acute renal failure? hl
Treatment
- How to treat CKD? A
- How will you treat chronic renal failure? hl
- How will you treat anemia in chronic renal failure? Hl
- What are the treatment modalities of hyperkalemia in case of CRF? Hl
- What are the drugs you should avoid in this patient? Hl
- Which antihypertensive is the drug of choice in renal disease and why? hl
- How do ACE inhibitor and ARBs delay progression of CKD? Hl
- When should ACE inhibitor or ARBs not be given in CKD? Hl
- Should ACE inhibitor or ARBs be stopped if serum creatinine rise? hl
- How to treat renal osteodystrophy? A
- What are the indications of urgent dialysis? A
- What are the indications of renal replacement therapy? A, hl
- What are the contraindications of renal transplantation? a
- What drugs are used to prevent rejection? a
Complications
- What are the complications after renal transplantation? A
- What is acute rejection? A
- What is chronic rejection? a
Related topics
- Hemodialysis
- What are the problems with hemodialysis? hl
- Peritoneal dialysis
- What are the problems with continuous ambulatory peritoneal dialysis? hl
- What are the complications of long-term dialysis? A
Solve
Definition
What is CKD/CRF?
Chronic kidney disease (CKD), previously termed chronic renal failure, refers to an irreversible deterioration in renal function which usually develops over a period of years.
* Davidson’s Principles and practice of medicine, 22nd edition
Chronic kidney disease is defined as structural or functional abnormalities of kidney present for >3 months, which is usually irreversible.
* Lecture, Assoc. Prof. Dr Swapan Kumar Mondal
What is ESRD?
End stage renal disease or failure (ESRD) is a stage when renal replacement therapy is compulsory either dialysis or renal transplantation, without which death is likely.
*Long Cases in Clinical Medicine, ABM Abdullah
What is renal osteodystrophy? What are its the componet?
This is a group of metabolic bone disease secondary to chronic renal failure. It comprises the following:
- Osteomalacia (or ricket, called renal ricket)
- Osteoporosis
- Osteosclerosis (in vertebral body, giving rise to Rugger jersey spine)
- Osteitis fibrosa cystica (Hyperparathyroid bone disease)
Note: Remember the following:
There may be adynamic bone disease in which bone formation and resorption are both depressed. Cause is unknown, may cause spontaneous fracture. There may be hypercalcemia, normal alkaline phosphatase, PTH is low, dual X-ray absorptiometry shows osteopenia. No proven treatment.
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker
What do you mean by renal replacement therapy (RRT)?
Renal replacement therapy means the facility to replace functions of the kidney.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the types of renal replacement therapy?
Types of renal replacement therapy are:
- Hemodialysis— Removal of toxic elements from the blood, which is filtered through a membrane while circulated outside of the body through a machine.
- Hemofiltration.
- Peritoneal dialysis—Filtration through the lining membrane of the abdominal cavity; fluid is instilled into the peritoneal cavity, then drained.
- Renal transplantation.
Figure: Options for renal replacement therapy. A In haemodialysis, there is diffusion of solutes from blood to dialysate across a semipermeable membrane down a concentration gradient. B In haemofiltration, both water and solutes are filtered across a porous semipermeable membrane by a pressure gradient. Replacement fluid is added to the filtered blood before it is returned to the patient. C In peritoneal dialysis (PD), fluid is introduced into the abdominal cavity using a catheter. Solutes diffuse from blood across the peritoneal membrane to PD fluid down a concentration gradient and water diffuses through osmosis (see text for details). D In transplantation, the blood supply of the transplanted kidney is anastomosed to the internal iliac vessels and the ureter to the bladder. The transplanted kidney replaces all functions of the failed kidney.
*Pre-exam preparation for medicine, HN Sarker; Figure: Davidson’s Principles and practice of medicine, 22nd edition
What is dialysis?
Dialysis is a process for removing waste materials and excess water from the blood, and is used primarily as an artificial replacement for lost kidney function in people with renal failure.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the types of dialysis?
- Peritoneal dialysis
- Hemodialysis
Etiology and Pathophysiology
What are the causes of CKD/CRF?
As follows:
- Glomerular diseases (30 to 40%), e.g. IgA nephropathy (most common**), MCGN
- Diabetes mellitus (20 to 40%)
- Hypertension (5 to 20%)
- Obstructive uropathy (reflux nephropathy)
- Chronic pyelonephritis (infective cause)
- Tubulointerstitial diseases (5 to 10%) (Often drug induced ** – analgesic nephropathy)
- Systemic inflammatory diseases (5 to 10%), e.g. SLE, vasculitis
- Renal artery stenosis (5%)
- Congenital and inherited (5%), e.g. polycystic kidney disease, Alport’s syndrome
- Unknown (5 to 20%).
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker; Lecture, Assoc. Prof. Dr Swapan Kumar Mondal; ** Davidson’s Principles and practice of medicine, 22nd edition;
What is the most common cause of CRF in developing countries?
Chronic glomerulonephritis is the most common cause of CRF in developing countries.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the common causes of CKD worldwide?
Common causes of CKD worldwide are:
– Diabetes mellitus
– Hypertension
– Chronic glomerulonephritis.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the inherited causes of chronic kidney disease?
Inherited causes of chronic kidney disease are:
– Polycystic kidney disease
– Alport’s syndrome.
*Pre-exam preparation for medicine, HN Sarker
What are the reversible factors in CKD?
As follows:
- Hypertension
- Reduced renal perfusion, such as—renal artery stenosis, hypotension due to drug treatment, sodium and water depletion, poor cardiac function
- Urinary tract infection
- Urinary tract obstruction
- Other systemic infections that causes increased catabolism and urea production
- Nephrotoxic drugs.
*Long Cases in Clinical Medicine, ABM Abdullah
What are the stages of CKD?
CKD stage-1 | GFR ≥9o ml/min/1.73 m2 but other evidence of kidney disease | Kidney damage with normal or ↑ GFR |
CKD stage-2 | GFR 60-89 ml/min/1.73 m2, with other evidence of kidney damage | Kidney damage with mild ↓ GFR |
CKD stage-3 | GFR 30-59 ml/min/1.73 m2, with or without other evidence of kidney disease | Moderate ↓ GFR
A and B (A: 45-59, B: 30-44)** |
CKD stage-4 | GFR 15-29 ml/min/1.73 m2 | Severe ↓ GFR |
CKD stage-5 | GFR 2 or patient is on dialysis | Kidney failure |
*Lecture, Assoc. Prof. Dr Swapan Kumar Mondal; Pre-exam preparation for medicine, HN Sarker; **Long Cases in Clinical Medicine, ABM Abdullah.
What are the causes of anemia in CKD?
Anemia is common in CKD, correlates with the severity of renal failure. It is usually normocytic and normochromic. The mechanisms are:
- Relative deficiency of erythropoietin*** (most significant)
- Diminished erythropoiesis due to toxic effects of uremia on bone marrow precursor cells. (Also by PTH, ACE inhibitor*)
- Reduced dietary intake and absorption and utilization of iron.** (Reduced dietary intake and absorption of hematinics – iron, vitamin B12, folic acid.**)
- Reduced red cell survival (Increased red cell destruction may also be during hemodialysis due to mechanical, oxidant and thermal damage*)
- Increased blood loss due to capillary fragility, poor platelet function**, occult gastrointestinal bleeding and blood loss during hemodialysis*
- Erythropoietin alpha therapy may cause anemia (by pure red cell aplasia).*
Note Remember the following:
– Anemia is less severe or absent in polycystic kidney disease, as erythropoietin is relatively more in this case.
– In CKD, the patient can tolerate mild to moderate anemia, because there is more release of oxygen from hemoglobin. The mechanisms are—in CKD patient, there is acidosis and high 2, 3 DPG level in RBC, which shifts the oxygen dissociation curve to the right and more oxygen is released from hemoglobin. So, the patient doesn’t require blood transfusion in mild to moderate anemia. Target hemoglobin is 11 to 12.5 g/dL.
– Anemia becomes obvious in stage B CKD.
– ***Relative deficiency of erythropoietin production: Until recently, it was believed that this was due to progressive destruction of erythropoietin producing cells in the kidney, leading to a reduced cellular capacity for erythropoietin production. More recent work, involving pharmacological inhibition of prolyl hydroxylase, suggests that there may be a defect of the oxygen-sensing system, rendering functioning cells less sensitive to hypoxia.
*Long Cases in Clinical Medicine, ABM Abdullah; ** Davidson’s Principles and Practice of Medicine, 22nd edition; Short and Long Cases in Clinical Medicine, HN Sarker; *** Oxford Textbook of Clinical Nephrology, 4th edition
What are the mechanisms of renal osteodystrophy?
As follows:
- Osteomalacia is secondary to deficiency of 1, 25-dihydroxycholecalciferol as kidney is unable to convert 25 hydroxycholecalciferol to 1,25 dihydroxycholecalciferol, due to deficiency of 1 α-hydroxylase enzyme
- Osteoporosis, though its mechanism is unknown, may be due to secondary hyperparathyroidism and hypocalcemia, also probably due to malnutrition
- Osteosclerosis—due to hyperparathyroidism which causes increased bone density, particularly seen in the spine in which there is bands of sclerosis in the margin and porotic bone in between, giving rise to Rugger jersey spine
- Osteitis fibrosa cystica—due to secondary hyperparathyroidism.
Figure: Rugger jersey spine.
*Long Cases in Clinical Medicine, ABM Abdullah
What are the common renal diseases causing hypertension?
The common renal diseases causing hypertension are:
– Glomerulonephritis
– Renovascular disease
– Interstitial diseases
– Renal artery stenosis
– Polycystic kidney disease.
*Pre-exam preparation for medicine, HN Sarker
Clinical manifestations
What is difference between CKD and CRF?
CKD refers to all stages ranging from kidney damage with normal or raised GFR to kidney failure but CRF means at least some impairment of renal function.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the clinical manifestations of CKD?
As follows:
- May be asymptomatic, until GFR falls below 30 mL/min/1.73 m2 of body surface area. Detected on routine blood biochemistry. High urea and creatinine may be found on routine investigation, sometimes there may be hypertension, anemia, proteinuria on routine urine examination.
- General features—early features may be (when GFR falls bellow 15-20 ml/min/1.73 m2 symptoms and signs are common) –
- nocturia (due to loss of concentration ability), polyuria,
- anorexia, nausea, vomiting, diarrhea,
- weakness, malaise, insomnia,
- breathlessness on exertion,
- paresthesia, bone pain, edema,
- amenorrhea in woman, sexual dysfunction in man.
- In ESRF—general features are more severe, and CNS symptoms may be more. Features like –
- hiccup, pruritus,
- deep respiration (Kussmaul’s respiration), muscular twitching,
- fit, drowsiness, even coma may occur.
- Other features may be present, which may occur due to involvement of different systems of the body.
*Long Cases in Clinical Medicine, ABM Abdullah; Pre-exam preparation for medicine, HN Sarker; Lecture, Assoc. Prof. Dr Swapan Kumar Mondal
What are the stigmata of chronic kidney disease?
Stigmata of chronic kidney disease are:
- Pallor
- Pruritus
- Pigmentation
- Persistent hypertension
- Progressive back pain (renal osteodystrophy)
- Proximal myopathy
- Peripheral neuropathy.
*Pre-exam preparation for medicine, HN Sarker
What are the different features due to involvement of different systems of the body?
CKD can involve any system of the body, symptoms and signs may develop according to the involvement:
- Bone diseases (renal osteodystrophy):
- Osteomalacia (or ricket called renal ricket)
- Osteoporosis
- Osteosclerosis (in vertebral body, giving rise to Rugger Jersey spine)
- Osteitis fibrosa cystica.
- Skin disease:
- Pruritus—due to retention of nitrogenous waste products, hypercalcemia, hyperphosphatemia, hyperparathyroidism and iron deficiency. Patient on dialysis, inadequate dialysis may have pruritus due to unknown mechanism
- Dry skin
- Eczematous lesions, particularly near arteriovenous fistula
- Ecchymosis in advanced disease due to increased bleeding tendency
- Porphyria cutanea tarda (PCT) due to decreased hepatic uroporphyrinogen decarboxylase and decreased clearance of porphyrins in urine or by dialysis
- Pseudoporphyria (features like PCT but without enzyme deficiency).
- Gastrointestinal—anorexia, nausea, vomiting. Also there may be decreased gastric emptying, increased risk of reflux esophagitis, peptic ulceration, acute pancreatitis and constipation.
- Metabolic abnormalities:
- Hyponatremia, hyperkalemia or sometimes hypokalemia
- Metabolic acidosis (due to increased tissue catabolism and retention of organic acids)
- Hyperuricemia and gout
- Hypocalcemia, hyperphosphatemia
- Lipid abnormalities (hypercholesterolemia, hypertriglyceridemia).
- Endocrine abnormalities:
- Secondary hyperparathyroidism, may be tertiary
- Prolonged half-life of insulin, due to reduced tubular metabolism of insulin. Also, insulin requirement in a diabetic patient decreases. But in advanced CKD, there may be end organ resistance to insulin, leading to impaired glucose tolerance
- Hyperprolactinemia (presents with galactorrhea in men as well as women, loss of libido and sexual dysfunction in both sexes).
- Others—increased LH, decreased serum testosterone (erectile dysfunction, decreased spermatogenesis), oligomenorrhea or amenorrhea (in female), impaired growth in children, abnormal thyroid hormone levels (hypothyroid feature), partly because of altered protein binding.
- Muscle dysfunction:
- Generalized myopathy (due to the combination of poor nutrition, vitamin D deficiency, electrolyte abnormalities, hyperparathyroidism)
- Muscle cramps
- Restless leg syndrome.
- Nervous system:
- Peripheral nervous system:
- Polyneuropathy—both motor and sensory. Improves or resolve with dialysis
- Median nerve compression in the carpal tunnel due to β 2 microglobulin related amyloidosis
- Restless leg syndrome.
- Central nervous system:
- Clouding of consciousness, convulsion, coma
- Asterixis (flapping tremor)
- Tremor
- Myoclonus
- Dialysis disequlibrium syndrome
- Dialysis dementia
- Psychiatric problems—(anxiety, depression, phobia, psychosis)
- CVD secondary to hypertension.
- Autonomic dysfunction:
- Postural hypotension
- Fixed heart rate
- Urinary retention or incontinence
- Constipation
- Impotence
- Pupillary constriction
- Gustatory sweating
- Anhydrosis.
- Peripheral nervous system:
- Calciphylaxis (calcific uremic arteriolopathy)—rare but life threatening
- Cardiovascular:
- Hypertension
- Cardiac failure
- Pericarditis, pericardial effusion or tamponade, chronic constrictive pericarditis
- Uremic cardiomyopathy
- Increased atherosclerosis
- Left ventricular hypertrophy is common in ESRF, even arrhythmia leading to death may occur
- Systolic dysfunction due to myocardial fibrosis, abnormal myocyte function due to uremia, calcium overload and hyperparathyroidism, carnitine and selenium deficiency
- Coronary artery calcification.
- Respiratory—pulmonary edema (uremic lung) due to fluid overload
- Malignancy—incidence is increased in CKD (RCC)
- Nephrogenic systemic fibrosis—seen in patients with moderate to severe CKD, particularly those on dialysis. There is skin involvement with plaques, papules and nodules. The affected skin becomes thick, firm and assume a peau d’orange appearance. There is also muscle stiffness, joint contracture and fibrosis of lungs, pleura, diaphragm, myocardium, pericardium and dura mater. Probably Gadolinium containing contrast agent is responsible for this.
*Long Cases in Clinical Medicine, ABM Abdullah
Investigations
What investigations do you suggest in CKD?
As follows:
- Urine:
- Urine R/M/E (to see pus cell, RBC or WBC cast, glycosuria, proteinuria, specific gravity) and culture
- 24 hour urinary protein
- Creatinine clearance
- Blood
- CBC with PBF (shows normocytic, normochromic anemia), ↑ESR
- Renal function tests (blood urea and serum creatinine are elevated)
- Serum electrolytes (hyperkalemia, acidosis)
- Serum calcium, phosphate, PTH: ↓Ca++,↑PO4 ,↑PTH
- Serum uric acid (may be high)
- Serum albumin: Low
- Serum immunoelectrophoresis
- Blood glucose: If diabetes mellitus
- Serum iron profile: If anemia
- Lipid profile: Cardiovascular risk
- Imaging
- USG of the whole abdomen (shows shrunken kidneys. Kidneys may be large in diabetic glomerulosclerosis, amyloidosis, PKD and bilateral hydronephrosis)
- Plain X-ray KUB (calcification, renal stone, kidney size may be seen)
- Chest X-ray: Pulmonary edema, cardiomegaly
- CT scan of abdomen
- Pyelogram (intravenous or retrograde) (rarely needed)
- Isotope renogram
- Renal artery Doppler study
- Renal angiography and DTPA scan
- Renal biopsy (may be needed in some cases)
- ECG: Ischemic disease
- Other investigation according to suspicion of cause (autoantibody screening, ANA and anti ds-DNA for SLE, complement components, screening for hepatitis B and C, HIV, and immune complexes.).
Sugegsted reading: Urinalysis (investigations and normal findings) – WebMed, Aarogya
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition; Lecture, Assoc. Prof. Dr Swapan Kumar Mondal
What may be the findings of renal ultrasonography in chronic renal failure?
Renal ultrasound—
- Bilateral small kidney, cortical echogenicity increaded, poor corticomedullary differentiation are usual finding in advanced renal failure. Small kidneys suggest chronicity.
- Structural abnormalities, such as polycystic kidneys, also may be observed.
- This is a useful test to screen for hydronephrosis.
- Asymmetric renal size suggests renovascular or developmental disease.
*Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition; Lecture, Assoc. Prof. Dr Swapan Kumar Mondal
What are the causes of CRF with normal or enlarged kidney size?
- Diabetic nephropathy (early)
- Polycystic kidney disease
- Obstructive uropathy
- Infiltrative disease, e.g. amyloidosis, lymphoma
- Acute renal vein thrombosis
*Short and Long Cases in Clinical Medicine, HN Sarker
Diagnosis
Why do you consider this diagnosis?
A 54-year-old male presents with anorexia, nausea, nocturia, and recurrent swelling of face and feet for 6 months. Swelling is more in face and in the morning without any breathlessness, renal and cardiac disease but has an elevated level of serum creatinine. On examination, he is pale and has anemia, periorbital puffiness, half and half nail, scratch marks, mild- pitting edema, and BP 160/95 mm Hg. Bedside urine examination reveals presence of 2+ proteinuria. So, I consider this diagnosis.
*Short and Long Cases in Clinical Medicine, HN Sarker
Why is this not CCF?
As swelling is more in face and in the morning without any breathlessness, chest pain and history of cardiac disease but has an elevated level of serum creatinine. On examination, he is pale and has anemia, periorbital puffiness, half and half nail, scratch marks, mild pitting edema, and BP 160/95 mm Hg but JVP is not raised and liver is not enlarged and tender.
*Short and Long Cases in Clinical Medicine, HN Sarker
Why is this not acute renal failure?
History of 6 months’ illness, S. creatinine 2. 9 mg/dL 4 month back, presence of anemia, half and half nail, scratch marks, and elevated blood pressure exclude acute renal failure.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the features favoring chronic over acute renal failure?
History of more than 3 months, polyuria, nocturia, anemia, pruritus, long standing hypertension, renal osteodystrophy, peripheral neuropathy and myopathy favour the diagnosis of chronic renal failure.
*Short and Long Cases in Clinical Medicine, HN Sarker
Treatment
How to treat CKD?
- Dietary and lifestyle interventions:
- Protein (0.8-1.2 gm/kg/day)
- Salt (<5 gm/day)
- Fluid: According to urine output
- Fruit and juice restriction
- All patients should be advised to stop smoking, since there is evidence that this slows the decline in renal function in addition to reducing cardiovascular risk.
- Exercise and weight loss may also reduce proteinuria and have beneficial effects on cardiovascular risk profile.
- Control of hypertension (Goal – BP <120/80 mm Hg)
- Calcium channel blockers, β-blockers
- α-blockers
- Diuretics
- Control of proteinuria: ACE-I/ARB (Goal – proteinuria < 0.3 g/24 hours)
- Control of diabetes mellitus
- Treatment of dyslipidemia
- Treatment of complications
- Fluid overload: Diuretics
- Hyperkalemia: Diuretics, nebulization, Ca++ gluconate
- Metabolic acidosis: Sodibicarb
- Renal osteodystrophy: Vit. D, calcium carbonate
- Anemia: Iron, erythropoietin
- Renal replacement therapy (RRT)
- Hemodialysis
- Peritoneal dialysis
- Kidney transplantation
* Lecture, Assoc. Prof. Dr Swapan Kumar Mondal; Davidson’s Principles and Practice of Medicine, 22nd edition
How will you treat anemia in chronic renal failure?
- First look for iron deficiency – correct by iron supplementation.
- Then, recombinant human erythropoietin (EPO) – target Hb level 10-12 g/dL. Side effects are hypertension and thrombosis (including thrombosis of arteriovenous fistula, used for hemodialysis). Erythropoietin is less effective in the presence of iron deficiency, active inflammation or malignancy, and in patients with aluminium overload, which may occur in dialysis.
- Blood transfusion may be given in severe anemia. Risk of blood transfusion in CKD patient—fluid overload, potassium overload, increased chance of graft rejection after kidney transplant, so blood transfusion is better to be avoided. In severe anemia, BT should be given during hemodyalisis.
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition
What are the treatment modalities of hyperkalemia in case of CRF?
Treatment modalities are:
- Pharmacological—
- 10% glucose and insulin
- Salbutamol nebulization
- Dialysis
- Dietary potassium restriction.
*Short and Long Cases in Clinical Medicine, HN Sarker
What are the drugs you should avoid in this patient?
The drugs are tetracycline, frusemide and cephalosporin, aminoglycosides, potassium salt and potassium sparing diuretics.
*Short and Long Cases in Clinical Medicine, HN Sarker
Which antihypertensive is the drug of choice in renal disease and why?
ACE inhibitor and angiotensin II receptor antagonists are the drugs of choice because of their antihypertensive and antiproteinuric effects.
*Short and Long Cases in Clinical Medicine, HN Sarker
How do ACE inhibitor and ARBs delay progression of CKD?
In CKD glomerular perfusion is maintained by increased glomerular pressure caused by angiotensin II mediated vesoconstriction of the efferent arteriole; though it is immediately benificial but ultimately destructive as increased glomerular pressure predisposes to glomerular sclerosis.
*Short and Long Cases in Clinical Medicine, HN Sarker
When should ACE inhibitor or ARBs not be given in CKD?
ACE inhibitor or ARBs should not be given in –
- Hyperkalaemia
- Bilateral renal artery stenosis
- When serum creatinine is 5 mg/dL or more.
*Short and Long Cases in Clinical Medicine, HN Sarker
Should ACE inhibitor or ARBs be stopped if serum creatinine rise?
After initiation of these drug, serum creatinine may rise up to by 30% but if it remains constant and serum potassium is within normal limit, drug should be continued with frequent monitoring.
*Short and Long Cases in Clinical Medicine, HN Sarker
How to treat renal osteodystrophy?
As follows:
- Treatment of renal failure
- Calcium supplement
- 1-α hydroxylated synthetic analog of vitamin D (active vitamin D).
*Long Cases in Clinical Medicine, ABM Abdullah
What are the indications of urgent dialysis?
As follows:
- Severe hyperkalemia
- Pulmonary edema or severe fluid overload
- Severe metabolic acidosis
- Uremic pericarditis
- Uremic encephalopathy
- Toxicity with a dialyzable poison (methanol, barbiturate, etc.)
- Recurrent vomiting due to uremia.
*Long Cases in Clinical Medicine, ABM Abdullah
What are the indications of renal replacement therapy?
As follows:
- Hyperkalemia (plasma potassium > 6 mmol/L) if not corrected by medical treatment
- Metabolic acidosis if medical treatment fails (H+ > 56 nmol/L, pH < 7.25), HCO3 < 10 mmol/L
- Fluid overload and pulmonary edema if not responding to diuretic therapy
- Serum creatinine > 600 μmol/L, or e.GFR < 8
- Plasma urea level is >30 mmol/L
- Uremic pericarditis or encephalopathy
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker
What are the contraindications of renal transplantation?
As follows:
- Absolute:
- Active malignancy – a period of at least 2 years of complete remission recommended for most tumors
- Active vasculitis or recent anti GBM disease
- Severe heart disease or any severe co-morbid condition
- Severe occlusive aorto-iliac vascular disease.
- Relative:
- Age—while practice varies, transplants are not routinely offered to very young children (< 1 year) or older people (>75 years)
- High risk of disease recurrence in the transplant kidney
- Disease of the lower urinary tract—in patients with impaired bladder function, stricture urethra (ileal conduit may be considered.)
- Significant co-morbidity.
*Long Cases in Clinical Medicine, ABM Abdullah
What drugs are used to prevent rejection?
Usually a combination of:
- Cyclosporine or tacrolimus
- Azathioprine or mycophenolate mofetil/ sirulimus or evanolimus
- Prednisolone.
*Long Cases in Clinical Medicine, ABM Abdullah
Complications
What are the complications after renal transplantation?
As follows:
- Acute rejection
- Chronic rejection
- Infection—CMV, pneumocystis jiroveci, oral candidiasis, polioma virus. Bacterial infection is common in first few months
- Complication of immunosuppressive drugs including steroid
- Acute tubular necrosis (ATN)—it is the most common cause of cadaveric graft dysfunction (40 to 50%). It is associated with a worse long-term outcome and predisposes to rejection.
- Technical failures—occlusion or stenosis of the arterial anastomosis, occlusion of the venous anastomosis and urinary leaks
- Post transplantation lymphoproliferative disorder—EBV associated malignancies (such as lymphoma) are common in patients who received biological agents and in children
- Chronic allograft nephropathy—most common cause of late graft failure
- Malignancy—skin tumor (including basal and squamous cell carcinoma), renal, cervical and vaginal
- Hypertension
- Atherosclerosis
- Recurrence of renal disease.
Complication of Renal transplantation (Remember the formula— ‘TROPICAL’):
|
*Long Cases in Clinical Medicine, ABM Abdullah
What is acute rejection?
Acute rejection characterized by rising of creatinine, fever, loin pain, hypertension, swelling of the graft. Urine shows protein, lymphocyte, and renal tubular cells. Occurs in 10 to 30% cases within 6 months. Graft biopsy shows immune cell infiltrate and tubular damage.
Treatment—high dose methylprednisolone, resistant cases may require antithymocyte globulin or ALG or OKT3 may be used.
*Long Cases in Clinical Medicine, ABM Abdullah
What is chronic rejection?
It occurs usually after 6 months. The patient presents with gradual rise of creatinine and proteinuria. Graft biopsy shows vascular change, fibrosis and tubular atrophy. It is not responsive to increased immunosuppression.
*Long Cases in Clinical Medicine, ABM Abdullah
Related topics
What are the problems with hemodialysis?
- Hypotension during dialysis due to fluid removal and hypovolemia. There may be chest pain and leg cramps
- Cardiac arrhythmia due to potassium and acid base shift
- Hemorrhage due to anticoagulation. Also, venous needle disconnection may lead to hemorrhage
- Anaphylactic reaction – dialyser hypersensitivity
- Between treatment – Pulmonary edema due to fluid overload, systemic sepsis usually involving vascular access devices
- Hemolytic reactions
- Air embolism
- Hard water syndrome
- Dialysis disequilibrium due to rapid correction of uremia.
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker
What are the contraindications of hemodialysis?
- CCF with low EF%
- Generalized atherosclerosis with poor vascular access for AVF. (They are the ideal candidate for peritoneal dialysis).
*Long Cases in Clinical Medicine, ABM Abdullah
What are the problems with continuous ambulatory peritoneal dialysis? (CAPD)
- Peritonitis
- Catheter exit site infection
- Constipation
- Massive pleural effusion (dialysate leak through a diaphragmatic defect into the thoracic cavity). Dialysate may leak into the scrotum down through a patent processus vaginalis
- Ultrafiltration failure
- Failure of peritoneal membrane function due to long-term CAPD
- Sclerosing peritonitis (potentially fatal).
*Long Cases in Clinical Medicine, ABM Abdullah; Short and Long Cases in Clinical Medicine, HN Sarker
What are the contraindications of peritoneal dialysis?
- Previous peritonitis causing peritoneal adhesions
- Presence of a stoma (e.g. colostomy)
- Active intra-abdominal sepsis (absolute contraindication)
- Abdominal hernia
- Co-morbidities like coronary artery disease, congestive cardiac failure..
*Long Cases in Clinical Medicine, ABM Abdullah
What are the complications of long-term dialysis?
As follows:
- Cardiovascular disease
- Sepsis (leading cause of death in long term dialysis patient)
- Dialysis associated ascites
- Dialysis amyloidosis
- Dialysis associated arthropathy.
*Long Cases in Clinical Medicine, ABM Abdullah