44
Chronic Kidney Chronic Kidney Disease/Dialysis Disease/Dialysis Belinda Jim, MD Belinda Jim, MD January 15, 2009 January 15, 2009

Chronic Kidney Disease/Dialysis

  • Upload
    fahim

  • View
    64

  • Download
    0

Embed Size (px)

DESCRIPTION

Chronic Kidney Disease/Dialysis. Belinda Jim, MD January 15, 2009. Definition. NKF’s (National Kidney Foundation’s) K/DOQI (Kidney Disease Outcomes Quality Initiative) Work Group criteria for CKD are: Kidney damage for >3months, with or without decreased GFR manifest by either: - PowerPoint PPT Presentation

Citation preview

Page 1: Chronic Kidney Disease/Dialysis

Chronic Kidney Chronic Kidney Disease/DialysisDisease/Dialysis

Belinda Jim, MDBelinda Jim, MD

January 15, 2009January 15, 2009

Page 2: Chronic Kidney Disease/Dialysis

DefinitionDefinition NKF’s (National Kidney Foundation’s) NKF’s (National Kidney Foundation’s)

K/DOQI (Kidney Disease Outcomes Quality K/DOQI (Kidney Disease Outcomes Quality Initiative) Work Group criteria for CKD Initiative) Work Group criteria for CKD are:are:

Kidney damage for >3months, with or Kidney damage for >3months, with or without decreased GFR manifest by without decreased GFR manifest by either:either:

Pathological abnormalities orPathological abnormalities or Markers of kidney damage, including Markers of kidney damage, including

abnormalities in the composition of abnormalities in the composition of the blood or urine, or abnormalities the blood or urine, or abnormalities in the imaging tests.in the imaging tests.

OROR GFR < 60ml/min/1.73m2 for >3monthsGFR < 60ml/min/1.73m2 for >3months

Page 3: Chronic Kidney Disease/Dialysis

Causes of ESRDCauses of ESRD

Regardless of acute or chronic, Regardless of acute or chronic, should calculate renal function by should calculate renal function by eGFReGFR

Used to evaluate extent of Used to evaluate extent of impairment, follow course of disease impairment, follow course of disease and response to therapyand response to therapy

Dose adjustmentsDose adjustments

Page 4: Chronic Kidney Disease/Dialysis

Equations to Estimate Equations to Estimate GFRGFR

Gold Standard – inulin clearance, I-iothalmate, Gold Standard – inulin clearance, I-iothalmate, Tc-DTPA clearance. These tests are not uniform.Tc-DTPA clearance. These tests are not uniform.

Cockcroft-Gault equation-Cockcroft-Gault equation- (140-age) x wt/ 72 x SCr. (x 0.85 for women).(140-age) x wt/ 72 x SCr. (x 0.85 for women).

MDRD (Modification of Diet in Renal Disease) – MDRD (Modification of Diet in Renal Disease) – Abbreviated versionAbbreviated version 186 x SCr. To power of -0.203 (x 0.742 if 186 x SCr. To power of -0.203 (x 0.742 if

female) and (x1.210 if black).female) and (x1.210 if black). 24 hr. Urine for Cr.Cl –24 hr. Urine for Cr.Cl –

GFR = UCr.V/PCr x 0.70 (to convert to GFR = UCr.V/PCr x 0.70 (to convert to ml/min)ml/min)

Page 5: Chronic Kidney Disease/Dialysis

CKD Staging and CKD Staging and PrevalencePrevalence

CKD CKD StageStage

GFRGFR(mL/min/1.73 m(mL/min/1.73 m22))

Number Number of of

IndividuaIndividualsls

1190 and evidence of 90 and evidence of kidney damagekidney damage 5.6 million5.6 million

2260-89 and evidence of 60-89 and evidence of kidney damagekidney damage 5.7 million 5.7 million

33 30-5930-59 7.4 million7.4 million

44 15-2915-29 300,000300,000

55 <15 or dialysis<15 or dialysis 431,284431,284Coresh et al , J Am Soc Nephrol, 2005; 16: 180-188Coresh et al , J Am Soc Nephrol, 2005; 16: 180-188Data supplied by USRDS 2004 Annual Data Report.Data supplied by USRDS 2004 Annual Data Report.

Page 6: Chronic Kidney Disease/Dialysis

Natural History of Renal Natural History of Renal DiseaseDisease

Initial injury may vary in pathogenesisInitial injury may vary in pathogenesis Kidney adapts by increasing filtration rate in Kidney adapts by increasing filtration rate in

remaining normal nephronsremaining normal nephronsadaptive adaptive hyperfiltrationhyperfiltration

Long-term damage, manifested by proteinuria Long-term damage, manifested by proteinuria and progressive renal insufficiency and progressive renal insufficiency

Gradual decline usually asymptomaticGradual decline usually asymptomatic No exact correlation between level of BUN No exact correlation between level of BUN

and symptomsand symptoms Uremic symptoms: anorexia, nausea, Uremic symptoms: anorexia, nausea,

vomiting, fatigue, hiccups, pruritisvomiting, fatigue, hiccups, pruritis

Page 7: Chronic Kidney Disease/Dialysis

General ManagementGeneral Management

Treatment of reversible causesTreatment of reversible causes Decreased renal perfusionDecreased renal perfusion Administration of nephrotoxic drugsAdministration of nephrotoxic drugs Urinary tract obstructionUrinary tract obstruction

Prevention or slow the progression Prevention or slow the progression Treatment of complications Treatment of complications Identification and adequate Identification and adequate

preparation of renal replacement preparation of renal replacement therapy (RRT)therapy (RRT)

Page 8: Chronic Kidney Disease/Dialysis

Factors Affecting Factors Affecting Progression of CKDProgression of CKD

Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Age – incidence climbs after 65Age – incidence climbs after 65 Gender – more common in males Gender – more common in males

with a faster rate of decline.with a faster rate of decline. Race – incidence higher in AA and Race – incidence higher in AA and

Hispanics.Hispanics. Genetics – diabetic and non-diabetic Genetics – diabetic and non-diabetic

nephropathies cluster in families.nephropathies cluster in families.

Page 9: Chronic Kidney Disease/Dialysis

Modifiable Risk Factors Modifiable Risk Factors

Proteinuria – aim for <500mg/24hr.Proteinuria – aim for <500mg/24hr. Hypertension – aim for <130/80 or Hypertension – aim for <130/80 or

MAP <90 with ACE I/ARB.MAP <90 with ACE I/ARB. Glycemic control – Evidence is Glycemic control – Evidence is

conflicting in progression of CKD.conflicting in progression of CKD. Dyslipidemia – elevated levels Dyslipidemia – elevated levels

associated with more rapid decline – associated with more rapid decline – esp in DN.esp in DN.

Obesity - linked to faster rate of Obesity - linked to faster rate of progression in CKD.progression in CKD.

Hyperuricemia – May cause renal Hyperuricemia – May cause renal injury and HTN through stimulationinjury and HTN through stimulation of of renin-angiotensin systemrenin-angiotensin system..

Page 10: Chronic Kidney Disease/Dialysis

Treatment of Treatment of ComplicationsComplications

Volume overloadVolume overload HyperkalemiaHyperkalemia Metabolic acidosisMetabolic acidosis HyperphosphatemiaHyperphosphatemia AnemiaAnemia HyperparathyroidismHyperparathyroidism Bone diseaseBone disease Uremic symptomsUremic symptoms

Page 11: Chronic Kidney Disease/Dialysis

Volume OverloadVolume Overload

Sodium and intravascular volume Sodium and intravascular volume balance usually maintained until balance usually maintained until GFR falls below 10 to 15 ml/minGFR falls below 10 to 15 ml/min

Mild to moderate CKD less able to Mild to moderate CKD less able to respond to rapid infusions of sodium, respond to rapid infusions of sodium, prone to overloadprone to overload

Respond to combination of dietary Respond to combination of dietary sodium restriction and diuretic sodium restriction and diuretic therapytherapy

Page 12: Chronic Kidney Disease/Dialysis

HyperkalemiaHyperkalemia Problem with Problem with

AldosteroneAldosterone Distal flow in kidney (eGFR<10 -15ml/min).Distal flow in kidney (eGFR<10 -15ml/min).

Patient is either:Patient is either: Oliguric.Oliguric. Has high K diet.Has high K diet. Has increased tissue breakdown.Has increased tissue breakdown. Has Hypoaldosteronism (eg. ACE Has Hypoaldosteronism (eg. ACE

Inhibitors, type IV RTA).Inhibitors, type IV RTA). Treatment consists of low K diet Treatment consists of low K diet

(2gm/day), diuretics and kayexalate.(2gm/day), diuretics and kayexalate.

Page 13: Chronic Kidney Disease/Dialysis

Ion transport in collecting tubule cell

                                                              

Page 14: Chronic Kidney Disease/Dialysis

Metabolic AcidosisMetabolic Acidosis

Increasing tendency to retain HIncreasing tendency to retain H++

Decreased HCO3Decreased HCO3--, usually between 12-, usually between 12-20meq/L20meq/L

Bone buffering of excess HBone buffering of excess H++ ions associated ions associated with release of Cawith release of Ca2+2+ and Phos from bone and Phos from bone

Uremic acidosis increase skeletal muscle Uremic acidosis increase skeletal muscle breakdown and diminish albumin synthesisbreakdown and diminish albumin synthesis loss of lean muscle mass and fatigueloss of lean muscle mass and fatigue

Sodium bicarbonate or sodium citrate to Sodium bicarbonate or sodium citrate to keep HCOkeep HCO33 above 22meq/L above 22meq/L

Page 15: Chronic Kidney Disease/Dialysis

Secondary Secondary HyperparathyroidismHyperparathyroidism

Page 16: Chronic Kidney Disease/Dialysis

Treatment of Secondary Treatment of Secondary HyperparathyroidismHyperparathyroidism

Phosphate binders:Phosphate binders: Low Phos diet (<800 mg/day)Low Phos diet (<800 mg/day) Ca based:Ca based:

CaCO3CaCO3 Ca acetateCa acetate

Non absorbable agent:Non absorbable agent: Sevelamer Hydrochloride (Renagel)Sevelamer Hydrochloride (Renagel) Sevelamer Carbonate (Renvela)Sevelamer Carbonate (Renvela) Lanthanum carbonate (Fosrenol)Lanthanum carbonate (Fosrenol)

Aluminum binders.Aluminum binders. Vitamin D analogs:Vitamin D analogs:

Calcitriol (Rocaltrol)Calcitriol (Rocaltrol) Paricalcitol (Zemplar)Paricalcitol (Zemplar) Doxercalciferol (Hectoral)Doxercalciferol (Hectoral)

Calcimimetic: Cinacalcet (Sensipar)Calcimimetic: Cinacalcet (Sensipar)

Page 17: Chronic Kidney Disease/Dialysis

Renal OsteodystrophyRenal Osteodystrophy

Types of Bone DiseaseTypes of Bone Disease Osteitis fibrosaOsteitis fibrosa OsteomalaciaOsteomalacia Adynamic bone diseaseAdynamic bone disease

Target PTHTarget PTH Stage 3 (GFR 30-59): 35-70 pg/mLStage 3 (GFR 30-59): 35-70 pg/mL Stage 4 (GFR 15 to 29): 70-110 pg/mLStage 4 (GFR 15 to 29): 70-110 pg/mL Stage 5 (GFR less than 15): 150-300 Stage 5 (GFR less than 15): 150-300

pg/mLpg/mL

Page 18: Chronic Kidney Disease/Dialysis

Metastatic CalcificationMetastatic Calcification

Page 19: Chronic Kidney Disease/Dialysis

HypertensionHypertension

Mostly volume mediatedMostly volume mediated Start with ACEI/ARB and diureticStart with ACEI/ARB and diuretic Thiazides become ineffective when Thiazides become ineffective when

GFR falls below 20GFR falls below 20 Goal is less than 130/80, but even Goal is less than 130/80, but even

lower systolic with urine prot/creat lower systolic with urine prot/creat >1>1

Page 20: Chronic Kidney Disease/Dialysis

Anemia in CKDAnemia in CKD The primary cause of anemia in

patients with CKD is insufficient production of erythropoietin (EPO) by the diseased kidneys.

Other causes include: Iron deficiency. Secondary hyperparathyroidism. Decreased RBC lifespan. Folate deficiency.

Page 21: Chronic Kidney Disease/Dialysis

K/DOQI Guidelines for Anemia K/DOQI Guidelines for Anemia in CKDin CKD

Target Hgb between 11-12 g/dLTarget Hgb between 11-12 g/dL Anemia work-up when

Hgb <11g/dL (Hct is <33 percent) in pre-menopausal females and pre-pubertal patients.

Hgb <12g/dL (Hct is <37 percent) in adult males and post-menopausal females.

Use of erythropoietic agents Use of erythropoietic agents (Epo,Procrit,Aranesp)(Epo,Procrit,Aranesp)

Page 22: Chronic Kidney Disease/Dialysis

DyslipidemiaDyslipidemia Primary finding in CKD is Primary finding in CKD is

hypertriglyceridemiahypertriglyceridemia

Goal of LDL in CKD in similar to CHD Goal of LDL in CKD in similar to CHD – LDL <100, but there is not much – LDL <100, but there is not much evidence whether this is beneficial.evidence whether this is beneficial.

One large study in CKD Stage V One large study in CKD Stage V showed a negative association with showed a negative association with very low cholesterol levelsvery low cholesterol levels

Page 23: Chronic Kidney Disease/Dialysis

Preparation for Renal Preparation for Renal Replacement TherapyReplacement Therapy

Refer to nephrology when GFR < 60Refer to nephrology when GFR < 60 Early education of CKDEarly education of CKD Choice of renal replacement therapyChoice of renal replacement therapy

In-center hemodialysisIn-center hemodialysis Peritoneal dialysisPeritoneal dialysis Home hemodialysisHome hemodialysis

Access placementAccess placement Referral to vascular surgery of AVF placement Referral to vascular surgery of AVF placement

if patient choses HD and advising patient to if patient choses HD and advising patient to save non-dominant arm from venopuctures save non-dominant arm from venopuctures and heplocks.and heplocks.

Page 24: Chronic Kidney Disease/Dialysis

What is Dialysis?What is Dialysis?

Page 25: Chronic Kidney Disease/Dialysis

Initiation of Emergent Initiation of Emergent DialysisDialysis

• Uremic syndromeUremic syndrome• Refractory volume overloadRefractory volume overload• Uncontrollable hyperkalemiaUncontrollable hyperkalemia• Severe metabolic acidosisSevere metabolic acidosis• Steady worsening of renal Steady worsening of renal

function, with BUN exceeding 70-function, with BUN exceeding 70-100 mg/dL or creatinine clearance 100 mg/dL or creatinine clearance of less than 15-20 ml/min/1.73 m2of less than 15-20 ml/min/1.73 m2

Page 26: Chronic Kidney Disease/Dialysis

DiffusionDiffusion Transport process by which a solute Transport process by which a solute

passively passively diffusesdiffuses down its concentration down its concentration gradient from one fluid compartment into gradient from one fluid compartment into the otherthe other

Page 27: Chronic Kidney Disease/Dialysis

Dialysis MembraneDialysis Membrane

Page 28: Chronic Kidney Disease/Dialysis

Contents of Dialysate Contents of Dialysate SolutionSolution

Page 29: Chronic Kidney Disease/Dialysis

Ultrafiltration (UF)Ultrafiltration (UF) Fluid removal occurs via hydrostatic Fluid removal occurs via hydrostatic

pressure gradient across membrane pressure gradient across membrane generated by dialysis machinegenerated by dialysis machine

Page 30: Chronic Kidney Disease/Dialysis

Peritoneal Dialysis (PD)Peritoneal Dialysis (PD) Uses peritoneal Uses peritoneal

membrane to membrane to transport solutes and transport solutes and water across two water across two compartmentscompartments

One compartment is One compartment is blood in the blood in the peritoneal capillaries, peritoneal capillaries, second compartment second compartment is dialysate solution is dialysate solution in peritoneal cavityin peritoneal cavity

Page 31: Chronic Kidney Disease/Dialysis

Continuous Renal Continuous Renal Replacement Therapies Replacement Therapies

(CRRTs)(CRRTs) Slower rate of solute or fluid Slower rate of solute or fluid

removal per unit of timeremoval per unit of time Slower blood flow rate for the Slower blood flow rate for the

hemodynamically unstable patienthemodynamically unstable patient Better tolerated than conventional Better tolerated than conventional

therapytherapy

Page 32: Chronic Kidney Disease/Dialysis

ComplicationsComplications

HypotensionHypotension InfectionInfection Catheter DysfunctionCatheter Dysfunction

Page 33: Chronic Kidney Disease/Dialysis

HypotensionHypotension Common CausesCommon Causes

Fluctuations in UF rateFluctuations in UF rate

High UF rate High UF rate

Target dry weight set too lowTarget dry weight set too low

Dialysis solution too warmDialysis solution too warm

Food ingestionFood ingestion

Autonomic neuropathyAutonomic neuropathy

Antihypertensive medicationsAntihypertensive medications

Page 34: Chronic Kidney Disease/Dialysis

Hypotension-CardiacHypotension-Cardiac

Diastolic dysfunction due to LVH, Diastolic dysfunction due to LVH, ischemic heart diseaseischemic heart disease

Failure to increase cardiac rateFailure to increase cardiac rate Inability to increase cardiac output Inability to increase cardiac output

for other reasonsfor other reasons

Page 35: Chronic Kidney Disease/Dialysis

HypotensionHypotension

Less common reasonsLess common reasons Pericardial tamponadePericardial tamponade Myocardial infarctionMyocardial infarction Arrhythmia Arrhythmia Occult hemorrhageOccult hemorrhage Dialyzer reactionDialyzer reaction HemolysisHemolysis Air embolismAir embolism

Page 36: Chronic Kidney Disease/Dialysis

Dialysis Catheter Dialysis Catheter InfectionsInfections

Localized exit site infectionLocalized exit site infection Erythema and/or crust, no purulent discharge, Erythema and/or crust, no purulent discharge,

treat with antibiotics for up to 2 weekstreat with antibiotics for up to 2 weeks Tunnel InfectionTunnel Infection

Purulent exudate present, and pain/warmth Purulent exudate present, and pain/warmth along the tunnel, removal of catheter with along the tunnel, removal of catheter with antibiotic administration for 3 weeksantibiotic administration for 3 weeks

Systemic InfectionSystemic Infection Fever, leukocytosis, may have no overt signs Fever, leukocytosis, may have no overt signs

of catheter infectionof catheter infection

Page 37: Chronic Kidney Disease/Dialysis

Microbiology Microbiology

Staph species (40-81%)Staph species (40-81%) Enterococci, gram neg organisms, Enterococci, gram neg organisms,

fungal organismsfungal organisms Empiric treatment with Vancomycin Empiric treatment with Vancomycin

and Gentamicinand Gentamicin Treat with Nafcillin if MSSA!Treat with Nafcillin if MSSA!

Page 38: Chronic Kidney Disease/Dialysis

Complications of Catheter Complications of Catheter InfectionInfection

EndocarditisEndocarditis OsteomyelitisOsteomyelitis ThrombophlebitisThrombophlebitis Spinal epidural abscessSpinal epidural abscess

Page 39: Chronic Kidney Disease/Dialysis

Catheter DysfunctionCatheter Dysfunction

Early Early less than 5 daysless than 5 days Due to malposition or to intracatheter Due to malposition or to intracatheter

thrombosisthrombosis Fibrin sleeves and mural thrombiFibrin sleeves and mural thrombi

TreatmentTreatment Catheter exchange Catheter exchange TPATPA

Page 40: Chronic Kidney Disease/Dialysis

Catheter DysfunctionCatheter Dysfunction

Late (more than 5 days)Late (more than 5 days) More likely due to intracatheter More likely due to intracatheter

thrombosis than malpositionthrombosis than malposition TreatmentTreatment

TPATPA Catheter exchangeCatheter exchange

Page 41: Chronic Kidney Disease/Dialysis

Vascular AccessVascular Access

Permanent catheterPermanent catheter AV graftAV graft AV fistulaAV fistula

Page 42: Chronic Kidney Disease/Dialysis

Permanent CatheterPermanent Catheter

Cuffed venous catheters an Cuffed venous catheters an alternative form of long-term accessalternative form of long-term access

High rate of complicationsHigh rate of complications ThrombosisThrombosis InfectionInfection

Inadequate blood flowInadequate blood flow

Page 43: Chronic Kidney Disease/Dialysis

AV GraftAV Graft

AdvantagesAdvantages• AV connection made using a tube graft AV connection made using a tube graft

from synthetic materialfrom synthetic material• Maturation requires 2-3 weeks for Maturation requires 2-3 weeks for

adhesion of subcutaneous tunnel and adhesion of subcutaneous tunnel and graftgraft

DisadvantagesDisadvantages• Higher rates of infectionHigher rates of infection• Higher rates of thrombosisHigher rates of thrombosis• Shorter lifespanShorter lifespan

Page 44: Chronic Kidney Disease/Dialysis

AV fistulaAV fistulaAdvantagesAdvantages• Subcutaneous anastomosis of artery to Subcutaneous anastomosis of artery to

adjacent veinadjacent vein• Safest longest lasting permanent accessSafest longest lasting permanent access• Excellent patencyExcellent patency• Lower morbidityLower morbidity• Lower complicationLower complication

DisadvantagesDisadvantages• Long maturation timeLong maturation time• Failure to mature in some patientsFailure to mature in some patients• May not be feasible in patients with May not be feasible in patients with

vascular diseasevascular disease