CHRONIC KIDNEY

DISEASE

Marichel Cobcoban-Samporna
IM- Nephrology
 Chronic Kidney Disease
v  a spectrum of different
pathophysiologic processes associated
with abnormal kidney function and a
progressive decline in GFR

v  ESRD UREMIC SYNDROME

 Chronic Kidney Disease

v pathophysiology
1. inititiating mechanisms specific to the
underlying etiology

2. set of progressive mechanisms
(hyperfiltration and hypertrophy) with long
term reduction in renal mass
Leading Categories of Etiologies of CKD
KDIGO Classification of CKD

R I S K
v Cockcroft- Gault Formula
(140- Age) (wt. kg)
(72) (creatinine) * 0.85% for females
 Classification of CKD
I. 35 yo II. 65 yo
male female
wt. 45 kgs 70 kgs
creatinine: 2 mg/dl 5 mg/dl
urine albumin: 500 mg/g 200 mg/g



 Risk Factors for CKD
v  small for gestational weight
v  childhood obesity
v  hypertension
v  diabetes
v  autoimmune disease
v  advanced age
v  African ancestry
v  family hx of kidney disease
v  AKI
v Proteinuria/sediment
v  structural abnormalities
 Classification of CKD
v  normal decline of GFR: 1 ml/min per year:
120 ml/min/m3



v  age 70: 70 ml/min/m3
 Signs and Symptoms of CKD and Uremia:
HYPERNATREMIA

SODIUM Intake > urinary excretion

Sodium
Extracellular Fluid Volume Expansion
Retention

Nephron Injury Hypertension

 Signs and Symptoms of CKD and Uremia:
HYPERKALEMIA
Increase dietary K intake
Protein Catabolism

Hemolysis/Hemorrhage
Transfusions

Metabolic Acidosis
Drugs
Calcium and Phosphate Metabolism

DECREASE GFR

DECREASE PO4 EXCRETION

FGF-23 PTH

DECREASE DECREASE
CALCITRIOL CALCIUM
Calcium and Phosphate Metabolism
Calcium and Phosphate Metabolism
Calcium and Phosphate Metabolism
 Calcium and Phosphate Metabolism:
Calciphylaxis
v  calcific uremic arteriolopathy
v  exclusive on patients on advanced CKD
v  vascular occlusion with extensive vascular
and soft tissue calcification
v  hyperphosphatemia, hypercalcemia
v  oral calcium for phosphate binder
v  warfarin: decrease vitamin K dependent
regeneration of matrix GLA protein
Calcium and Phosphate Metabolism:
Calciphylaxis
Livedo reticularis
Patches of ischemic
necrosis
Legs, thighs, abdomen,
breast

Tx: hyperbaric O2
IV thiosulfate
discontinue drugs
 Cardiovascular Abnormalities

v  10-200 fold
1.  Ischemic Heart Disease
* Cardiac troponin I
2. Heart Failure: uremic cardio, AMI, LVH
3. Hypertension and LVH
4. Pericardial Disease
* PR depression and diffuse ST segment
elevation
 Hematologic Abnormalities
Interstitial fibroblast

TARGET Hb: 100-115 g/L

 Neuromuscular Abnormalities
v  Peripheral Neuropathy

v  Restless Leg Syndrome

 Dermatologic Abnormalities
v  Pruritus

v  Hyperpigmentation

v  Nephrogenic Fibrosing Nephropathy
MR contrast gadolinium
avoid: < 30 ml/min
*Hemodialysis after even if not on HD
 Gastrointestinal Abnormalities

v  Uremic Fetor

v  Dysgeusia
 Endocrine-Metabolic Abnormalities

v  Insulin
progressive dose reduction as renal
function deteriorates

v  Estrogen

v  Testosterone
Evaluation and Management with CKD

v  History and PE

v  Laboratory

v  Imaging studies

v  kidney Biopsy
 Management with CKD

v  Goals
BP
Hb
Phosphorous
Calcium

v  Renal Replacement Therapy