Progression of chronic kidney disease by S7iOuiRJ

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									Progression of chronic kidney
          disease
        Dr (Mrs) Rasika Sirsat
 Consultant nephrologist P D Hinduja
              Hospital
K/DOQI CKD Staging
Does CKD ever regress??

NO CKD ALWAYS PROGRESSES
Increased burden on surviving
          nephrons
       Sodium balance maintained by increased
                fractional excretion

                      100      65       33     20     10


[Na]                  140      140      140    138    134


Na excretion          150      150      150    150    150
mEq/day

Filtered load of Na   25,200   16,380   8316   4968   2412
mEq/day

Fractional            0.6      0.9      1.8    3      6
Excretion of Na%
Pahophysiologic Basis of Sodium
      Retention in CKD


         Decreased GFR

    Decreased Filtered Load

          Na Retention
  Consequence of Na retention ?
• Hypertention

• edema

• Pulmonary edema
Two major factors for progression of CKD

HT & PROTEINURIA
Natural History of Nephropathy
Early treatment makes
  a difference in CKD




           Brenner, et al., 2001
Other measures besides BP control

AVOID NEPHROTOXIC AGENTS
       Avoid in patients with CKD
•   NSAIDS , including gels
•   contrast agents
•    aminoglycosides
•    smoking
         As CKD progresses more
           complications occur
•   CKD- MBD
•   Anemia
•   Metabolic acidosis
•   Fluid overload
•   Electrolyte disturbance - hyperkalemia
•   Cardio vascular disease
     Regulation of solutes with progressive nephron loss: Plasma
        concentration and urine concentrating ability by GFR

             100%      65%       33%        20%        10%
Cr           1         1.3       3.1        5          10.4
BUN          14        18        29         46         82
[Pi]         4         4.2       4.3        5.2        5.8
[HCO3]       24        24        22         16         13
[Na+]        140       140       140        138        136
[K+]         4         4         4          4.5        5.5
pH           7.4       7.4       7.37       7.3        7.26
Max U osm 1200         1000      500        350        310
Min U osm    50        50        70         200        310
Clinical Manifestations of Water Balance in CKD

• Decreased concentrating ability
  - Nocturia, polyuria
  - Hypernatremia (if water intake is
  compromised)
• Decreased diluting ability
  - Hyponatremia (if water intake is “excessive’)
• Kidney failure: Isosthenuria – the restriction of
  operating urine osmolality to prevailing plasma
  osmolality
                                              Prevalence of Abnormalities
                                                  at each level of GFR
                                             Hypertension*                    Hemoglobin < 12.0 g/dL
                                             Unable to walk 1/4 mile          Serum albumin < 3.5 g/dL
                                             Serum calcium < 8.5 mg/dL        Serum phosphorus > 4.5 mg/dL
                                        90
         Proportion of population (%)



                                        80
                                        70
                                        60
                                        50
                                        40
                                        30
                                        20
                                        10
                                         0
                                                15-29            30-59             60-89             90+
                                                           Estimated GFR (ml/min/1.73 m2)
*>140/90 or antihypertensive medication                                  p-trend < 0.001 for each abnormality
                 CKD Features – Stage wise

 CKD      eGFR     B.P   ACR   Urine   Edema   Anemia   Ca x P   SHPT


Stage 1   >90      N     MAU    N       No      No        N      No


Stage 2   60+      ↑     MAU    ↑       No               N      No


Stage 3   30 +     ↑     ALB    ↑       No               N       

Stage 4   15+      ↑     ALB    ↑↓                     ↑       ↑

Stage 5   <15      ↑↑    ALB    ↓                      ↑       ↑
Many patients succumb to cardiovascular disease before reaching

ESRD
 Anemia
                                                        Hyperlipidemia
 Hypertension
                                                        Diabetes mellitus
 Hypervolemia
                          Hyperparathyroidism           Hyperhomocysteinemia
 AV fistula
                          Ca and P abnormalities
                          Uremia
                          Malnutrition



Concentric LVH
LV Dilatation                                        CAD
Systolic dysfunction                                 Vascular calcification
Diastolic dysfunction




         Cardiomyopathy                             Ischemic heart disease



                                  Cardiac Failure
Death rates from all causes (panel A) and cardiovascular
              events (panel B), as per eGFR




                                   Go, A, et al. NEJM 351: 1296
Since regression of CKD is not possible our aim should be to retard the
progression to

ESRD & PREVENTION OF CVD
Thank you

								
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