CHRONIC KIDNEY DISEASE Immune system in CKD and infection in GN pts - PowerPoint Presentation

Slide1

CHRONIC KIDNEY DISEASE

Immune system in CKD and infection in GN pts

In CKD and HD patients dysfunction of immune system alterations belonge

to

involv

ing

i

nnate

and

a

daptive

i

mmunity

in T and B lymphocytes (

Reduced

T regulatory cells and memory cells and increased innate cells).

In GN patients on IS

th

is important to put c

orrect diagnosis

and treatment

of infection

, as well as w

eighing the risk of infection with the risk of untreated glomerular disease

ANCA vasculitis, SLE and MGRS

New drugs in treatment ANCA vasculitis and SLE are not well established. In patients with MGRS the role of nephrologist is to perform kidney Bx in order to

assess

the

MGRS

type

and

evaluate

the

severity

of

renal

disease

Alport and Fabry

27% of heterozygous women with XLAS (COL4A5 mutation) develop ESRD. For the DG of

Fabry

disease you must think that it could be

Oncology patients and elderly outpatients

It is important to estimate of renal function in oncology patients (GFR formulas adjusted for body surface area)

In elderly outpatient

drug-related

clinically relevant blood pressure overtreatment

,

resulting in hypotension

.

Contrast induce AKI

Although there is evidence that CI-AKI is associated with worse outcomes, there is no evidence of a causal relationship or that reducing CI-AKI improves overall outcome.To date there has been no conclusive benefit demonstrated from interventions except for low

osmolar

or

iso-osmolar

contrast and IV hydration.

How to retarding the t

ransition from CKD to ESRD

Detection of CKD at risk groups and r

eferral to nephrology

in CKD 3B stage

Good partnership

and education of the

primary care

physicians

and other specialties

Dialysis access should be placed sufficiently early to preclude the need for central venous catheters

Patients

e

ducat

ion

(

low-protein diets;

ketoanalogs

; correct metabolic acidosis; oral antioxidants

)

HEMODIALYSIS

In elderly patients is more difficult to construct permanent vascular access

and is appropriate starting with a tunnel rather than a temporary catheter. Between diabetics and non-

diabeticsIn

there

i

s no significant difference in

color

Doppler findings but

s

uccessful creation of VA in

diabetics

is less common

Vascular access

Vascular calcification

Think about association between vascular calcification and anticoagulation therapy (old and new) in CKD and HD patients. Potential role of indoxyl sulphate as an uremic toxin in delopment

od

LVH in ESRD.

CV disease

In ESRD patients clinical, diagnostic and therapeutic approach

of

different CV manifestation

differ

from

that

in

non-dialysis

population

and o

utcome

is

less

favourable

Oxidative stress in HD patients

HD patients mortality is associated with higher inflammation and OS. Biomarkers of inflammation (hsCRP), oxidative stress (PAB) and hsTnI are

good predictors of all-cause and CVD mortality.

The combination of

2

biomarkers

of

different

pathophisiological

pathways

proved

to be

better

tool

for the assessment of all-cause

and

CVD

mortality

than

single

biomarker

Fraility

Nephrologists should actively attempt to identify the frail patients with CKD because they are more likely to require hospitalization and more likely to die than their non-frail counterparts.

Kidney transplantation

14th BANTAO congress confirmed

Great difference between Balkan countries in number and development of kidney Tx

The development of transplantation program

in countries with small number of kidney Tx improved many medical fields and provided continuous education of medical staff

Donor program

Severe organ shortage crisis represents a universal challange which should be faced under the scope of a planned and integrated approach primarily focused on solutions to increase deceased organ donation.Organisation model, legislation and public opinion are necessary frame,

but proactive hospital approach to organ donation is mandatory

to expand the national pool of solid organs for transplantation.

Hypertension after kidney Tx

Elevated BP levels post-transplant identify patients at high risk of AR independently of graft function. CCB is useful in antagonizing the vc effects of CNI. The RAS inhibitors seem a good option, especially in patients with proteinuria, but their effects on long-term graft and patient survival are controversial.

β -Blockers could be beneficial in pts with coronary heart disease

Thiazide diuretics could be the reasonable option for patients with glomerular filtration rate ≥30 mL/min/1.73 m2

Patients with HCV infection should be transplanted

but the timing of treatment (before or after TX) should be individualizedDirect acting antiviral therapy have revolutionarized the field

HCV and

Tx

IgA and kidney Tx

Recurrence of IgA nephropathy is common after kidney Tx, especially in young patients, and may be more prevalent in those who receive their transplant from

living related donors.

I

S

therapy specifically directed toward treatment of recurrent IgA may be used in selected

patients

.

The majority of studies demonstrate that overall graft survival in

those with

IgAN

is no worse than those with other causes of ESRD

.