Structural or functional abnormalities of the kidneys for gt 3 months from early to latestage disease Chronic Kidney Disease as manifested by either 1 Kidney damage with or without decreased GFR as ID: 919192
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Slide1
Chronic Kidney Disease
Definition of CKD
Structural
or functional abnormalities of the kidneys for
>
3 months
from early to late-stage disease,
Slide2Chronic Kidney Disease
as
manifested by either:
1. Kidney
damage, with or without decreased GFR, as
defined
by
• pathologic abnormalities
•
markers
of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests
Slide3Chronic Kidney Disease
2. GFR <60 ml/min/1.73 m2, with or without kidney damage
• Estimated glomerular filtration rates (
eGFR
) range from 90 mL/minute/1.73 m2 in the early stages to 15 mL/minute/1.73 m2 in the late stages of disease is known as end-stage renal disease (ESRD).
• Complications include fluid and electrolyte abnormalities, anemia, cardiovascular disease, hyperparathyroidism, bone disease, and malnutrition.
Slide4Chronic Kidney Disease
Patients with ESRD require
renal replacement therapy
in the form of dialysis or transplantation to sustain life.
The prevalence of chronic kidney disease (CKD)
increases with age and is greater in females
and some ethnic populations.
CKD is classified according to
severity from 1 to 5
, where 5 is the most advanced and 1 the least.
Slide5Chronic Kidney Disease
The
renin-angiotensin-aldosterone system (RAAS)
Most
of the renal effects of this system are through
regulating
intraglomerular
pressures and salt and water balance.
First, In patients with CKD, intra-renal pressures are often low and sympathetic
overactivity
is common; lead to increased renin secretion.
.
Slide6Chronic Kidney Disease
This can occur with normal or elevated systemic blood pressure. this promote production of the mineralocorticoid hormone aldosterone, and promotes antidiuretic hormone (ADH) release,
In
combination, these lead to salt and fluid retention, high intravascular volumes, hypertension and
oedema
.
Slide7Chronic Kidney Disease
Second, a direct vasoconstrictor and promotes systemic and (preferential) renal hypertension on the efferent glomerular arteriole.
Vasoconstriction at this site is mediated by a high density of angiotensin II receptors. When these receptors are ligated by angiotensin II, there is increased intra- glomerular pressures.
Chronic Kidney Disease
Whilst this leads to an overall increase in GFR in the short-term, over a longer period glomerular hypertension promotes accelerated glomerular scarring and worsening CKD.
Slide9Chronic Kidney Disease
In addition there is a local immune modulatory role for this system. Both resident (e.g. tubular epithelial) cells and inflammatory (monocytes and macrophages) cells, they express the angiotensin II receptor and activation through this receptor leads to an enhanced inflammatory and fibrotic phenotype of the cell.
Slide10Slide11Chronic Kidney Disease
Measurement of renal function
Serum
creatinine
This
becomes important in advanced CKD (stages 4 and 5) and limits the value of measuring serum
creatinine
to determine renal function in advanced CKD
Slide12Chronic Kidney Disease
Glomerular filtration rate equation
Eight
eGFR
equations were validated for the MDRD(Modification of Diet in Renal Disease Study)
equation
eGFR
(mL/min/1.73m2) = 186 x [serum
creatinine
(
μmol
/L)/88.4]–1.154 x [age]–0.203 x [0.742 if female] x [1.212 if African-American
]
Slide13Chronic Kidney Disease
Creatinine
clearance
Measurements of
creatinine
clearance (
ClCr
) require accurate collection of 24 h urine samples with a serum
creatinine
sample midway through this period.
Fig. 18.3
Creatinine
clearance calculation
Slide14Chronic Kidney Disease
Cockroft
–
Gault
equation
The
Cockroft
–
Gault
equation uses weight, sex and age to estimate
creatinine
clearance and was derived using average population data
Fig
. 18.4 The
Cockroft
–
Gault
formula.
Slide15Chronic Kidney Disease
Estimates of glomerular filtration rate in
paediatric
patients
Using
the Schwartz formula or the
Counahan
– Barratt method which both rely upon inclusion of the height of the child in estimating
creatinine
clearance, since height correlates with muscle mass.
Slide16Chronic Kidney Disease
Urea
Urea
is also used in the assessment of renal function despite a
variable production rate and diurnal fluctuation in response to the protein content
of the diet
it may also be
elevated by dehydration
or an
increase in protein catabolism
such as that accompanying
gastro-intestinal
haemorrhage
,
severe infection, trauma (including surgery) and high-dose steroid therapy.
Serum urea levels are, therefore, an
unreliable measure
of renal function, but can be used as an indicator of the patient's general condition and state of hydration
.
Slide17Chronic Kidney Disease
Stages
of Chronic Kidney Disease
Slide18Chronic Kidney Disease
Significance of CKD
CKD
is of
progression to end-stage
renal disease, and a strong association with
accelerated cardiovascular disease
, similar in
diabetics.
Patients with CKD
1–3 are frequently asymptomatic
.
The reduction of GFR is insufficient to
cause
uraemic
symptoms
and any minor abnormalities in the urine such as
proteinuria or
haematuria
.
Slide19Chronic Kidney Disease
There is association with
high blood pressure
which may be the cause or a consequence of renal damage. as it allows early modification of cardiovascular risk factors
Patients with CKD
stages 4 and 5
require specialist management of the complications of CKD such as
anaemia
and bone disease
, whilst many will be undergoing preparation for renal replacement therapy.
Slide20Chronic Kidney Disease
Causes of CKD
Ischaemic
nephropathy
has traditionally
Vascular diseases
(renal artery disease, hypertension,
microangiopathy
) been referred to under perfusion of the kidneys
Diabetes mellitus
(
Diabetic Kidney Disease
) is the most common metabolic disease that leads to CKD, whilst the predominant lesion is glomerular and referred to as diabetic nephropathy.
Slide21Chronic Kidney Disease
All types of
chronic glomerulonephritis
(GN) or
Glomerular diseases
(autoimmune diseases, systemic infections, drugs,
neoplasia
) cause about 15% of cases of advanced CKD.
Lower urinary tract disease
or
Tubulointerstitial
diseases
(urinary tract infection, stones, obstruction, drug toxicity) they represent 5–10% of all cases of CKD
.
Slide22Chronic Kidney Disease
Hereditary/congenital diseases
/
Cystic diseases
(polycystic kidney disease) they represent 5% of CKD cases
CKD to be unknown
and this is the case in around 30% of patients who typically present with small kidneys and unremarkable immunological investigations.