Chronic Kidney Disease
Dr Mohan B. Biyani
A. Professor of Medicine
University of Ottawa/Ottawa Hospital
Health Seminar Series
Date 12 May 2013
Objectives
• Normal functioning of Kidneys.
• Risk factors to develop Chronic kidney disease.
• Early indicators of Chronic kidney disease.
• Prevention and treatment of Chronic kidney
disease.
How Do the Kidneys Work?
How Do the Kidneys Work?
• Two kidneys, size of a
fist.
• The kidneys perform job
of filtering and returning
to the bloodstream about
200 litres of fluid every
24 hours.
• About two litres are
removed from the body in
the form of urine, and
about 198 litres are
recovered.
How Do the Kidneys Work?
• First blood enters the
kidneys via the renal
arteries.
• Then, inside the kidneys,
millions of mini-filtering
systems called nephrons
sieve the blood.
• waste products removed
in the form of urine
• The clean blood returns
to the body through the
renal veins.
Functions of the kidney
• Produce urine by
filtering waste products
and excess fluid from
your blood.
• Maintain water
balance.
• Maintain acid-base
balance.
• Remove medications.
Functions of the kidney
• Regulate blood
pressure(Hormones
and volume)
• Help produce red
blood cells.(EPO)
• Maintain healthy
bones(Vit D, role in
Ca and Po4 balance)
Kidneys and Aging
• With Age kidneys sizes become smaller.
• Kidney function start declining after the
age of 40.
• Kidney function decline is usually by 0.5-1
ml/year.
• The decline in function may vary based on
other medical conditions.
What is Chronic Kidney Disease
• The presence of Kidney Damage or an
eGFR < 60 ml/min/1.73m2 and
• Present for ≥ 3 months and
• Not treated with dialysis or transplant
The diagnosis of CKD is only present in patients with eGFR ≥60ml/min if other
abnormalities (i.e. proteinuria, hematuria, anatomical) are also present.
eGFR- estimated glomerular filtration rate-test to check kidney function
Stages in Progression of Chronic Kidney Disease.
Complications
Normal
Screening
for CKD
risk factors
Increased
risk
CKD risk
reduction;
Screening for
CKD
Damage
 GFR
Kidney
failure
Diagnosis
Estimate
Replacement
& treatment; progression;
by dialysis
Treat
Treat
& transplant
comorbid complications;
conditions;
Prepare for
Slow
replacement
progression
CKD
death
Stages of CKD
• Stage 1*: GFR >= 90 mL/min/1.73 m2
– Normal or elevated GFR/Urine abnormalities.
• Stage 2*: GFR 60-89 (mild)/Urine abnormalities.
• Stage 3: GFR 30-59 (moderate)
• Stage 4: GFR 15-29 (severe)
• Stage 5: GFR < 15 (kidney failure)
GFR: Glomerular filtration rate-measure of Kidney
function
CKD is common
Estimated prevalence of CKD in
Canadians ≥ 20 years old
Stage 1 CKD > 90 ml/min
Stage 2 CKD 60 – 89 ml/min
Stage 3 CKD 30 – 59ml/min
Stage 4 CKD 15 – 29 ml/min
Stage 5 CKD < 15 ml/min
792,000
720,000
1,032,000
48,000
24,000
Numbers are estimates based on an extrapolation of US data
Stigant, C, et al. CMAJ 2003;168:1553-60.
Detection of CKD
• Early detection and treatment of chronic
kidney disease is the key.
• Some simple tests can be done to detect
early kidney disease.
• More so important in patients who have
risk factors to develop Kidney disease.
Chronic kidney disease
• Majority of CKD does not progress to
ESRD.
• Major risk factor for Cardiovascular
disease.
• Patients with CKD have other health
problems.
• Once you have End stage kidney disease,
management is expensive.
Cardiovascular Mortality in the General Population
and in ESRD Treated by Dialysis
Annual mortality (%)
100
Dialysis
10
General population
1
0.1
Male
Female
0.01
Black
White
25–34 35–44 45–54 55–64 65–74 75–84
Age (years)
85
Age-Standardized Rates of Death from Any Cause (Panel A) and Cardiovascular Events
(Panel B), According to the Estimated GFR among 1,120,295 Ambulatory Adults
Go, A, et al. NEJM 351: 1296
Life expectancy and CKD
How Do We Assess Your Kidney
Function?
 Lab tests:
Blood
Urine
 Health assessment
Simple test to detect CKD
• Blood pressure measurement.
• A test for protein/blood in the urine.
• A test for blood creatinine. (eGFR)
• Your GFR tells how much kidney function
you have.
Causes of chronic kidney
disease
Anyone can get chronic kidney
disease at any age.
• Diabetes
• Hypertension
• Glomerulonephritis
(Inflammation)
• Drugs and toxins
• Blockage
• Heredity
• Others
Clinical Presentatation
• Early stages of CKD asymptomatic.
• Symptoms may be non specific.
• Only way to find out is by doing lab tests.
Symptoms of CKD
•
•
•
•
•
•
•
feel more tired and have less energy
have trouble concentrating
have a poor appetite
have trouble sleeping
have swollen feet and ankles/puffyeyes.
have dry, itchy skin
need to urinate more often, especially at
night.
Warning signs of CKD
• High blood pressure.
• Blood and/or protein in the urine/Frothy urine.
• Serum creatinine and Blood Urea) blood test,
outside the normal range.
• A glomerular filtration rate (GFR) less than 60.
Prevention of CKD
• Eat healthy-Diet.
• Physical Activity.
• Control of High blood pressure.
• Avoiding pain meds /other nephrotoxins.
Chronic kidney disease
Who should be tested for CKD?
Patients with following medical problems
Diabetes mellitus.
Hypertension.
Heart failure.
Atherosclerotic heart disease.
Cerebrovascular or peripheral vascular disease.
Unexplained anemia.
Family history of ESRD .
First nations peoples.
Diet in CKD
• In order to help maintain healthy kidneys it is important
to eat properly.
• Keep track of daily calories
• Limit total fat
• Watch high fructose corn syrup
• Control salt intake.
• Watch fluid intake.
Sources of Sodium
Sodium
• Sodium causes thirst
• Sodium holds water
in the body
What about medications and the
Kidney
• Some meds can
cause kidney
problems.
• Some meds can
worsen the
kidney function.
• Some meds are
very safe with the
kidneys.
• Some meds are
used to help your
kidney function.
Natural Products
• Generally NOT
recommended.
• Natural product does
not mean safe
product.
• Talk to your doctor or
pharmacist before
taking any new
medication
Smoking and Kidneys
• Cigarette smoking induces blood vessel
stiffness which may persist for a decade
after smoking cessation.
• Shown to be a risk factor for development
of Chronic kidney disease.
Exercise and Kidney
• Exercise can help you improve physical
functioning and emotional well-being,
increase physical stamina.
• Improve blood pressure and reduce the risk
of heart disease, lower cholesterol, help you
sleep better and control body weight.
• Incorporating consistent aerobic exercise,
even taking a 20-minute walk, can help
especially if your CKD is a result of
hypertension or diabetes.
Benefits of early education
• Delay or prevent the worsening of cardiovascular
disease, hypertension and diabetes.
• Delay or prevent the progression to chronic kidney
disease.
• Improve outcomes if kidney replacement therapy
ever becomes necessary.
• Psychologically prepare one for kidney disease.
• Reduce health care costs
Common tests used in CKD
•
•
•
•
•
•
Blood urea.
Serum Creatinine.
eGFR.
Urine exam.
Ultrasound of kidneys.
Electrolytes.
Treatment of CKD
•
•
•
•
•
•
•
•
Treat the underlying disease.
Treat associated problems.
Slowing the loss of kidney function.
Prevent heart disease.
Avoidance of Nephrotoxins.
Controlling protein leak by medications.
Preparation for dialysis/transplantation
Kidney transplant or dialysis
Stages in Progression of Chronic Kidney
Disease and Therapeutic Strategies
Complications
Normal
Screening
for CKD
risk factors
Increased
risk
CKD risk
reduction;
Screening for
CKD
Damage
 GFR
Kidney
failure
Diagnosis
Estimate
Replacement
& treatment; progression;
by dialysis
Treat
Treat
& transplant
comorbid complications;
conditions;
Prepare for
Slow
replacement
progression
CKD
death
Diabetic Nephropathy
• Have your urine, blood and blood pressure
checked regularly by your doctor.
• Maintain good control of your blood sugar.
• Control high blood pressure (less than 130/80*
on most readings)
• Stop smoking, Exercise regularly, Make the
proper food choices, Avoid excess alcohol
CKD
ESRD
Dialysis
• Dialysis is process for removing waste and
excess water from the blood.
• Artificial replacement of kidney function.
• 2 main kinds of dialysis
-Hemodialysis
-Peritoneal dialysis
• It can be done at home or in hospital
setting.
Hemodialysis
• Typically 4 hours
3/week.
• Can be done more
often or at night.
• Can replace 10-15%
of native renal
function only.
Home dialysis Therapies
There are 2 types of home dialysis:
1. Peritoneal
Dialysis
2. Home
Hemodialysis
What Is A Kidney Transplant?
• A surgery in which a
healthy kidney from
one person is placed
into another person
What Is A Living
Kidney ?Donor?
• Living person (usually
family or friend) who
chooses to give you
one kidney.
• Age 18 to 70’s.
• In good health.
• Blood compatibility
/Paired Exchange
Program.
What is A Deceased
Kidney Donor?
• Deceased person,
previously in good
health, who had
consented to donate
kidneys.
• An option for people
who don’t have living
donors (usually once
dialysis started).
Renal stones
• Affects 11% of males and 9% of females
by age of 70 years.
• Kidney stone can be formed when
substances like Ca, Oxalate, Uric acid are
high( or if urine volume is low).
• Diet with high levels of animal protein, high
levels of sugars, High sodium, high
spinach consumption.
Renal stones
• Pain, blood in urine, gravel or
asymptomatic.
• US or CT scan.
Management:
• Pain control
• Lithotripsy.
• Uretroscopy
• Diet/Fluid/Medications
Conclusions
• Chronic kidney disease is increasingly
recognized as a health concern.
• Early recognition and management is the
key in management of CKD patients.
• Prevention is better then cure.
Resources
• National Kidney foundation.
http://www.kidney.org
• Kidney foundation of Canada.
http://www.kidney.ca/