3Objectives Explain the scope of CKD and its stages. Discuss options for renal replacement therapy.Review commonly seen problems in renal patients.Explore the reasons for markedly higher incidence of cardiovascular disease in the renal population.
4Estimating Severity of CKD Can use many formulas.ALL require steady state, BUT not on dialysis.MDRD Calculator many sites:
6USRDS Projected Growth of Prevalent Dialysis and Transplant Populations U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008
7Geographic variations in adjusted incident rates of ESRD per million population, 2009, by HAS Fig 1.4 (Vol 2)Adj: age/gender/race; ref: 2005 ESRD patients.U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011
8Prevalent counts & adjusted rates of ESRD, by race Fig 1.12 (Vol 2) December 31 point prevalent ESRD patients. Adj: age/gender; ref: 2005 ESRD patients.U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011
9Prevalent Counts & adjusted rates of ESRD, by diagnosis Fig 1 Prevalent Counts & adjusted rates of ESRD, by diagnosis Fig 1.14 (Volume 2)December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011
10Causes of Renal Failure DM 30-40%HTN 25-35%GNGeneticPolycystic Kidney DiseaseAlport’sObstructive nephropathyDrug-inducedUnknownU.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008
11Adjusted all-cause mortality in the ESRD & general populations, by age, 2009 Fig 5.2 (Vol 2) Prevalent ESRD & general Medicare (non-ESRD) patients. Adj: gender/race; ref: Medicare patients, 2009.U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011
12FIGURE 17-15 Causes of death among U. S FIGURE 17-15 Causes of death among U.S. transplant recipients with a functioning graft. CVD, cardiovascular disease. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 152.)
13Overview of Dialysis Therapy Outpatient (in-center) Hemodialysis (HD) – usually done 3 times a week. Most common type.Home therapies:Daily or nocturnal HD.Chronic Ambulatory Peritoneal Dialysis (CAPD)Cyclic Peritoneal Dialysis usually performed at night.Require patient or caregiver be thoroughly trained to perform independently.Less common as in-center hemodialysis.
17Hypotension Occurs in 20-30 % of HD treatments Causes:Rapid reduction of plasma osmolality causing extracellular water to shift into cells.Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr.Poor cardiac reserve.Autonomic neuropathy.BP meds.Eating before or during dialysis.May present 1-2 hours post-treatment.Therapies- Volume replacement, adjust meds, UF slowly, check EF.
18Hypertension Seen in 85% of renal patients. Salt/water excess usual cause.Elevated renin secretion from diseased kidneys is common.
19Hypertension ESA side effect Sympathetic over activity. Non-compliance with meds or withholding prior to dialysis.Salt and water restriction not followed.
20Malnutrition Associated with decreased survival Causes:Drug effects.Chronic constipation.Lack of understanding of renal nutrition.Low income.Malabsorption and GI motility disorders.Impaired taste.All Patients are evaluated and followed by dietician in dialysis unit. CKD patients should receive dietary education as part of CKD care.
21GI BleedDon’t assume anemia is simply from CKD. Check iron levels and w/u when deficient.Gastritis - most common.Angiodysplasia - second most common.Uremic platelet dysfunction contributes to the severity- DDAVP can help short-term.If patient is possible transplant candidate, use WBC filter with PRBC transfusions when blood products needed… decreases HLA antibody formation.
22Nephrogenic Systemic Fibrosis Typically starts with patients reporting swelling and a “tight” feeling in extremities.Skin changes may be red or dark patches, papules, plaques, or nodules.Progressing over days to weeks to inhibit flexion and contraction of joints & contractures.Skin becomes “woody” with peu d’orange consistencyLesions often symmetrical, involving LE first, then UE.Most common with GFR < 30 and Gadolinium exposure.From Cowper NFD/NSF Website.
23Nephrogenic Systemic Fibrosis Raised and erythematous nodular plaques,& linear and confluent regions of fibrosisSoft tissue swelling & contracturesFrom nephrogenic-systemic-fibrosis.info
24Neurologic Complications of Uremia Uremic neuropathy is the most common neurologic finding.Uremic encephalopathy (UE) develops when GFR < 10% of normal.Rare in well dialyzed patients.Seizures are seen in 25% of patients with UE.Restless legs syndrome is reported in > 40% of uremic patients.Myopathy, optic neuropathy and mononeuropathies noted.Hyperkalemia can cause flaccid quadriparesis.Goetz: Textbook of Clinical Neurology, 3rd ed
25Neurologic Complications of Uremia (cont.) Vestibulocochlear and neuromuscular junction disturbances can be seen in association with aminoglycoside atb.Loop diuretics can cause tinnitus.Amyloid fibrils (b2 microglobulin deposits) can cause carpal tunnel syndrome.Goetz: Textbook of Clinical Neurology, 3rd ed
26Neurologic Complications of Uremia (cont.) Subdural hemorrhage.Dialysis headaches.Exacerbation of migraine headaches.Ischemic monomelic neuropathy.Goetz: Textbook of Clinical Neurology, 3rd ed
27Neurologic Complications of Uremia (cont.) Dysequilibrium SyndromeCerebral edema d/t rapid reduction of omolality during hemodialysis.Dialysis dementia (vascular, b2- macroglobulin).Goetz: Textbook of Clinical Neurology, 3rd ed
28Neurologic Complications of Uremia (cont.) Vitamin deficiencyWater soluble vitamins dialyzed out.Poor nutrition common.Nephrology vitamins available.Goetz: Textbook of Clinical Neurology, 3rd ed
29Neurologic Complications of Uremia (cont.) Phenytoin has decreased plasma binding and higher free (active) drug.Check free phenytoin level.Usually the same loading and maintenance dosed used.Since half-life decreased, TID dosing regimen is favored over BID.Goetz: Textbook of Clinical Neurology, 3rd ed
30Syncope in Renal Disease ArrhythmiasIntrinsicElectrolyte induced (K, Calcium, Mg.)Acidemia, or rarely alkalemia.Intra- or post-dialytic hypotension.Common causes occur commonly.Given CVD risk, need thorough evaluation for vascular disease.Barbour et al. Semin Nephrol 2001; 21 (1) :
31CVD and CKD Primary cause of death is accelerated CVD AHA: ESRD should be considered highest risk.1 Considered a CV risk equivalent.Entire spectrum of CKD associated with increased risk. 2-4Very high prevalence of traditional CKD risks.HTN & cholesterol have U-shaped relationship.1. Sarnak et al. Circulation 2003; 108:2. Collins et al. Kidney Int suppl 2003. S24-S31.3. Henry et al. Kidney Int 2002; 62:4. Muntner et al. J Am Soc Nephrol 2002; 13:
32Dyslipidemia Lipids combine with apolipoproteins to form lipoproteins. Lipoprotein profiles are affected by CKDHDL, LDL and total cholesterol decline with worsening renal function.1Dense LDL and lipoprotein (a) are increased. 2Elevated lipoprotein(a) is an independent risk factor for CVD in hemodialysis patients and is associated with vascular events. 3Kanske BL. Am. J Kidney Dis, 1988; 32 (suppl 3) : SKwan et al. J. Am. Soc Nephrol 2007; 18 (4) :Cressman et al. Circulation 1992; 86 (2) :
33CV Mortality Foley et al. Am J Kidney Dis 32 (suppl):S112–S115, 1998 Brenner and Rector's The Kidney, 8th ed.
34CVD in patients with or without CKD, 2009 fig 4.1 (Vol 1) December 31 point prevalent Medicare enrollees age 66 & older, with fee-for-service coverage for all of 2009.U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011
35Effects of CKD on Cardiovascular System McCullough PA: Why is chronic kidney disease the “spoiler” for cardiovascular outcomes? J Am Coll Cardiol 41;725, 2003
37Dyslipidemia (cont.)Triglycerides tend to increase with CKD, especially NS and those on dialysis.1NFK recommends lifestyle modifications for those with CKD.Target LDLC is < 100 mg/dl for all renal patients.1. Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) :
38Dyspnea in ESRD Pulmonary edema, often non-cardiogenic. Failure to decrease est dry weight (EDW) in those losing weight.Excess intake, exceeding capacity for UF.Peritoneal dialysate leakage.High output cardiac failure can develop from AV grafts or fistulae which can have blood flow of >20-30% of cardiac output .Pneumothorax or hemothorax after catheter placement.Pericardial effusion or cardiac tamponade.
39Initial Rx of Pulmonary Edema in Renal Failure Supplemental oxygen.Morphine.High dose loop Diuretic (if significant residual UO).May work as vasodilator.Preload reduction with nitrates.Rx of HTN.Definitive rx is fluid & salt removal with dialysis- not always “urgent.”
40Chest Pain in CKD50% of renal deaths are related to ischemic heart disease, so ACS has to be in Ddx.Baseline EKG often abnormal d/t LVH, e-lyte disturbances or fluid overload.ST segment elevation is indicative of ACS.1Chronic troponin elevations are misleading.Uremic PericarditisPulmonary embolus, 12.5% incidence in ESRD vs 22% in general population.2Goldsmith et al, Kidney Int 2001; 60 :Wiesholder et al, Am J Kidney Dis 1999; 33:702-8.
41Chest Pain in Renal Disease (cont) Higher prevalence of silent ischemia.Patient with CKD presenting with chest discomfort has 40% cardiac event 30 days.1ESRD patients have highest mortality after AMI. 2McCullough et al: Arch Intern Med 2002; 162:2464.Braumwald
42Approach to ESRD patient with Suspicion of CAD McCullough PA: Kidney Int Suppl 95:s51-58, 2005
43Long-term survival by CAD management strategy in patients with CKD or ESRD. Keely et al. Am J Cardiol 92: , 2003
44Management of CVD in Renal Failure Lifestyle modification, as per general population.Including physical activity when possible.Control BP.Goal LDL < JNC7 recognizes CKD as independent risk factorHave low threshold to evaluate atypical findings:Worsening fatigue.Hypotension in someone with hx HTN.Atypical chest discomfort.Dyspnea not related to pulmonary edema.
45Calcification & vasculature Calcifications of the pelvic arteries.London GM, et al. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant ;18(9): , by permission of Oxford University Press .
46Infections and Renal Disease Renal failure = immunocompromised state.Hypothermia common in renal failure.Fever often absent.Low grade temps can indicate serious infection.Catheters and grafts are often source.Higher incidence of HCV.Note many antibiotics are dialyzable and require dose adjustment .
47Fatal Bacterial Infections in HD & PD in Australia and New Zealand 1995-2005 Johnson et al. AM J Kidney Dis 53:
48Acquired Renal Cystic Disease (ARCD) Renal neoplasms seen in 10% of chronic HD patients. Adenomas most common.With ARCD, prevalent incidence is 20-25%.Present silently or w flank pain and hematuria.RCC has 3-7X higher incidence in ESRD than general population.ARCD may regress post-tx.Wein: Campbell-Walsh Urology, 9th ed.
50Secondary Hyper-parathyroidism (SPTH) CKD is the most common cause of SPTH.Failing kidneys do not convert enough vitD to its active form.Failing kidneys inadequately excrete phosphorus. This results in (insoluble) ca-phos complexes that remove calcium from the circulation.Both processes leads to hypocalcemia & secondary hyperparathyroidism.Vascular calcification common.
51Rx Secondary Hyperparathyroidism Low phos diet and phos binders.Active Vit D supplements calcitriol (Rocaltrol), doxercalciferol (Hectorol), paricalcitol (Zemplar)Calcimimetic- cinacalcet (Sensipar) mimics the action of calcium on tissues by allosteric activation of ca-sensing receptor.Educate and reinforce, re-educate.
52SummaryRenal failure is a systemic disease that affects every other organ system.For any age, CKD and ESRD patients have markedly increased mortality compared to general population.CVD has very high incidence and needs to be looked for and treated aggressively.Vague presentations of infection or CVD are common.