Chronic Kidney Disease Dr.Niazy b hussam PhD Clinical Pharmacy

Chronic Kidney Disease (CKD) Involves progressive, irreversible loss of kidney function Defined as either presence of Kidney damage Pathological abnormalities Glomerular filtration rate (GFR) <60 ml/min for 3 months or longer

Chronic Kidney Disease Disease staging based on decrease in GFR What is the normal GFR? What diagnostic test reflects GFR? Last stage of kidney failure End-stage renal disease (ESRD) occurs when GFR <15 ml/min

Chronic Kidney Disease Leading causes of ESRD Diabetes Hypertension

Chronic Kidney Disease Clinical Manifestations Uremia Syndrome that incorporates all signs and symptoms seen in various systems throughout the body

Manifestations of Chronic Uremia Fig. 47-5

Chronic Kidney Disease Clinical Manifestations Urinary system Polyuria Results from inability of kidneys to concentrate urine Occurs most often at night Specific gravity fixed around 1.010

Chronic Kidney Disease Clinical Manifestations Urinary system Oliguria Occurs as CKD worsens Anuria Urine output <40 ml per 24 hours

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances Waste product accumulation As GFR ↓, BUN ↑ and serum creatinine levels ↑ BUN ↑ Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headaches occur

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Potassium Hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysrhythmias

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Sodium May be normal or low Because of impaired excretion, sodium is retained Water is retained Edema Hypertension CHF

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Calcium and phosphate alterations Magnesium alterations Metabolic acidosis Results from Inability of kidneys to excrete acid load (primary ammonia)

Chronic Kidney Disease Clinical Manifestations Hematologic system Anemia Due to ↓ production of erythropoietin From ↓ of functioning renal tubular cells Bleeding tendencies Defect in platelet function

Chronic Kidney Disease Clinical Manifestations Hematologic system Infection Changes in leukocyte function Altered immune response and function Diminished inflammatory response

Chronic Kidney Disease Clinical Manifestations Cardiovascular system Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis

Chronic Kidney Disease Clinical Manifestations Respiratory system Kussmaul respiration-Why? Dyspnea-Why? Pulmonary edema-Why? Uremic pleuritis-Why? Pleural effusion Predisposition to respiratory infections Depressed cough reflex “Uremic lung”

Chronic Kidney Disease Clinical Manifestations Gastrointestinal system Every part of GI is affected Due to excessive urea Mucosal ulcerations Stomatitis Uremic fetor (urinous odor of the breath) GI bleeding Anorexia N/V

Chronic Kidney Disease Clinical Manifestations Neurologic system Expected as renal failure progresses Attributed to Increased nitrogenous waste products Electrolyte imbalances Metabolic acidosis Demyelination of nerve fibers Altered mental ability Seizures and Coma Dialysis encephalopathy Peripheral neuropathy

Chronic Kidney Disease Clinical Manifestations Neurologic system Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate

Chronic Kidney Disease Clinical Manifestations Musculoskeletal system Renal osteodystrophy Syndrome of skeletal changes Result of alterations in calcium and phosphate metabolism Weaken bones, increase fracture risk Two types associated with ESRD: Osteomalacia Osteitis fibrosa

Renal Osteodystrophy Fig. 47-6

Chronic Kidney Disease Clinical Manifestations Integumentary system Most noticeable change Yellow-gray discoloration of the skin Due to absorption/retention of urinary pigments Pruritus Uremic frost Dry, pale skin

Chronic Kidney Disease Clinical Manifestations Integumentary system Dry, brittle hair Thin nails Petechiae Ecchymoses

Chronic Kidney Disease Clinical Manifestations Reproductive system Infertility Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction

Chronic Kidney Disease Diagnostic Studies Laboratory tests (cont’d) Urinalysis Urine culture Hematocrit Hemoglobin Renal ultrasound Renal scan

The aims of the treatment of CKD can be summarised as • Reverse or arrest the process causing the renal damage (this may not be possible)• Avoid conditions that might worsen renal failure(Box 18.1) • Treat the secondary complications of CKD (renal anaemia and bone disease) • Relieve symptoms • Implement regular dialysis treatment and/or transplantation at the most appropriate time.

Chronic Kidney Disease Collaborative Care Drug therapy Hyperkalemia IV insulin and glucose IV 10% calcium gluconate Raises threshold for excitation Sodium bicarbonate Shift potassium into cells Correct acidosis

Chronic Kidney Disease Collaborative Care Drug therapy Hyperkalemia (cont’d) Sodium polystyrene sulfonate (Kayexalate) Cation-exchange resin Resin in bowel exchanges potassium for sodium Evacuates potassium-rich stool from body Educate patient that diarrhea may occur due to laxative in preparation

Chronic Kidney Disease Collaborative Care Drug therapy Hypertension (cont’d) Antihypertensive drugs Diuretics β-Adrenergic blockers Calcium channel blockers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blocker agents

Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy Phosphate intake restricted to <1000 mg/day Phosphate binders Calcium carbonate (Tums) Bind phosphate in bowel and excreted Sevelamer hydrochloride (Renagel) Lowers cholesterol and LDLs

Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Phosphate binders (cont’d) Should be administered with each meal Side effect: Constipation Supplementing vitamin D Calcitriol (Rocaltrol) Serum phosphate level must be lowered before administering calcium or vitamin D

Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Controlling secondary hyperparathyroidism Calcimimetic agents Cinacalcet (Sensipar) ↑ Sensitivity of calcium receptors in parathyroid glands Subtotal parathyroidectomy

Chronic Kidney Disease Collaborative Care Drug therapy Anemia Erythropoietin Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Side effect: Hypertension

Chronic Kidney Disease Collaborative Care Drug therapy Anemia (cont’d) Iron supplements If plasma ferritin <100 ng/ml Side effect: Gastric irritation, constipation May make stool dark in color

Chronic Kidney Disease Collaborative Care Drug therapy Anemia (cont’d) Folic acid supplements Needed for RBC formation Removed by dialysis Avoid blood transfusions

Chronic Kidney Disease Collaborative Care Drug therapy Complications Drug toxicity Digitalis Antibiotics Pain medication (Demerol, NSAIDs)

Chronic Kidney Disease Collaborative Care Nutritional therapy Protein restriction 0.6 to 0.8 g/kg body weight/day Water restriction Intake depends on daily urine output

Chronic Kidney Disease Collaborative Care Nutritional therapy Sodium restriction Diets vary from 2 to 4 g depending on degree of edema and hypertension Sodium and salt should not be equated Patient should be instructed to avoid high-sodium foods Salt substitutes should not be used because they contain potassium chloride

Chronic Kidney Disease Collaborative Care Nutritional therapy Potassium restriction 2 to 4 g High-potassium foods should be avoided Oranges Bananas Tomatoes Green vegetables

Chronic Kidney Disease Collaborative Care Phosphate restriction 1000 mg/day Foods high in phosphate Dairy products Most foods high in phosphate are also high in calcium

Patiemt care Excess fluid volume Risk for injury Imbalanced nutrition: Less than body requirements Grieving Risk for infection

Patient care Health promotion Identify individuals at risk for CKD History of renal disease Hypertension Diabetes mellitus Repeated urinary tract infection Regular checkups and changes in urinary appearance, frequency and volume should be reported

Chronic Kidney Disease Gerontologic Considerations Diminished cardiopulmonary function Impaired cognition Altered drug metabolism Bone loss Immunodeficiency

Chronic Kidney Disease Gerontologic Considerations Most common cause of death in the elderly ESRD patient Cardiovascular disease (MI, stroke) Withdrawal from dialysis

Read the treatment and renal transplantation page 283=293 chap 18 All tables and figures in this chapters are included