1. Chronic Kidney Disease
Dr.Niazy b hussam
PhD Clinical Pharmacy

2. 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

4. 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

5. Chronic Kidney Disease
Leading causes of ESRD
Diabetes
Hypertension

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

7. Manifestations of Chronic Uremia
Fig. 47-5

8. 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

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

10. 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

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

12. 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

13. 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)

14. 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

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

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

17. 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”

18. 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

19. 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

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

21. 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

22. Renal Osteodystrophy
Fig. 47-6

23. 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

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

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

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

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

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

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

39. 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

40. 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

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

42. 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

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

44. 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

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

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

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