Renal Anatomy Renal Anatomy Renal Anatomy Renal Function

Renal Anatomy

Renal Anatomy

Renal Anatomy

Renal Function 1. Excretory & Regulatory – Solute : electrolyte & non-electrolyte – Solvent : water 2. Synthetic – Erythropoietin RBC stimulation – 1, 25 -(OH)2 Vitamin D 3 (Calcitriol) – Etc.

Renal Function GFR (90 ml/min. /1. 73 m 2)

RENAL FAILURE • Definition : ↓ Renal function • ↓ GFR (Glomerular filtration rate) → ↓ Uremic toxin excretion → ↑ Serum BUN, Cr

GFR Measurement 1. Direct clearance of substance • Inulin – Gold standard • Radioisotope - 99 m. Tc EDTA, 125 I Iothalamate • Creatinine – practical • CCr (Cr Clearance) ~ GFR • CCr (ml/min. ) = UCr x V (urine volume) PCr

GFR Measurement 2. Formula • Cockcroft-Gault CCr (ml/min) = (140 - Age) x Body weight x (0. 85 if Female) 72 x SCr • MDRD e. GFR (ml/min/1. 73 m 2) = 186 x (SCr)-1. 154 x (Age)-0. 203 x (0. 742 if Female) x (1. 210 if African-American)

GFR Measurement 2. Formula • CKD-EPI – Recommended formula Serum Cr Female Male e. GFR (ml/min/1. 73 m 2) ≤ 0. 7 144 × (Scr/0. 7)-0. 329 × (0. 993)Age > 0. 7 144 × (Scr/0. 7)-1. 209 × (0. 993)Age ≤ 0. 9 141 × (Scr/0. 9)-0. 411 × (0. 993)Age > 0. 9 141 × (Scr/0. 9)-1. 209 × (0. 993)Age

GFR Measurement http: //www. nephron. com/MDRD_GFR. cgi

RENAL FAILURE • ARF (Acute Renal Failure) – ↓ Renal function in hours to days • AKI (Acute Kidney Injury) • CRF (Chronic Renal Failure) – ↓ Renal function in > 3 months • CKD (Chronic Kidney Disease)

Reversible ! ARF CRF Irreversible…

Clues in Diagnosis of CKD (from AKI) 1. Uremia > 3 months - Previous high serum BUN, Cr - Clinical : nausea, edema, hematuria, nocturia 2. Small size kidneys : < 9 cm 3. Anemia 4. Renal osteodystrophy

Chronic Kidney Disease (CKD) Definition: duration ≥ 3 months 1. Kidney damage – Pathology – Structure: Stone, Cyst, Mass, etc. – Function: Proteinuria, Albuminuria Hematuria, Abnormal Cast And / Or 2. GFR < 60 ml/min/1. 73 m 2

Stages of CKD Stage Description GFR Action 0 At increased risk ≥ 90 Screening, CKD risk reduction 1 Kidney damage with normal GFR ≥ 90 Dx & Rx, Rx of comorbid condition, Slowing progression, CVD risk reduction 2 3 60 -89 Estimating progression Kidney damage with mild GFR Moderate GFR 30 -59 Assess & Rx complication 4 Severe GFR 15 -29 Praparation for RRT 5 Kidney failure < 15 Renal replacement

Stages of CKD Stage Description GFR Action 0 At increased risk ≥ 90 Screening, CKD risk reduction 1 Kidney damage with normal GFR ≥ 90 Dx & Rx, Rx of comorbid condition, Slowing progression, CVD risk reduction 2 3 60 -89 Estimating progression Kidney damage with mild GFR Moderate GFR 30 -59 Assess & Rx complication 4 Severe GFR 15 -29 Praparation for RRT 5 Kidney failure < 15 CRF Renal replacement

Male, BW 60 Kg, Age 60 Serum Cr CKD-EPI Cockcroft- CKD Gault stage 1. 3 59 51 3 2. 5 27 27 4 5. 0 12 13 5

Stages of CKD Stage Description GFR 0 At increased risk ≥ 90 1 Kidney damage with normal GFR ≥ 90 8. 9 % 3 60 -89 Kidney damage with mild GFR Moderate GFR 30 -59 4 Severe GFR 15 -29 5 Kidney failure < 15 2 Prevalence in THAILAND 2550 8. 7 % (4, 500, 000 – Thai) (120, 000 – Chiang. Mai)

How to approach CKD Patients • Work up cause & Correction • Slow progression of CKD • Comorbidity treatment • Counseling & Patient education – Cost – Mode of Renal replacement therapy : HD, CAPD, Kidney transplantation – Nutrition – Vascular access (in HD) • Renal replacement therapy

Causes of CKD § § DM : most common (~ 30 -40 %) Chronic glomerulonephritis (CGN) Vascular disease : HT Tubulointerstitial : Stones, NSAIDs, Gout § Others : Polycystic kidney, etc.

Initial investigation for CKD • U/A : proteinuria, sediment Proteinuria trace – repeat in 3 -6 m. +1 – repeat in 3 -6 m. or urine protein-creatinine ratio (UPCR) > +2 – urine protein-creatinine ratio (UPCR) Abnormal : UPCR > 0. 2 (or urine protein > 0. 3 g/day) • Serum creatinine, e. GFR • Plain KUB (or ultrasound) • Others (depend on patient)

Slow Progression in CKD • Control BP • ACEI, ARB • Low Protein, Low Salt Diet • Control Blood Sugar • Control Lipid Level (? ) • Avoid Smoking • Avoid Nephrotoxic Agents

Control BP • Goal: ~ 130/80 – 140/90 mm. Hg • Lifestyle modifications – Weight reduction: BMI 19 -23 – Diet: Low Salt Low Fat (saturated) – Exercise (30 min. x 5 / week) – Moderate Alcohol consumption (Beer 720 cc, Wine 300 cc, Whisky 90 cc)

Control BP • Medication – ACEI, ARB – ACEI (Angiotensin Converting Enzyme Inhibitor): • Enaril (Enalapril) • Coversil (Perindopril) • Tritace (Ramipril)

Control BP • Medication – ARB (Angiotensin II Receptor Blocker) • Cozaar (Losartan) • Diovan (Valsartan) • Micardis (Telmisartan) • Aprovel (Irbesartan)

Control BP • Medication – Ca 2+-channel blocker • Amlodipine • Adalat (Nifedipine) • Madiplot (Manidipine) • Zanidip (Lercanidipine) • Isoptin (Verapamil) • Herbesser (Diltiazem)

Control BP • Medication – Diuretics • Lasix (Furosemide) • HCTZ (Hydrochlorothiazide) • Aldactone (Spironolactone) – Beta-blocker • Metoprolol • Atenolol • Propranolol

Control BP • Medication – Alpha-blocker • Cardura, Pencor (Doxazosin) • Minipress (Prazosin) – Centrally acting agent • Aldomet (Methyldopa) – Direct vasodilator • Apresoline (Hydralazine) • Minoxidil

RAAS (Renin-Angiotensin-Aldosterone System)

Diet Protein • GFR < 30 ml/min/1. 73 m 2 (stage 3) o 0. 8 g/kg/day • CKD at risk of progression o avoid high protein (1. 3 g/kg/day) Salt • < 2 g/day of Na+ (5 g of Na. Cl, ������ 1 ������ , ������ 2 ���� )

Control Blood Sugar • Goal – Fasting: 80 -120 mg/dl – Post-prandial: 80 -160 mg/dl – Hb. A 1 C: ~ 7 % – Precaution of “Hypoglycemia”

Control Lipid Level • Goal – Total Cholesterol: < 200 mg/dl – Triglyceride: < 200 mg/dl – HDL: > 45 mg/dl – LDL: < 100 mg/dl

Nephrotoxic Agents • NSAIDs : Diclofenac, Ibuprofen, Mefenamic acid (Ponstan), Indomethacin, Naproxen, etc. • Aminoglycoside : Gentamicin, Amikin • Herb medicine • ACEI, ARB – stop, if Cr > 25% or Hyperkalemia

Treatment of CKD

Treatment • Medication – Anti-hypertensive – Diuretics – Phosphate binder : Ca. CO 3, Al(OH)3 – Alkaline : Na. HCO 3 – Rx of Anemia : EPO (erythropoietin), PRC transfusion, Ferrous Goal Hb 10 -12 g/d. L (Hct 30 -36%) – Vitamin : Bco, C, Folic – Others : DM, IHD, Dyslipidemia, Hyper K+

Treatment • Diet Control – Low Protein – Low Salt – Low K+ – Low Phosphate – Low Fat – Restricted Fluid Intake

Treatment • Correct Volume Status – Dehydration: • Volume replacement • Avoid diuretics – Volume overload: • Restrict fluid intake • Diuretics • Dialysis: HD, PD

Treatment • Renal Replacement Therapy Indications for Dialysis in CKD (ESRD) – GFR ≤ 6 ml/min. /1. 73 m 2 (Serum Cr ~ 10 mg/dl) – Volume overload, Uncontrolled BP – Hyper K+, Hyper P – Uremic encephalopathy – Uremic pericarditis, pleuritis – Protein-Energy Malnutrition

Treatment • Mode of Dialysis – Hemodialysis (HD) : • Intermittent • Continuous (CRRT, Continuous Renal Replacement Therapy) – CVVH(F), CAVH(F), CVVHDF, etc. – Peritoneal Dialysis (PD) : • Intermittent • Continuous – CAPD (Continuous Ambulatory PD), etc.

Convection

Hemodialysis Ultrafiltrate (UF) Diffusion Blood Uremic toxins & Water M E M B R A N E Dialysate Convection

Peritoneal Dialysis. Ultrafiltrate (UF) Diffusion Blood Uremic toxins & Water M E M B R A N E Peritoneal Cavity Dialysate

Nutrition Daily Requirement in HD patients • Energy 30– 35 kcal/kg • Protein 1. 2 g/kg High biological value > 50% • Na+ 3 g อาหารโปรตนทม essential • K+ 3 g amino acid ครบถวน ในสดสวนทเหมาะสม • Phosphate 1. 2 g ไดแก เนอสตว ไข นม • Water 500– 1000 ml + Urine output

Kidney Transplantation - Living-related KT - Cadaveric KT

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Peritoneal Dialysis. Ultrafiltrate (UF) Diffusion Blood Uremic toxins & Water M E M B R A N E Peritoneal Cavity Dialysate

Mode of PD 1. Continuous • Continuous Ambulatory PD (CAPD) • Continuous Cyclic PD 2. Intermittent • Day-time Ambulatory PD • Nightly Intermittent PD Manual / Automated

Mode of PD Auto mated PD

PD Prescription • Mode: CAPD • Peritoneal Dialysate Fluid • 1. 5%, 2. 5%, 4. 25% Dextrose • 2 Litre / bag • 4 - 6 cycles / day • Adequacy • Weekly Kt/V > 1. 7 • Weekly n. CCr > 50 Litre / 1. 73 m 2

Complications • • Infection Volume overload Catheter malfunction Metabolic: Hypo. K+, Hyperglycemia Anemia Cardiovascular Malnutrition Inadequacy

Complications Infection 1. Exit site infection & Tunnel infection - common cause: staph. aureus - Empirical Rx of exit site infection : Dicloxacillin, oral, 14 d

Complications Infection 1. Exit site infection & Tunnel infection - common cause: staph. aureus - Empirical Rx of exit site infection : Dicloxacillin, oral, 14 d Acute Exit Site Infection

Complications Infection 1. Exit site infection & Tunnel infection - common cause: staph. aureus - Empirical Rx of exit site infection : Dicloxacillin, oral, 14 d Chronic Exit Site Infection

Infection 1. Exit site infection & Tunnel infection - common cause: staph. aureus - Empirical Rx of exit site infection : Dicloxacillin, oral, 14 d Chronic Exit Site Infection Equivocal Exit Site Infection

Tunnel Infection

Complications Infection 2. Peritonitis - common cause: staph. epidermidis - PDF WBC > 100 /m. L, > 50% PMNs - PDF 10 ml in hemoculture media: yield - Empirical Rx: Cefazolin 1 gm, IP, od Ceftazidime 1 gm, IP, od or specific Rx 14 d

Complications Infection 2. Peritonitis - Heparin, 500 u/L, prevent occlusion of the catheter by fibrin - Indications for Catheter Removal: • Refractory peritonitis • Relapsing peritonitis • Refractory exit-site and tunnel infection • Fungal peritonitis

Complications Infection 2. Peritonitis < 4 weeks > 4 weeks Same organism Relapsing Repeat New organism Recurrent Refractory : failure of the effluent to clear after 5 days of appropriate ABO

Complications Infection 2. Peritonitis < 4 weeks > 4 weeks Same organism Relapsing Repeat New organism Recurrent Refractory : failure of the effluent to clear after 5 days of appropriate ABO

Complications Volume overload Edema - I/O, Salt & Water & Diet - Compliance - Residual renal function False UF Failure True UF Failure PET study High - Catheter malfunction - Leakage - Peritonitis - Large vascular area Low High Av/Low Av - Adhesion - SEP - Aquaporin def. - Lymphatic absorption

Complications • • Infection Catheter malfunction Volume overload Metabolic: Hypo. K+, Hyperglycemia Anemia Cardiovascular Malnutrition Inadequacy