​Kembara Xtra - Medicine - Chronic Kidney Disease

​Kembara Xtra - Medicine - Chronic Kidney Disease 
Introductionn 
As established by pathologic abnormalities or signs of damage (abnormalities in blood or urine tests, histology, imaging investigations), or by a glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2, chronic kidney disease (CKD) is characterized by structural or functional abnormalities of the kidney. Findings are available for around three months. The causes, GFR categories (G1 to G5), and albuminuria categories (A1 to A3) are used to categorize CKD.

GFR estimation categories according to Kidney Disease: Improving Global Outcomes (KDIGO) (in mL/min/1.73 m2): G1: kidney damage with a normal or elevated GFR 90; G2: mild; GFR 60 to 89; G3a: mild to moderate; GFR 45 to 59; G3b: moderate to severe; GFR 30 to 44; G4: severe; GFR 15 to 29; and G5: renal failure; GFR 15 or dialysis
Albumin-to-creatinine ratio (ACR) categories for CKD A1: normal to mildly increased: less than 30 mg/g or less than 3 mg/mmol; A2: substantially increased: more than 300 mg/g or more than 30 mg/mmol; and A3: severely increased: more than 300 mg/g or more than 30 mg/mm.


Incidence and prevalence in Epidemiology 

Similar in both sexes, however the rate of end-stage renal disease (ESRD) is 1.6 times higher in men than in women. African Americans are 3.6 times more likely to acquire CKD than Caucasians.
Incidence
Annual incidence of 1,700/1,000,000 estimated
Prevalence
14.8% of people worldwide have CKD (stages 1 to 5).
ESRD (stage 5) has unadjusted prevalence and incidence rates of 1,752 and 362.4/1 million, respectively. The prevalence of earlier stages of CKD (stages 1 to 4), which are predicted to impact 13.1% of the population in the United States, is not reflected in the statistics. Age-related increases in prevalence peak after age 70.

Pathophysiology and Etiology 
Degradation of renal nephrons occurs gradually; plasma Cr concentrations roughly double, GFR declines by 50%, and the mass of working nephrons is lost by 75%. When GFR drops to 20 to 25 mL/min or less, hyperkalemia typically occurs. Reduced renal production of erythropoietin leads to anemia.
Hematuria, red blood cell casts, hypertension (HTN), and variable proteinuria are symptoms of nephritic renal parenchymal/glomerular disease.
Systemic lupus erythematosus (SLE), Henoch-Schönlein purpura, Alport syndrome, proliferative glomerulonephritis, and crescentic glomerulonephritis are examples of focal proliferative conditions. Diffuse proliferative conditions include membranoproliferative glomerulonephritis, SLE, cryoglobulinemia, rapidly progressive glomerulonephritis
Amyloidosis, diabetic nephropathy, membranous nephropathy, and localized segmental glomerulosclerosis
Interstitial tubular: infections, obstruction, toxins, allergic interstitial nephritis, multiple myeloma, connective tissue disease, cystic disease, nephrolithiasis; Vascular: hypertension, thrombotic microangiopathies, vasculitis (Wegener), scleroderma, crush injury; Postrenal: obstruction (benign prostatic hyperplasia [BPH]), neoplasm,
Genetics
CKD can be brought on by the Alport syndrome, Fabry disease, sickle cell disease, SLE, and autosomal dominant polycystic kidney disease.
African Americans are more likely than Caucasians to have polymorphisms in the gene that codes for podocyte nonmuscle myosin IIA, and these polymorphisms seem to raise the risk for nondiabetic ESRD.

Risk Elements 

Age > 60, type 1 or type 2 diabetes mellitus (DM) (most common), obesity, smoking, drug use, chronic infection (hepatitis B/C, HIV), CVD (HTN, renal artery stenosis, atherosclerosis), prior kidney transplant, BPH, autoimmune disease, vasculitis, connective tissue disease, and nephrotoxic medications (NSAIDs, lithium, sulfonamide, aminoglycosides, vancomycin

Prevention 
Insufficient evidence, according to the U.S. Preventive Services Task Force, prevents the recommendation of CKD screening for asymptomatic people.


Introducing History 
Patients with CKD stages 1 to 3 are typically asymptomatic but may experience oliguria, nocturia, polyuria, change in urinary frequency, bone disease, edema, HTN, dyspnea, fatigue, depression, weakness, pruritus, ecchymosis, anorexia, nausea, and vomiting. They may also experience claudication, hyperlipidemia, erectile dysfunction, decreased libido, and amen


clinical assessment 

Examine the patient for signs of low blood pressure or orthostatic edema, pallor, jugular venous distention, weight, uremic frost, ammonia-like odor, murmurs, bruits, pericarditis, pleural effusions, enlarged prostate, and changes to the central nervous system like asterixis, confusion, seizures, coma, and peripheral neuropathy.

Diagnostic tests and laboratory results

Initial Tests (Lab, Imaging) GFR can be calculated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations. Cr clearance can be calculated using the Cockcroft-Gault formula to determine medication dosage. UA can be used to check for signs of damage (WBC casts in pyelonephritis and RBC casts in glomerulonephritis/vas

Tests in the Future & Special Considerations
Chemistry: elevated BUN, Cr, hyperkalemia, metabolic acidosis, increased parathyroid hormone (PTH), hyperlipidemia, hyperphosphatemia, decreased 25-(OH) vitamin D, hypocalcemia, decreased albumin; Hematology: normochromic, normocytic anemia; increased bleeding time; Serology: antinuclear antibody (ANA); double-stranded DNA, antineutrophil cytoplasmic antibody; complements (C3, C4, CH50); anti

Caution
Cimetidine reduces Cr tubular secretion, while Trimethoprim inhibits both Cr and K+ secretion and may aggravate hyperkalemia. Cefoxitin and flucytosine increase serum Cr.
Diltiazem and verapamil show substantial antiproteinuric effects in CKD patients, similar to ACE-Is/ARBs (angiotensin-converting enzyme inhibitors).


Other/Diagnostic Procedures

 Biopsy: nephritic or nephrotic syndrome, acute/progressive renal failure, proteinuria, and hematuria
There is modest support for a one-time cystatin-C GFR estimation in patients with an estimated GFR(eGFR) 60 mL/min/1.73 m2.

ECG: Check for irregular heartbeats caused by electrolyte abnormalities.

Administration of Medicine 

HTN: Using standardized office measurements, adults with high blood pressure and CKD G1 to G3 should get treatment to achieve a goal systolic blood pressure of 120. 
Patients undergoing renal transplantation should maintain a target blood pressure of 130/80 mm Hg.
- Based on evidence of benefits, ACE-I or ARB is suggested for diabetic and nondiabetic persons with albumin excretion >30 mg/24 hr.
Patients without albuminuria can nevertheless be given an ACE-I or ARB. However, there is a lower chance of CKD advancement in those patients.
ACE-I, ARB, and DRI medication should not be combined in diabetic and non-diabetic patients with CKD. Women receiving ACE-I or ARB therapy should be advised to use contraception, and treatment should be stopped if they are planning a pregnancy or have already given birth.
In order to minimize potential drug-induced side effects and prevent allograft failure in adult kidney transplant patients, CCB or ARB is the first line of defense.
– Ambulatory blood pressure monitoring (ABPM) of 24-hour mean arterial pressure in children with CKD should be lowered to 50th percentile for age, sex, and height. The first line in this population is either ACE-I or ARB.
Proteinuria is significantly reduced when an ACE-I or ARB is used in conjunction with a low-sodium diet.

Hyperparathyroidism secondarily
If intact PTH is elevated in patients with GFR 45, check for hyperphosphatemia, hypocalcemia, and vitamin D deficiency.
The use of calcimimetic medications in CKD patients who are not receiving dialysis has not been approved by the U.S. Food and Drug Administration (oral cinacalcet or IV etelcalcetide). These ought to be saved for ESRD sufferers.

Hyperphosphatemia: Use the following to keep serum phosphate levels within normal range:
- CKD stages 3 to 5 (without receiving dialysis): Limit your daily phosphate intake to 800–1,000 mg.
- Sevelamer and lanthanum, non-calcium phosphate binders (taken with meals).
– Calcium binders have not been linked to better cardiovascular or death results.
 Vitamin D: calcitriol (active vitamin D 1,25 [OH]), inactive vitamin D 25 (ergocalciferol or cholecalciferol): Vitamin D may increase intestinal phosphate absorption; it should not be started until serum phosphate concentration is under control.
To treat anemia, use erythropoietin-stimulating drugs (ESAs) or iron replacement treatment.
If Hb is between 9 and 10 g/dL, think about ESA. Hb >10 g/dL is not recommended for the start of an ESA. Goal Hb should be between 10 and 11 g/dL if using ESA, but not more than 11.5 g/dL.

 Hyperlipidemia: low-density lipoprotein (LDL) target of 70; statins

Goal range for glycemic control is 6.5-8.0% for HbA1c. In patients with reduced RBC, HbA1c may be erroneously low; glucose logs may be a more reliable indicator of glycemic management. The usage of metformin should be evaluated for GFR between 30 and 44 and stopped if GFR is less than 30 mL/min/1.73 m2. Patients with type 2 DM and GFR more than 30 mL/min/1.73 m2 should also take metformin in combination with sodium-glucose cotransporter-2 (SGLT2) inhibitors. SGLT2 inhibitors can be utilized to slow the course of the disease in both DM and non-DM individuals.
Metabolic acidosis: Begin treatment when bicarbonate levels are below 22 mEq/L with the aim of preserving normal levels.


Factors to Consider Before a Nephrology Consultation
- GFR 15: immediately, GFR 15 to 29: urgent, GFR 30 to 59: nonurgent referral, and GFR 60 to 89: not necessary except with comorbidities.
- The management of complications (metabolic management, electrolyte abnormalities, acidosis, etc.), patients without diabetes with heavy proteinuria (24-hour urine protein >500 mg, urine PCR >.5, urine ACR >300), and patients with diabetes who have >3 g proteinuria or hematuria.
a consultation with a urologist for hematuria, renal masses, complex renal cysts, symptomatic nephrolithiasis, and hydronephrosis; a Registered Dietitian; a psychologist; a social worker; a physical therapist; and an occupational therapist to help with mobility and dietary choices; and
Renal replacement: When GFR is less than 30 mL/min/1.73 m2, get ready for dialysis or a transplant.

For individuals with established cardiovascular disease, secondary prevention with aspirin is an additional kind of care.

Acetaminophen is regarded as the first-line treatment for mild CKD-related discomfort. NSAIDs shouldn't be used topically, orally, or even by children.
Opioids may be prescribed for moderate to severe pain, but because many of them are renally eliminated, there is a higher risk of overdose or toxicity. Although fentanyl, methadone, and oxycodone are favored, dose modification is still advised. Meperidine is not advised for those with CKD.
When using morphine and codeine, exercise caution.
Anticonvulsants and gabapentinoids, which should be administered renally, can be used to treat chronic pain syndromes.

Admission

Patients should have eGFRs > 30 mL/min/1.73 m2 in order to use contrast in imaging. Prior to and after iodinated contrast, volume expansion with IV isotonic saline is advised.
Prior to iodinated contrast imaging, metformin should be stopped and then resumed 48 hours later.

Patient Follow-Up Monitoring
Within 2 to 4 weeks after starting an ACE-I or ARB, check your blood pressure, serum creatinine, and serum potassium levels. Correct acute renal injury, reevaluate medications, and reduce/stop the existing ACE-I or ARB dose if the creatinine level rises by more than 30%. In cases of uncontrolled hyperkalemia or symptomatic hypotension, therapy should be stopped.
After using metformin for more than four years, people who are taking it should have their eGFR measured annually.
Carefully watch the levels of creatinine in CKD patients who are pregnant.
Track calcidiol levels, HbA1c twice to four times annually, volume status, electrolytes, and kidney function (urine albumin, GFR, and serum creatinine) in addition to monitoring Hgb twice a year for GFR 30 to 59 and once a year for GFR 30.
Starting at CKD stage G3, calcium, phosphate, PTH, and alkaline phosphate


Sodium intake: 2 grams each day. Avoid sugar-sweetened beverages, refined carbs, and processed foods. phosphorus and potassium restrictions. Limit protein intake to 0.8 g/kg per day. fluid restrictions based on volume status.
Nutritional advice for the CKD diet


Progression is characterized by a 25% drop in GFR from baseline. A GFR decline of more than 5 mL/min/1.73 m2/year indicates rapid development. Patients with CKD progress to ESRD over time. In the United States, dialysis patients have a 35% 5-year survival rate.

complications include metabolic calcification, anemia, secondary hyperparathyroidism, renal osteodystrophy, sleep difficulties, infections, starvation, electrolyte imbalances, platelet dysfunction/bleeding, pseudogout, and gout.