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Dr. Abdul Halim bin Abdul Gafor Associate Professor and Consultant Nephrologist Nephrology Unit, Medical Department Universiti Kebangsaan Malaysia Medical Centre
Contents
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1. 2. 3. 4. 5. 6. 7.
Kidney functions Renal syndromes Acute kidney injury Chronic kidney disease Acute on chronic renal failure End stage renal disease Summary
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As kidney function deteriorates, clinical problems related to the above functions become more apparent.
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Acute RF
90-120 ml/min
Acute on Chronic
CKD
ESRD
Time
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Causes
Causes can be divided to Pre-renal renal failure
Due to reduced blood supply/volume to kidneys eg bleeding, hypotension, septic shock
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Signs:
Tachypnoeic Disorientated Body swelling (oedema) Raised jugular venous pressure Cardiomegaly Lungs-crepitation, pleural effusion
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Imaging Studies
Plain film of abdomen good screen for calcium containing stones Ultrasound Kidney ureter bladder (KUB) Screen for size and obstruction All patients with AKI of unknown cause should have one CT scan MRI/MRA (gold standard for Renal Vein Thrombosis) Renal arteriography/venography Radionuclide scans (eg DTPA/DMSA) Voiding cystourethrogram Retrograde pyelography Intravenous pyelogram
CT scan: Computed tomogram scan MRI: Magnetic Resonance Imaging MRA: Magnetic Resonance Angiogram 9
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We have to rule out pre-renal and post-renal causes first In renal transplantation, renal biopsy more commonly done for evaluation of acute transplant dysfunction
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Treatment of AKI
Treat the underlying cause Hydration with iv fluid and N-acethycysteine (NAC) in the prevention of contrast induced nephropathy (CIN) in high risk patients. Saline, urinary alkalinization, and diuresis are helpful in myoglobinuria or hemoglobinuria Blood purification therapy
Eg haemodialysis and peritoneal dialysis
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AKI
90-120 ml/min
Renal Function (GFR)
Although renal functions will recover, the degree of recovery depends on the intensity of the cause/insult
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Definition of CKD
Kidney damage at least for 3/12 with or without decreased glomerular filtration rate (GFR).
Structural damage : based on pathological Functional damage: based on markers (blood or urine)
Stages of CKD
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Early detection
Renal disease is often progressive once GFR < 25% of normal. Early detection is important to prevent further injury and progression of CKD.
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Important causes
Diabetes Mellitus (DM) Hypertension (HPT) Obstructive uropathy Drugs especially NSAIDs and traditional medications Autoimmune disease eg Systemic Lupus Erythematosus
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Progression factors
1. 2. 3. 4. 5. 6. 7. 8. 9. These are factors that cause progressive decline in renal functions Persistent activity of underlying disease Persistent proteinuria Elevated blood pressure Elevated blood glucose in diabetic patients High protein/phosphate diet Dyslipidaemia Anaemia Cardiovascular disease Smoking
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Reversible causes
1. 2. 3. 4.
These are potential reversible causes for worsening renal functions Effective circulatory volume depletion,thus cause persistent hypotension Uncontrolled hypertension Obstructive uropathy Toxic causes:
Contrast induced nephropathy , Nephrotoxic drugs
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Clinical features
1.
2.
Signs and symptoms that due to the failure of kidneys endocrine functions.
Anaemia Renal bone disease
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Diagnosis
Renal functions
Serum creatinine Estimated GFR
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Treatment
Depends on the underlying cause. Correct the progression factors and reversible causes. DM
Glucose control, HbAIC < 7% BP < 125/75mmHg Low protein diet ACE-I/ARB irrespective of blood pressure Control dyslipidaemia Healthy life style
Hypertension
Target BP BP < 130/85mmHg in all CKD BP< 125/75 mmHg in proteinuric CKD Anti-HPT choice ACE-I/ARB Non-dihydropyridine CCB
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Summary
AKI is a potential reversible condition, thus early and correct management is very important. Patients with CKD have excretory failure, endocrine failure and very high risk of developing cardiovascular disease. Management are geared to retard the progression of CKD. CKD patients also are more prone to develop AKI ( acute on chronic renal failure) Renal replacement therapy must be initiate once patient reached end stage renal disease ( stage 5 CKD)
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