Date: 02.06.

2024

Live MCQTM
Special BCS Health
Lecture No-22

Medicine-07
Topic:
Nephrology, Acid Base & Electrolyte disorders

Mentor:
Dr. Mohammad Rasel
Registrar (Medicine)
Mymensingh Medical College Hospital
 Chronic kidney disease

✓ Chronic kidney disease (CKD) refers to an irreversible deterioration in renal

function that usually develops over a period of years.

Uraemia: Clinical symptoms and signs of renal failure due to loss of the excretory,
metabolic and endocrine functions of the kidney, collectively referred to as
uraemia.
End-stage renal disease (ESRD): When death is likely without RRT (CKD stage 5),
it is called end-stage renal disease (ESRD).

Stages of CKD:
Common Causes of CKD

Most patients with slowly progressive disease are asymptomatic until GFR falls
below 30 mL/min/1.73 m2
Some can remain asymptomatic with much lower GFR values than this.
When GFR falls below 15–20 mL/min/1.73 m2, symptoms and signs are common and
can affect almost all body systems.

• Nocturia: Early symptom, due to the loss of concentrating ability of kidney.

• Tiredness or breathlessness: which may be related to renal anaemia or fluid
overload.
• Pruritus
• Anorexia
• Weight loss
• Nausea
• Vomiting
• Hiccups
Clinical features of CKD…
In very advanced renal failure:
o Deep respiration (Kussmaul breathing) may be due to profound metabolic
acidosis
o Muscular twitching
o Fits
o Drowsiness
o Coma
Fig: Kussmaul breathing→

Physical signs of advanced CKD

Complications of CKD
• Hyperkalaemia
• Metabolic acidosis
• Fluid retention:
— Oedema
— Pulmonary oedema
— Hypertension
• Proteinuria
• Anaemia
• Renal Osteodytrophy
 • Cardiovascular disease
— Atherosclerosis
— Hypertension
— Left ventricular hypertrophy
— Arrhythmias
— Sudden cardiac death

• Renal Bone Diseases (renal osteodystrophy)

— Osteitis fibrosa cystica: In severe cases this may result in bony pain and
increased risk of fractures
— Adynamic bone disease: Low bone turnover due to over-treatment with
vitamin D metabolites
— Osteomalacia: Due to over-treatment of hyperphosphataemia.
— Osteoporosis: In patients with poor nutritional intake.

• Osteitis Firosa Cystica =

• Osteoporosis =
Complications of CKD…

• Mechanism of renal bone disease:

— Hypocalcaemia: Failure of the renal tubular cells to convert 25-

hydroxyvitamin D to its active metabolite, 1,25-dihydroxyvitamin D.

— Hyper-phosphataemia: Impaired excretion of phosphate

— Secondary hyperparathyroidism: Hypocalcaemia &

hyperphosphataemia induced parathyroid hyperplasia and inceased
PTH release.

— Tertiary hyperparathyroidism: due to autonomous production of

PTH by the parathyroid glands; this presents with hypercalcaemia.

Pathogenesis of Renal Osteodystrophy…

Investigations
Main aims of investigations are-
1. To exclude AKI requiring rapid investigation; in patients with
unexpectedly high urea and creatinine (when there is an increase from
previous results or no prior results are available), renal function should be
retested within 2 weeks to avoid missing AKI
2. To identify the underlying cause where possible, since this may influence
the treatment
3. To identify reversible factors that may worsen renal function, such as
hypertension or urinary tract obstruction
4. To screen for complications of CKD, such as anaemia and renal
osteodystrophy
5. To screen for cardiovascular risk factors.
Management:
The aims of management in CKD are to:
1. Monitor renal function
2. Prevent or slow further renal damage
3. Limit complications of renal failure
4. Treat risk factors for cardiovascular disease
5. Prepare for RRT, if appropriate

Monitoring of renal function

Renal function should be monitored
➢ Every 6 months in patients with stage 3 CKD
➢ More frequently in patients who are deteriorating rapidly or have stage 4 or
5 CKD.
Reduction of rate of progression

• Therapies directed towards the primary cause of CKD should be employed

where possible.

• Tight blood pressure control is applicable to CKD regardless of cause.

• Reducing proteinuria is a key target in those with glomerular disease.

Antihypertensive therapy:

— A target blood pressure of less than 140/90 mmHg is recommended for

patients with CKD

— A lower target of 130/80 mmHg is recommended for those with diabetes.

— Often requires multiple drugs.

Reduction of proteinuria: ACE inhibitors and ARBs reduce proteinuria and retard
the progression of CKD.

Treatment of complications:
• Maintenance of fluid balance
— Patients with evidence of volume expansion should be instructed to
consume a low-sodium diet (< 100 mmol/24 hrs) and
— In severe cases fluid intake should also be restricted.
— Diuretics are commonly required: Loop diuretics or combinations of
loop, thiazide and potassium-sparing diuretics may be necessary.
• Management of Hyperkalaemia
— Dietary advice to reduce daily potassium intake to below 70 mmol
— Potassium-binding compounds to limit absorption: sodium
zirconium, patiromer
— Control of acidosis with sodium bicarbonat: Plasma bicarbonate
concentrations should be maintained above 22 mmol/L by
prescribing sodium bicarbonate supplements
• Management of Renal bone disease:
1. Management of Hyperphosphataemia
— Dietary restriction of foods with high phosphate content (milk,
cheese, eggs and protein-rich foods.
— Phosphate-binding drugs (calcium carbonate, aluminium hydroxide,
lanthanum Carbonate, sevelamer.)
2. Management of Hypocalcaemia:
— Active vitamin D metabolites (either 1-α-hydroxyvitamin D or 1,25-
dihydroxyvitamin D

Management of Anaemia:

— Iron supplements
— Recombinant human erythropoietin
— The target haemoglobin is usually between 100 and 120 g/L or
avoidance of blood transfusions.
3. Treatment of risk factors for cardiovascular disease

— Adopt a healthy lifestyle, including regular exercise, and weight loss

and smoking cessation where appropriate
— Lipid-lowering drugs

Preparing for renal replacement therapy

• Patients who are known to have progressive CKD should be referred to a
nephrologist in a timely manner
• Those who are referred late, when they are very close to requiring dialysis,
tend to have poorer outcomes.
• Preparations for starting RRT should begin at least 12 months before the
predicted start date.
— Psychological and social support
— Assessing home circumstances
— Discussing the various choices of treatment
— Vaccination against hepatitis B.

Indications for dialysis

RRT
1. Dialysis
• Haemodialysis
• Haemofiltration
• Peritoneal dialysis
2. Kidney transplantation
• The aim of RRT is to-
➢ Replace the excretory functions of the kidney and to
➢ Maintain normal electrolyte concentrations and fluid balance.

Kidney transplantation in Bangladesh

• Right now, regular transplantation is done only in four centers in the
country, namely-
1. Bangabandhu Sheikh Mujib Medical University (BSMMU)
2. Center for Kidney Diseases and Urology (CKD & Urology) Hospital
3. Kidney Foundation
4. BIRDEM General Hospital.

Acute Kidney Injury

• Acute kidney injury (AKI) is not a diagnosis, rather it describes the situation
where there is a sudden and often reversible loss of renal function, which
develops over days or weeks and is often accompanied by a reduction in
urine volume.

Causes of aki
Management
UTI
Renal Stone
AGN vs NS