Chronic Renal Failure

1. Chronic Renal Failure

2. What are our kidneys? • Bean shaped organs about the size of our fists • Found in our flanks or lower back • We have two kidneys, one on either side • Each is made up of a million tiny subunits called nephrons

3. What do our kidneys do? • Best known for making urine, which is formed within the tiny sub-units of the kidneys • Each kidney has an outlet for urine called the ureter • The two ureters drain into our bladder, which stores our urine until we are ready to urinate out of our urethras

5. What do our kidneys do?

6. Other important functions of the kidneys include: • Regulation of salts in the body • Removing drugs and toxins from our body • Regulating the density and strength of our bones • Blood pressure regulation • Promotion of red blood cell production

7. What are the causes of Chronic Kidney Disease (CKD) ? • DIABETES is a condition that causes uncontrolled increase in blood sugar. If blood sugar goes unregulated, it can cause damage in many parts of the body, including the kidneys • HYPERTENSION can cause kidney damage if blood pressure is not kept under control through medication, exercise and diet

8. POLYCYSTIC KIDNEY DISEASE is a condition that can cause multiple cysts that eventually enlarge in both kidneys. This can be diagnosed based on ultrasound which shows at least three to five cysts in each kidney. It can occur at any age, but most frequently causes symptoms when people reach their 30s or 40s. Chronic flank pain from enlarging kidneys may be prominent.

9. GLOMERULONEPHRITIS is a disease that can cause malfunction of the microscopic glomeruli, which are a part of the nephrons KIDNEY STONES or stones in any part of the urinary tract can cause kidney damage if they obstruct the flow of urine. Blockage caused by stones can cause pressure buildup or infections that may lead to kidney damage

10. MECHANICAL OBSTRUCTIONS to the flow of urine can cause damage to the kidneys. Examples of mechanical obstructions include enlarged prostates (in men) and cervical cancer (in women) URINARY TRACT INFECTIONS usually come from microbes that can travel up the urethra into our kidneys from the urinary tract. Some congenital abnormalities in the urinary tract can make you more prone to UTI

11. DRUGS sold over the counter (many pain medications) and illegally (heroin, shabu) can cause kidney damage through prolonged and continuous use

12. Who are at risk for CKD? • 65 years or older • Diabetic • Hypertensive • Have history of kidney disease in the family • Have systemic lupus erythematosus • Recurrent urinary tract infections • Congenital abnormalities of the urinary tract

13. What are the basic tests requested to evaluate kidney function? • Urinalysis is an analysis of urine. An important indication is protein in the urine. • When the kidneys filter and clean blood, they usually keep protein from leaking out into the urine. But when kidneys are damaged, protein leaks from the blood into the urine.

14. Creatinine is a waste product that is usually removed by the kidneys from the body and eliminated through the urine. When the kidneys are damaged, creatinine can build up to high levels in the blood. Ultrasound of the kidneys can give important information like: kidney size, the presence of obstructions, cysts and swelling or inflammation in parts of the urinary tract.

15. Fasting blood sugar for diabetes. It is important to screen for its presence and to check for sugar control in known diabetics. Diabetes may be diagnosed by a fasting blood sugar of 126mg/dl or 7 mmol/L or higher.

16. Other tests may include: • CBC • Blood chemistries for calcium, potassium, sodium and phosphorus • Arterial Blood Gas (ABG) • Antinuclear Antibody (ANA)

17. What do we do about risk factors? • Diabetes • Control blood sugar level. About a third (33%) of diabetics develop kidney disease, so it’s important for diabetics to monitor for signs of kidney disease • Follow doctor’s advice regarding diet and medication. Self monitoring of blood sugar before meals at home will help your doctor in adjusting your medication • The target blood sugar before meals is 80-100mg/dl. After meals, the target blood sugar is below 140mg/dl

18. Hypertension Control blood pressure. In general BP of 140/90 or higher confirmed twice by a doctor is considered high. For diabetics and patients found to have protein spillage in their urine, the target BP is 125/75 or lower. Controlling BP will take a combination of a healthy diet, exercise and taking the right medications.

19. Obese lose weight and exercise. Measure your Body Mass Index (BMI) to gauge how badly overweight you are. BMI= (body weight in kgs) / (height in meters)2 the recommended BMI range for Asians is 18-24kg/m2 moderate exercise for 30 minutes per day for 4-5 days a week is advisable.

20. Cut down on Vices quit smoking limit alcohol don’t do drugs. Aside from illegal drugs like heroin and shabu, some over the counter medications like most pain medications can harm kidneys if taken in large amounts for prolonged periods limit salt intake and protein moderation in diet can help protect kidneys

21. What are the signs and symptoms of kidney disease? • Fatigue • Lethargy • Lack of appetite • Pale skin and itchy, scaly skin • Insomnia • Muscle cramps • Swelling around the eyes and areas like ankles and feet • Decrease in the amount of urine per day or, conversely more frequent need to urinate

22. What are the stages of CKD? • The stages of kidney disease are determined by the GFR (Glomerular Filtration Rate). The GFR is a score that your doctor can compute to tell you how well your kidneys are functioning. Your creatinine value can be used to determine your GFR.

24. Dealing with CKD at Stages 1 - 4 • Controlling diabetes – your doctor might advise you to switch from pills to insulin for control of blood sugar. The need for adjustment in diabetes medication with CKD emphasizes the importance of blood sugar monitoring and regular follow-ups with the doctor.

25. Controlling hypertension - medications like ACE inhibitors (drugs that end with “pril”) or ARBs (drugs that end with “tan”) Preventing heart disease - controlling hypertension and diabetes will help in controlling heart problems. Smoking is bad for the heart. Changes in diet like decreasing salt and protein intake will be needed.

26. Controlling other complications Anemia • symptoms include paleness, weakness and getting tired easily • iron supplements and erythropoietin injections are given Bone disease • bones may become brittle and easy to break because of low calcium, high phosphorus and decreased formation of vitamin D • treatment includes low phosphorus diet, taking phosphate binders to lower body absorption of phosphorus and Vitamin D supplements

27. Acidosis- occurs when the kidneys start failing to keep the balance of acids and bases in blood ABG measurement measures acid levels. Sodium bicarbonate tablets help correct acidosis Electrolyte Imbalances- CKD patients might experience some changes in a lot of chemicals in their blood including potassium, calcium and phosphates. Levels of these should be monitored and medication adjusted accordingly

28. Dealing with Stage 5 CKD • When GFR decreases below 30ml/min, advice about options for kidney failure such as dialysis or kidney transplant • When GFR decreases to less than 15ml/min, advice to start treatment with above options.

29. What is Dialysis? • Dialysis is a treatment that cleanses blood of excess water and waste that has built up due to kidney failure. • There are 2 kinds of dialysis: hemodialysis and peritoneal dialysis • When GFR decreases to below 20ml/min the doctor will advise for arrangement of a permanent access to either of the above 2 options

30. Hemodialysis • In hemodialysis, a dialysis machine which contains a special filter, a dialyzer, will become the substitute of your kidney. • An access is needed to be able to filter blood from the bloodstream into the tubes going to the machine. • Treatments should be done at least three times a week • Each dialysis session lasts 3-5 hours

32. The “access” can be through a fistula or a catheter Catheters are usually used as temporary access only. They can be attached at the side of the neck for jugular catheters, in the upper chest for subclavian catheters and through the inguinal area for femoral catheters

33. Jugular catheter

34. Fistulas are used for more permanent access. These are inserted by surgeons by connecting an artery to a nearby vein in the arm. Fistulas can take a month to a few months to enlarge before it can be ready for access. The advantages of fistulas are that they are less prone to infections and clogging and they are less visible because they are under the skin.

35. Peritoneal Dialysis • In peritoneal dialysis, there is no machine. Instead of an artificial filter, the lining of the abdomen, the peritoneum is used as a natural filter. The peritoneum has a lot of small vessels in it. • Excess waste and water from the blood can travel from the peritoneum into a dialysate solution that can be infused into the belly. • The access for infusing the dialysate solution is a peritoneal catheter.

38. More efficient clearance Shorter treatment time Muscle cramps Hemodynamic changes Vascular access route Specially trained nurses Vascular access care Restricted diet Easy access Few hemodynamic complications Hyperglycemia Bowel perforation Peritoneal adhesions Intra-abdominal catheter Simple Less complex training More flexible diet Hemo vs peritoneal dialysis

39. Kidney transplant • surgery can be planned. This is an operation that involves the transfer of a healthy kidney into a CKD patient’s body. A donor of a healthy kidney is required for this treatment. • This treatment starts with finding a willing donor. Once found, tests are done to match the blood and tissue types of the patient and the donor. This is to lessen the chance of rejection of the transplanyed kidneys. Once a match is available, surgery can be planned.

41. What is the recommended diet for a patient with CKD? • Getting enough calories • Getting just the right amount of protein • Getting the right vitamins and minerals • Be careful of the content of the following in your food: sodium, calcium, phosphorus, potassium and fluids

43. Thank you