The document provides information on acute kidney injury (AKI) and chronic kidney disease (CKD) in Nepal. It discusses the epidemiology, causes, clinical features, diagnosis and management of AKI and CKD. It also presents data on the prevalence and outcomes of patients with AKI and CKD from two hospitals in Nepal. The economic burden of dialysis and the increasing availability of treatment options over time are also reviewed.

1. Approach to AKI and CKD
Presentation by:
Junior intern Group B1
1

2. Epidemiology
AKI
• Approximately 7% of all hospitalized patients and 20% of acutely ill patients develop AKI
• In uncomplicated AKI; mortality is low even when RRT is required
• In AKI associated with sepsis and multi-organ failure, mortality is 50-70%
CKD
• Prevalence of CKD stages 3-5 in many countries is around 5-7%
• More prevalent in people aged 65 years and older
• Substantially higher in the patients with HTN, DM and vascular diseases
Source: Davidson’s Principles and Practice of medicine 2

3. CKD in context of Nepal
• 3rd most prevalent disease among chronic disease: COPD (11.7%) > DM (8.5%)> CKD
(6%) among studied population
• Prevalence of CKD above 60 years and above: 11.5%
• Males (6.5%) > Females (5.7%)
Source: Population based prevalence of selected NCDs in Nepal 2019 (NHRC)
Social security/Bipanna Nagarik Aushadi Upachar Programme
• MoH began offering free lifetime hemodialysis in 2016
• In FY 2075/76; 5297 kidney patients (9.93% among those who were included in the
social security scheme for various diseases) were benefitted from the impoverished
citizens service scheme
Source: DoHS Annual Health Report 2075/76
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4. • 1st Hemodialysis in Nepal: Bir Hospital (1987)
• In 2016:
42 HD Centres existed (223% increase since 2010)
Serving 1975 ESRD patients (303% increase since 2010)
36 nephrologists (200% increase since 2010) and 12 were trained in transplantation
Economic Aspect
• Annual cost of approx. US $2300 per dialysis patient
• Free dialysis could potentially cost the government US $6.7 million per year, suggesting
that 2.1% of annual health budget would be allocated to 0.01% of the population
• 50% of Hemodialysis center In Nepal cover only 14.5% of Nepal population as most of
them are centralized in and around valley
Source: TUTH 38th souvenir/Deputy Nursing controller: Gyanu Gurung
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5. Timeline of events in TUTH….
1992: Nephrology service
1996/97 (2053 B.S): 1st HD service with 2 HD machines
2008: initiation of living donor kidney transplantation services
2009: Department of nephrology was convened
2076:
11,104 HD; 289 jugular insertion; 320 femoral insertion; 52 plasmapheresis; 69
kidney transplant and 8 permanent catheter insertion was performed
Separate team for renal replacement
Services
Currently; 8 functioning dialysis machines in dialysis unit and 1 in ICU
Till March 2020, over 650 living kidney transplant has been done including that of PM of
Nepal
Source: TUTH 38th souvenir/Deputy Nursing controller: Gyanu Gurung
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6. 6
mangsir 25-poush25 poush 25-magh25
CKD 2.93% 2.41%
AKI 1.17% 0.96%
75
68
30 27
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
percentage
months
Percentage of CKD/AKI patients among total emergency
admission
CKD AKI

7. 7
mangsir 25-poush25 poush 25-magh 25
male 60% 67.64%
female 40% 32.36%
45
46
30
22
0%
10%
20%
30%
40%
50%
60%
70%
80%
percentage
among
CKD
patients
month
CKD gender-wise
male female

8. 8
0-10 10 to 20 20-30 30-40 40-50 50-60 60-70 70-80 80-90
Mangsir 25-poush 25 0 1 9 12 9 14 18 7 5
Poush 25-Magh25 0 3 10 9 15 12 11 6 2
0
2
4
6
8
10
12
14
16
18
20
number
Age group
CKD Age-wise
Mangsir 25-poush 25 Poush 25-Magh25

9. 9
DOPR LAMA COVID ER Admission Discharge
status
unknown
expired
mangsir 25-posh 25 17.33% 13.33% 17.33% 20% 13.33% 17.33% 1.33%
poush 25-magh25 16.17% 11.76% 20.58% 17.64% 13.23% 14.70% 2.94%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Percentage
outcome
CKD OUTCOME MONTHWISE COMPARISON
mangsir 25-posh 25 poush 25-magh25

10. 10
mangsir 25-poush25 41.33%
poush25-magh25 35.29%
31
24
32.00%
33.00%
34.00%
35.00%
36.00%
37.00%
38.00%
39.00%
40.00%
41.00%
42.00%
percentage
percentage of CKD patients among total CKD pateints under dialysis
mangsir 25-poush25 poush25-magh25

11. 11
17
20
13
7
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
mangsir 25-poush 25 poush 25-magh25
Percnetage
maong
total
AKI
patients
Months
AKI gender wise
male female

12. 12
0-10 10 to 20 20-30 30-40 40-50 50-60 60-70 70-80 80-90
mangsir 25-poush 25 0 1 3 6 1 3 7 6 3
poush 25-magh 25 0 2 2 2 6 7 5 0 1
0
1
2
3
4
5
6
7
8
number
Age group
AKI age wise
mangsir 25-poush 25 poush 25-magh 25

13. 13
DOPR LAMA COVID ER Admission Discharge
Status
unknown
expired
mangsir 25-poush 25 10% 3.33% 20% 40% 13.33% 13.33% 0%
poush 25-magh 25 22.22% 3.70% 14.81% 22.22% 18.51% 18.51% 3.70%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Percentage
outcome
AKI Outcome monthwise comparison
mangsir 25-poush 25 poush 25-magh 25

14. AKI: Definition
AKI is defined as –
Increase in Serum Cr by 0.3 mg/dl within 48 hours
OR
 Increase in Serum Cr to 1.5 times of baseline, which is known or
presumed to have occurred within the prior 7 days
OR
 Urine volume <0.5 ml/kg/h for 6 hours.
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15. 15

16. Causes
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17. Natural history of AKI
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(8-22%)
(2-8%)

18. Clinical Features
• Asymptomatic
• elevations in the plasma creatinine
• abnormalities on urinalysis
• Signs and symptoms resulting from loss of kidney function:
• decreased or no urine output, flank pain, edema, hypertension, or discolored
urine
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19. Clinical Features
• Symptoms and/or signs of renal failure:
• weakness and
• easy fatiguability (from anemia),
• anorexia,
• vomiting, mental status changes or
• Seizures
• edema
• Systemic symptoms and findings:
• fever
• arthralgias,
• pulmonary lesions
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20. Diagnosis
• Detailed history
• Blood urea nitrogen and serum creatinine
• CBC, peripheral smear, and serology
• Urinalysis
• Urine electrolytes
• Ultrasonography, CT
• Serology: ANA,ANCA, Anti DNA, HBV, HCV, Anti GBM, cryoglobulin, CK, urinary
Myoglobulin
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21. Complications of AKI
1) Uraemia
2) Hyper / hypovolemia
3) Hyponatremia
4) Hyperkalemia
5) Hyperphosphatemia / hypocalcemia
6) Metabolic acidosis
7) Bleeding
8) Infection risk
9) Cardiac –pericarditis, arrhythmia &pericardial effusion
10) Malnutrition
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22. Treatment
• Optimization of hemodynamic and volume status
• Avoidance of further renal insults
• Optimization of nutrition
• If necessary, institution of renal replacement therapy
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23. Indication for RRT
1) Symptoms of uremia ( encephalopathy)
2) Uremic pericarditis
3) Refractory volume over load
4) Refractory hyperkalemia
5) Refractory metabolic acidosis
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24. CKD: Definition(criteria)
• Kidney damage for >= 3 months, as defined by structural or functional
abnormalities of the kidney, with or without decreased GFR, manifest
by either:
• Pathological abnormalities or
• Markers of kidney damage, including abnormalities in the composition of
blood and urine, or abnormalities in the imaging tests
• GFR <60 ml/min/1.73m2 for >=3 months, with or without kidney
damage
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25. Staging
Stage Description GFR (ml/min/1.73m2)
I Kidney damage with normal or increased
GFR
>=90
II Kidney damage with mild decrease in GFR 60-89
III Kidney damage with moderate decrease in
GFR
30-59
IV Kidney damage with severe decrease in GFR 15-29
V Kidney failure <15 (or dialysis)
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26. Causes
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27. Clinical features
• Most asymptomatic till GFR falls below 30 ml/min
• Nocturia- early symptom (but non-specific)
• GFR < 20 ml/min- affect almost all systems
• Tiredness, breathlessness- anemia, fluid overload
• Pruritus, anorexia, weight loss, nausea, vomiting and hiccups
• Advanced renal failure- kussmaul breathing(metabolic acidosis),
muscular twitching, drowsiness and coma
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28. Investigations
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29. Management
• Aims of management in CKD are
• To monitor renal function
• To prevent or slow further renal damage
• To limit complications of renal failure
• To treat risk factors for cardiovascular diseases
• To prepare for RRT, if appropriate
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30. Management
Conservative
 Slowing the Progession
 Limiting the adverse
effects
 Preparing for Renal
Replacement Therapy
Definitive
RENAL REPLACEMENT
THERAPY (RRT)
• Dialysis:
• Hemodialysis
• Peritoneal Dialysis
• Renal Transplantation
• Live
• Cadaveric
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31. Limiting the adverse effects of CKD
• Anemia
• Fluid and electrolyte balance
• Acidosis
• Cardiovascular disease and lipids
• Renal Osteodystrophy
• Infection
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32. Anaemia
 Defined as Hemoglobin < 13.5 g/dl in males
< 12 g/dl in females
 Normocytic normochromic anaemia – as early as in Stage III CKD or
universally by Stage IV CKD
 Primary cause : insufficient production of Erythropoetin
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33. Other factors causing anemia
 Iron deficiency/Folate and Vit B12 deficiency
 Chronic inflammation (ACD)
 Hyperparathyroidism / bone marrow fibrosis
 Decreased erythropoeisis
 Decreased RBC survival
 Increased blood loss
 Occult gastrointestinal bleeding
 Platelet dysfunction
 Blood loss during hemodialysis
 Blood sampling
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34. Anemia - goals
 Target Hb : not more than 11.5g/dl
 Target Iron status : TSAT : lower limit > = 20
 Check Hb monthly while on ESAs (Erythropoeisis stimulating agents)
 Iron studies monthly when started on ESA
 On stable ESA Therapy : Iron studies can be done 3 monthly
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35. Anemia – treatment options
 Oral iron
 IV Iron Dextran
 IV Iron Sucrose
 IV Sodium Ferric Gluconate Complex
 Folic acid and Vitamin B 12 supplements
 Erythropoetin Stimulating Agents : Epoetin alfa*
Epoetin beta
Darbepoetin alfa
 Epoetin alfa / beta : 50 -100 IU / Kg SC per week
 Darbepoetin alfa : 40 mcg SC every 2 weeks
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36. Refractory anaemia
• Blood loss
• Secondary hyperparathyroidism
• Substrate deficiency
• Active inflammation or malignancy
• Aluminium overload
36

37. Bone mineral disorder
(CKD-MBD)
• Renal bone disease – significantly increase mortality in CKD patients
• Hyperphosphatemia – one of the most important risk factors
associated with cardiovascular disease in CKD patients
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38. 38

39. Bone Disorders Causative factors
• Osteitis Fibrosa Cystica
• Osteomalacia
• Adynamic bone disease
• Mixed osteodystrophy
• Secondary
Hyperparathyroidism
• Vitamin D deficiency
• Acidosis
• Aluminium accumulation
• Osteoporosis in elderly
• Osteopenia caused by
steroids
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40. Treatment
 Reduce dietary phosphate intake
 Phosphate binders : calcium carbonate
calcium acetate
aluminium hydroxide
magnesium carbonate ( rarely used )
sevelamer hydrochloride
lanthanum carbonate
 The use of calcium salts is limited by development of
hypercalcemia
 Calcium acetate poses a less problem as less calcium is absorbed 40

41.  Calcimimetics – Cinacalcet
Agent that increase calcium sensitivity of the calcium sensing
receptor expressed by parathyroid gland
Down regulating the parathyroid hormone secretion
Reduce hyperplasia of parathyroid gland
 Calcitriol 0.25 mcg OD
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42. Immunization
• Hepatitis B vaccination : 4 doses (0,1,2,6 months )
higher dose ( 40 mcg / ml )
• Pneumococcal vaccination :
single dose one time
(revaccination 5 yrs after initial vaccination)
• Influenza vaccination : recommended annually
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43. Preparation for Renal Replacement Therapy
 Patients of CKD Stage IV approaching Stage V should be referred for
Vascular access if hemodialysis is preferred
Peritoneal dialysis catheter placement if peritoneal dialysis is preferred
 AVF is most preferred access for HD patients
Ideally created 6 months prior to start of HD
Non dominant upper extremity
And that arm is to be preserved – no iv lines
 AVG : 3-6 weeks prior to start of HD
 PD Catheter : 2 weeks prior to start of HD
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44. 44

45. Look for reversibility !
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46. Causes of emergency in CKD patients???
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47. Differences between AKI & CKD
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48. References
• Davidson’s Principles and Practice of Medicine, 23rd edition
• TUTH emergency record book
• Annual report, 2075/76
• TUTH 38th anniversary souvenir
• Tintinalli emergency medicine, 8th edition
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49. Thank You
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