Chronic Kidney Disease (CKD), End Stage Renal Disease (ESRD)

1. CHRONIC KIDNEY DISEASE (CKD)
END STAGE RENAL DISEASE (ESRD)
PPE III/IV
PHAR 660/665
ZEINAB NOORMONAVAR
4/29/2021
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2. ALL YOU NEED TO KNOW
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3. OUTLINE
At the end of a presentation, you will be able to:
 Recall the pathophysiology, diagnosis, symptoms, epidemiology, causes and types of
CKD.
 Identify the classification and pharmacological treatment modalities of ESRD
 Learn the different techniques used.
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4. DEFINITION
 Chronic kidney disease (CKD) is a type of kidney disease in which there is gradual
loss of kidney function over a period of months to years.
 The persistence of the damage or decreased function for at least three months is
necessary to distinguish CKD from acute kidney disease (AKI).
 Initially there are generally no symptoms; later, symptoms may include leg swelling,
feeling tired, vomiting, loss of appetite, and confusion.
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6. EPIDEMIOLOGY
Has been recognized as a
leading public health problem
worldwide
Prevalence of CKD is 13.4%
patients with end-stage kidney
disease (ESKD) needing renal
replacement therapy is
estimated between 4.902 and
7.083 million
Global prevalence of CKD was
higher in women and girls
(9.5%) than in men and boys
(7.3%)
Resulted in 1.2 million deaths
and was the 12th leading cause
of death worldwide.
Nearly one-third of all cases of
CKD were in China
(132.3 million) or India
(115.1 million)
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7. PATHOPHYSIOLOGY
 3 key elements:
 Loss of nephron mass
 Glomerular capillary hypertension
 Proteinuria
Exposure to any
risk factors 
cause loss of
nephron mass
With time 
intraglomerular
hypertension (by
angiotensin II)
causes systemic
arterial
hypertension and
endothelial cells
Endothelial cells injury
leads to proteinuria
 Passage of proteins
into the kidney
 Albumin, transferrin,
complement factors,
immunoglobulin,
cytokines…
The remaining
kidney mass will
undergo
hypertrophy as
a compensatory
mechanism
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8. FACTS ABOUT CKD
• Early detection can help prevent the progression of kidney disease to kidney failure
• Heart disease is the major cause of death for all people with CKD.
• Glomerular filtration rate (GFR) is the best estimate of kidney function.
• Hypertension causes CKD and CKD causes hypertension
• High risk groups include those with diabetes, hypertension and family history of kidney failure
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9. Other
causes
Glomerul
onephriti
Polycystic
Kidney
Disease
Lupus
Repeated
Urinary
Infection
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10. Other
symptoms
Increase
urination at
night
Muscle
cramping at
night
Trouble in
concentration
Back and belly
pain
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11. DIAGNOSIS AND CLASSIFICATION
The presence of kidney damage usually detected as:
 Urinary albumin excretion of ≥30 mg/day or equivalent
 Estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2
 Imagining studies abnormalities (renal ultrasound, biopsy)
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13. COMPLICATIONS
Volume overload Hyperkalemia Metabolic acidosis
MBD Hypertension Anemia
Dyslipidemia Sexual dysfunction
Cardiovascular disease
(pericarditis)
CNS damage
Decrease immune
response
Pregnancy risk
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Thiazide
Furosemide
Sevelamer
Lanthanum
Cenacalcet

15. NON PHARMACOLOGICAL TREATMENT
 Life style Changes:
 physical activity  at least 30 minutes 5 times/week
 Healthy weight (BMI 20-25 Kg/m2)
 Smoking cessation
 Reduce salt Intake
 Helps controlling BP
 Lower salt intake to <2 g/day of sodium (corresponding to 5g of sodium chloride) in
adults, unless contraindicated.
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17. TREATMENT
 End-stage renal disease treatment may include:
Kidney
transplant
Dialysis
Supportive
care
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18. KIDNEY TRANSPLANTATION
 A kidney transplant is a surgical procedure to place a healthy kidney from a
live or deceased donor into a person whose kidneys no longer function
properly.
 kidney transplants allow people with severe disease to avoid or discontinue
dialysis.
 The kidney transplant process takes time. It involves finding a donor, living or
deceased, whose kidney best matches your own.
 During kidney transplant surgery, the donor kidney is placed in your lower
abdomen. Blood vessels of the new kidney are attached to blood vessels in
the lower part of your abdomen, just above one of your legs. The new
kidney's urine tube (ureter) is connected to your bladder. Unless they are
causing complications, your own kidneys are left in place.
 Need to take medications daily, including anti-rejection medication.
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20. Anti- Rejection Medications
Agents MOA Administration Side Effect
Prednisone (PREDICORE)
Corticosteroid
High dose (20-50 mg) right
after the transplant and dose
be reduced over time.
Weight gain, hyperglycemia,
osteoporosis, poor wound
healing
Mycophenolate
(IMUNOCELL) Immune suppressant
Inhibit T & B cell proliferation
MMF: 1g PO/IV BID infused
over 2 hours
MPA: 720mg PO BID
Decrease blood count,
stomach upset
Azathioprine (IMURAN)
DMARD
On day of surgery: 3-5
Maintenance: 1-3 mg/kg/d
IV/PO
Stomach upset, muscle pain
Tacrolimus (ADVAGRAF)
Calcineurin Inhibitor
IV: 0.03- 0.05 mg/kg/d
continuous infusion
Hyperglycemia, HTN, tremor,
hyperkalemia
Sirolimus (SIROMUNE) Inhibit T-cell activation and
proliferation
5 mg/d PO
Combined with Tacrolimus
Swelling, hyperlipidemia,
proteinuria,
Cyclosporine (NEORAL)
DMARDs
4-12 hr pre-surgery: 15 mg/kg
1-2 wk post-surgery: 5-10
mg/kg
HTN, Excess gum and hair
growth, hyperkalemia
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21. DIALYSIS
 Dialysis does some of the work of your kidneys when your kidneys can't do it
themselves. This includes removing extra fluids and waste products from your
blood, restoring electrolyte levels, and helping control your blood pressure.
Hemodialysis
Peritoneal
Dialysis
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22. HEMODIALYSIS
 It is a procedure where a dialysis machine and a special filter called an artificial
kidney, or a dialyzer, are used to clean your blood.
 During hemodialysis, blood is removed from a vein.
 It is run through filters to remove waste products.
 The blood is then returned to the body.
 Hemodialysis usually is done at a dialysis center.
 The treatments are done 3 times/ week, in 3-4 hours/ session.
 Temporary access is usually a catheter placed in a central vein.
 Permanent access types include arteriovenous (AV) fistula or graft.
 Access is usually placed in the non-dominant arm.
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23. HEMODIALYSIS
A. AV fistula:
 is the preferred access.
 The artery is connected to a vein.
 A fistula takes 2 to 3 months to
mature before it can be used. During
maturation, the vein dilates and
thickens
 A fistula is less likely to become
infected or clot, and provides better
blood flow rates.
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25. B. AV graft:
 A synthetic tube connects the artery and vein.
 A graft takes 2 to 3 weeks before it can be used.
 Grafts are more likely to become infected or clot
than fistulas.
HEMODIALYSIS
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26. C. Temporary catheter:
 A venous catheter is inserted into a vein in the
neck, chest, or leg near the groin, for short-term
dialysis.
 This is only option when patient is not prepared
and needs immediate hemodialysis.
 Catheters increase risk of infection, clotting, and
inadequate dialysis.
HEMODIALYSIS
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27. PERITONEAL DIALYSIS (PD)
 PD requires surgery for catheter placement.
 PD is a continuous therapy providing a “steady state” which may be
better tolerated than intermittent hemodialysis.
 Continuous ambulatory peritoneal dialysis (CAPD) is done manually.
 Continuous cycler-assisted peritoneal dialysis (CCPD) is automated.
 Dextrose is the most common osmotic agent used in the dialysate.
 Osmotic gradient helps move water into the peritoneal cavity.
 Exchanges are 2–3 liters in volume.
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28. PERITONEAL DIALYSIS (PD)
CAPD requires 4 or more manual
exchanges per day
The cycler does 3–5 automated exchanges during the night
in CCPD
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30. • People with chronic kidney disease
have a higher risk of severe
infection with coronavirus disease
2019 (COVID-19).
• Reports from China, England, Italy
and France have suggested
between 9% and 27% of patients
with ESRD who tested positive for
COVID-19 died, compared to 4%
globally as of July 2020.
• In this study, 13% of people with
ESRD died with COVID-19,
compared to 3% of historical
controls.
• COVID-19 further increases
mortality nearly 4-fold in people
with ESRD.
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31. Kaplan-Meier survival curve of 30-day
mortality for cases (adults with end stage
renal disease and COVID-19) compared to
historical controls (adults with end stage
renal disease without COVID-19):
Survival rate was higher in patient with ESRD
and not infected with COVID-19.
Survival rate:
12.7%
Survival rate:
3.4%
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32. REFERENCES
1. https://www.kidney.org/atoz/content/about-chronic-kidney-disease
2. https://www.mayoclinic.org/diseases-conditions/end-stage-renal-disease/symptoms-causes/syc-20354532
3. https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-
adults?search=end%20stage%20renal%20disease&source=search_result&selectedTitle=1~150&usage_type=
default&display_rank=1
4. https://www.nature.com/articles/s41581-020-0268-7
5. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2021-BP-GL.pdf
6. http://www.pathophys.org/ckd/
7. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/peritoneal-dialysis
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649657/
9. Link for VIDEOS: https://www.mayoclinic.org/diseases-conditions/end-stage-renal-disease/diagnosis-
treatment/drc-20354538
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33. THANK YOU
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