Chronic Kidney Injury

Presenter: Adili Salum Mnjagila (2013-04-04887)

MD3
Facillitator: Dr. Francis Furia
Introduction
Chronic kidney disease (CKD) refers to a state of
irreversible kidney damage and/or reduction of
kidney function that can lead to a progressive
decrease in kidney function.
Initially, it manifests only as a biochemical
abnormality
Loss of the excretory, metabolic and endocrine
functions of the kidney leads to the clinical
symptoms and signs of renal failure.
Kidney Disease: Improving Global Outcomes
(KDIGO) 2012 Clinical Practice Guideline
(CPG)
1. GFR of less than 60 mL/min per 1.73 m2 for
greater than three months with implications for
health regardless of whether other CKD markers are
present.

2. GFR greater than 60 mL/min per 1.73 m2 that is

accompanied by evidence of structural damage or
other markers of functional kidney abnormalities
including proteinuria, albuminuria, Renal tubular
disorders, or pathologic abnormalities detected by
histology or inferred by imaging.
Epidemiology
Number of Deaths attributed to CKD has doubled for in past 20
years, ranking it among the top twenty causes of death globally
Incidence of CKD in high income countries is relatively low and
congenital anomalies of the kidney and urinary tract (CAKUT)
contribute more than 50% in etiology. The incidence is 2-3 times
higher among African American children than among Caucasian
Risk factors of CKD common among children in SSA include
itrauterine injury to the developing kidney and malnutrition,
parasitic infection such as schistosomiais, post infectious
glomerulonephritis, HIV-related nephropathy and sickle cell
disease.
Etiology of CKD
Non-glomerular disease
• Pathology in the tubulointerstitial
space
• They are primarily comprised of
congenital anomalies of the kidney
and urinary tract (CAKUT) and cystic
kidney diseases.
Clinical manifestations
Polyuria; esp for congenital
anomalies of the kidney or Urinary
tract (e.g Obstructive uropathy),
inherited disorders (e.g
nephronophthiasis) &
tubulointerstitial disorders (e.g
Nephrogenic Diabetes inspidus)
Elevation of serum creatine
Poor growth
Glomerular disease
Includes;
Primary glomerulonephritis disease (e.g
focal segmental glomerulosclerosis)
Secondary glomerular disease (e.g
systemic infectious disease bacterial
endocarditis, HBV, HCV or HIV, lupus
nephritis )
Hereditary Nephritis (Alport's syndrome)
Clinical presentation
Tea coloured or Coca-Cola coloured urine
Proteinuria persistent for >3months
Edema
Elevation of serum creatinine
concentration
Blood pressure elevation
Staging
• Stage 1: Kidney damage with the normal or increased
GFR (>90ml/min/1.73m2)
• Stage 2: Mild reduction in GFR (60-89ml/min/1.73m2)
• Stage 3a: Moderate reduction in GFR
(45-59ml/min/1.73m2)
• Stage 3b: Moderate reduction in GFR
(30-44ml/min/1.73m2)
• Stage 4: Severe reduction in GFR (15-29ml/min/1.73m2)
• Stage 5: Kidney failure (GFR <15ml/min/1.73m2 or
dialysis)
Reducing GFR alone does not clinch the
diagnosis esp in stage 1 and stage 2
Establish the diagnosis by one or more of the following
maker
① Albuminuria (>30mg/24hr) or albumin:creatinine
ratio >30mg/g [3mg/mmol]
② Urine sediment abnormalities
③ Electrolyte abnormalities due to tubal disorders
④ Histologic abnormalities
⑤ Structural abnormalities detected by imaging
⑥ History of Kidney transplantation in such cases
 Signs and Symptoms
Stage 1-3 CKD patient are frequently asymptomatic.
Endocrine/metabolic derrangements or disturbance in water or
electrolyte balance clinically manifest in stge 4-5 CKD a.k.a symptoms of
Uremia

Signs
Symptoms
① Protein Energy Malnutrition
① Anorexia
② Loss of lean body mass
② Vomiting
③ peripheral edema
③ Easy Fatigability
④ pulmonary edema
④ Growth retardation
⑤ Hypertension
⑤ Peripheral neuropathy
⑥ Anaemia
⑦ Uremic frost
 Complications
• Disorders of fluid and electrolytes
• Mineral and bone disorder
• Anemia
• Hypertension
• Dyslipidemia
• Endocrine abnormalities
• Growth impairment
• Decreased clearance of renally excreted substances
from the body (e.g hyperuricemia)
Evaluation
History Physical Imaging Lab testing
(age and duration of examination • Ultrasound • Serum creatinine
symptom) • Anthropometric • Voiding and GFR
• Family hx measurement cystourethrogram • Elctrolytes
• Growth hx • BP measurement (VCUG), Haematologic
• Enuresis, Polyuria • Signs of • CT scan profile
Polydispsia hypovolemia & • MRI • Urinalysis
• congenital anomaly edema • Serum calcium,
• UTI • Cardiac auscultation phosphorus, 25-
• Unexplained • Pallor hydroxyvitamin D,
anaemia, seizures • Deformity of and PTH level
extremities • Fasting lipid profile

Findings Assessment Assessment Assessment

Urologic surgery Growth and Kidney Growth and Staging
UTI Neurodevelopment structure Erythropoietin
Blood transfusion Hypertension Underlying production
Seizures Edema, Rales, structural cause Evidence for
Radiologic Hepatic Systemic disease
examination of the enlargement/ Bone and mineral
hip tenderness & metabolism
Orthopedic surgery Cardiac gallop Dyslipidemia
Treatment
• Medication
Hypertension
ACE inhibitors:Captopril (0.3 to 1.5 mg/kg Oral 8hrly), enalapril (0.1 to 0.5 mg/kg Oral 12 or 24 hrly) , and cilazapril
ARB: Losartan, Telmisartan, and Valsartan
High Cholestrol
Statins:atorvastatin, fluvastatin and simvastatin.
Water retention
Reduction of salt and fluide intake
Duiretics: Loop diuretics (Furosemide), thiazide diuretics (chlorothiazide, hydrochlorothiazide, and metolazone.),
potassium sparing (spironolactone and eplerenone)
Anaemia
Epoetin alfa and Darbepoetin alfa and Iron supplements
Bone problems
Phosphate binder: calcium carbonate or calcium acetate
Limit phosphate rich food; egg, diary products, red meat and fish
Vitamin D supplements:Colecalciferol or Ergocalciferol
Glomerulonephritis
steroid medication or cyclophosphamide
• Life style changes
• Dialysis
• Renal Replacement therapy
Common causes of End stage
renal disease
Disease Frequency Comments FOLLOW-UP EVALUATION
In most cases, chronic kidney disease (CKD) is
Congenital and 5% Polycystic kidney progressive, and thus, children with CKD
Inherited disease, Alport's
syndrome require;
Ongoing monitoring of their kidney function
Renovascular 5% Atheromatous Screening for complications associated with
disease CKD.
Hypertension 5-20% Renal disease
Parameters to be closely monitored
Glomerular 10-20% IgA nephropathy ●Growth including measurements of weight
disease and height. For patients who are three years
of age and younger, head circumference
Interstitial 20-30% Drug abuse, should also be measured.
disease ●Blood pressure.
Systemic 5-10% Systemic lupus ●Nutritional status.
inflamatory erythematosus ●Laboratory tests, including serum
disease Vasculitis creatinine, electrolytes, calcium and
phosphorus, hemoglobin, fasting lipid profile,
Diabetes mellitus 20-40% Racial and 25-hydroxyvitamin D, parathyroid hormone
Geographic level, urinalysis, and determination of the
difference
urinary protein-to-creatinine ratio.

Unknown 5-20%
Referrence
Wong. C, Warady. B, Srivastava. T.Clinical presentation and
evaluation of chronic kidney disease in children. 2016
Chan. J, William. D, Roth. K. Kidney failure in infants and
children. Kidney disease. 2012.
N.M. Kayange, L. Smart, R. Peck. Kidney disease among
children in sub-Saharan Africa: a systemic review. 2015
KDIGO 2012 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease volume 3.
issue1.January 2013