Chronic Kidney Disease: Diagnosis and management

1. Chronic Kidney Disease:Chronic Kidney Disease:
Diagnosis and managementDiagnosis and management
Dr Vilas Naik,Dr Vilas Naik, Consultant NephrologistConsultant Nephrologist
Kolhapur Kidney Care and Superspeciality Centre,Kolhapur Kidney Care and Superspeciality Centre,
VijayVijay HospitalHospital,, KolhapurKolhapur
IMA Ratnagiri
4th
July 2009

2. OverviewOverview
CaseCase
DefinitionDefinition
Epidemiology: Indian ScenarioEpidemiology: Indian Scenario
Risk Factors and CausesRisk Factors and Causes
How do we suspect?: Clinical features andHow do we suspect?: Clinical features and
complicationscomplications
DiagnosisDiagnosis
Management and Slowing the progression of KidneyManagement and Slowing the progression of Kidney
DiseaseDisease

3. CaseCase
36 yrs young lady36 yrs young lady
2 kids, No pregnancy complications2 kids, No pregnancy complications
Presenting illnessPresenting illness
– Generalized weakness & bone painsGeneralized weakness & bone pains
– dyspnea on exertiondyspnea on exertion
– decreased appetite since 6 monthsdecreased appetite since 6 months
– Wt loss by 2-3 kgsWt loss by 2-3 kgs

4. CaseCase
– Investigated 4 months ago:Investigated 4 months ago:
Weight: 34 kgs, ? Fever, BP- 150/ 96,Weight: 34 kgs, ? Fever, BP- 150/ 96,
Hb- 9.2 gm %,Hb- 9.2 gm %,
Bilirubin, SGOT and SGPT was normalBilirubin, SGOT and SGPT was normal
– Urine: albumin – 3+, RBCs- 12-15, WBCs- 10-12Urine: albumin – 3+, RBCs- 12-15, WBCs- 10-12
– Creatinine-Creatinine- 1.4 mg %1.4 mg % (lab range 0.5 to 1.4 mg%)(lab range 0.5 to 1.4 mg%)
– CXR- NormalCXR- Normal

5. CaseCase
– Treated with antibiotics for ? Fever, antimalarials,Treated with antibiotics for ? Fever, antimalarials,
then as UTI.then as UTI.
– She felt persistently unwell + weight loss: So wasShe felt persistently unwell + weight loss: So was
started on AKTstarted on AKT
– Presently: May 2009Presently: May 2009
HT: 160/96, Wt- 33 kgs, Nothing else on examinationHT: 160/96, Wt- 33 kgs, Nothing else on examination
Anemia: Hb: 8.8 gm%, Sr.Ca: 7.3 mg%Anemia: Hb: 8.8 gm%, Sr.Ca: 7.3 mg%
Urine: Albumin- 4+, RBCs- 3-4, Pus Cells- 6-8.Urine: Albumin- 4+, RBCs- 3-4, Pus Cells- 6-8.
SGOT, SGPT, Bilirubin- NormalSGOT, SGPT, Bilirubin- Normal
Creatinine:Creatinine: 2.4 mg%,2.4 mg%, USG – Kidney sizes 7.3 and 7.2 cmsUSG – Kidney sizes 7.3 and 7.2 cms

6. Case ContinuedCase Continued
Nephrology consulted for mild renal failureNephrology consulted for mild renal failure
Past Medical HistoryPast Medical History was evaluated inwas evaluated in
more detailmore detail
– Puffiness of face and mild edema feet – 1 yr agoPuffiness of face and mild edema feet – 1 yr ago
– was told to have slightly high BP, takenwas told to have slightly high BP, taken
amlodepin and lasix for 15 days.amlodepin and lasix for 15 days.
– Urine- albumin- 2+, RBCs- 8-10, Pus cells- 8-10.Urine- albumin- 2+, RBCs- 8-10, Pus cells- 8-10.
– CBC normal. Improved with symptomaticCBC normal. Improved with symptomatic
treatmenttreatment

7. Case continuedCase continued
Now I was asked by the consultant physicianNow I was asked by the consultant physician
– Are these symptoms related to kidney failure?Are these symptoms related to kidney failure?
– Can such a mild degree of renal failure (Can such a mild degree of renal failure (creatininecreatinine
of only 2.4of only 2.4) cause these symptoms?) cause these symptoms?
– What is the cause of renal dysfunction?What is the cause of renal dysfunction?
– Should we do a kidney biopsy?Should we do a kidney biopsy?
We will answer all these questions at the end of ourWe will answer all these questions at the end of our
discussion, and you can easily help me with this.discussion, and you can easily help me with this.

8. Definition of Chronic Kidney Disease (CKD)Definition of Chronic Kidney Disease (CKD)
Vs FailureVs Failure
CKD is defined as either kidney damage or
GFR < 60 ml/ min for 3 months.
Kidney Damage:
– pathological abnormalities or markers of
damage- includes blood,
– Urine: RBCs, Blood or proteins
– or imaging (eg USG showing renal
abnormalities

9. Definition: Kidney Disease outcomeDefinition: Kidney Disease outcome
Quality Initiative (K/DOQI)Quality Initiative (K/DOQI)
StageStage DescriptionDescription GFR((mL/min/1.73 m2GFR((mL/min/1.73 m2))
II Kidney damage with normal orKidney damage with normal or
increased GFRincreased GFR
9090
IIII Kidney damage with mildKidney damage with mild
decreased GFRdecreased GFR
60-8960-89
IIIIII Moderated decrease in GFRModerated decrease in GFR 30-5930-59
IVIV Severe decrease in GFRSevere decrease in GFR 15-2915-29
VV Kidney failureKidney failure < 15 or dialysis< 15 or dialysis
DRAWBACKS

10. Epidemiology: CKDEpidemiology: CKD
Worldwide public health problem: RisingWorldwide public health problem: Rising
USA: dialysis has increased from 10000 in 1973 toUSA: dialysis has increased from 10000 in 1973 to
> 506000 in 2006 (22 billion $ in 2006> 506000 in 2006 (22 billion $ in 2006))
Dialysis: No insurance covers itDialysis: No insurance covers it
Indian ScenarioIndian Scenario
– No National Registry data, reporting systemsNo National Registry data, reporting systems
– Only some some small observational studiesOnly some some small observational studies
– Prevalence of CKD:Prevalence of CKD: 0.79 to 0.87%:0.79 to 0.87%: alarming numberalarming number
– Dialysis:Dialysis: 150 to 250 per million150 to 250 per million..

11. Epidemiology: Indian ScenarioEpidemiology: Indian Scenario uhnuhn
Reasons:Reasons:
– Longer survival:L better Rx of ents with DM,Longer survival:L better Rx of ents with DM,
HT, heart disease, leading to involvement ofHT, heart disease, leading to involvement of
the kidneys in the later stagethe kidneys in the later stage
– Increased awareness: more detectionIncreased awareness: more detection
– Aging populationAging population

12. Epidemiology: Indian ScenarioEpidemiology: Indian Scenario
All CKD cases can progress to ESRD-All CKD cases can progress to ESRD-
unless identified early, and aggressive effortsunless identified early, and aggressive efforts
to slow the progressionto slow the progression
We all know the expenses… HD and TxWe all know the expenses… HD and Tx
So our best effort would beSo our best effort would be
– Prevention: Early recognition and referral toPrevention: Early recognition and referral to
nephrology services, is the keynephrology services, is the key
– Slowing the progression of CKD to ESRDSlowing the progression of CKD to ESRD
uhn

13. Risk FactorsRisk Factors
DM type 2: upto 40 % on dialysis have ESRDDM type 2: upto 40 % on dialysis have ESRD
secondary to DM 2secondary to DM 2
HT and Peripheral vascular diseases- leading toHT and Peripheral vascular diseases- leading to
atherosclerotic renal artery stenosis and ischemicatherosclerotic renal artery stenosis and ischemic
nephropathynephropathy
Obesity- hyperfiltration injuryObesity- hyperfiltration injury
SmokingSmoking
HyperlipidemiaHyperlipidemia

14. CausesCauses
Any kind of injury that causesAny kind of injury that causes
permanent damage to thepermanent damage to the
kidneys results in Chronic Renal Failurekidneys results in Chronic Renal Failure
or Chronic Kidney Diseaseor Chronic Kidney Disease

15. Adaptive hyperfiltration
(↑ PGC → maintenance of GFR)
Initial injury
(GN, ATN, AIN)
↓
Loss of renal parenchyma
↓
↓
Long-term damage
to remaining nephrons
↓
Proteinuria,
progressive renal
insufficiency

16. Main categories- Pre RenalMain categories- Pre Renal
Pre- RenalPre- Renal
– True Volume depletion:True Volume depletion: Bleeding, diarrhea,Bleeding, diarrhea,
volume depletion due to any causevolume depletion due to any cause
– Effective circulating volume depletion:Effective circulating volume depletion:
CirrhosisCirrhosis
Chronic congestive heart failure:Chronic congestive heart failure:
– Renin angiotensin aldosterone (RAAS) activationRenin angiotensin aldosterone (RAAS) activation
– leading to permanent kidney damage secondary toleading to permanent kidney damage secondary to
interstitial fibrosisinterstitial fibrosis

17. Concept of effective circulating volumeConcept of effective circulating volume
5 L container
5 L H2O
5 L container
5 L H2O
Empty part
5 L H2O
5 L H2O

18. Hypovolemia or hypotensionHypovolemia or hypotension
⇓⇓
Release ofRelease of ReninRenin from the JGA of Kidneysfrom the JGA of Kidneys
⇓⇓
AngiotensinogenAngiotensinogen release and gets converted torelease and gets converted to angiotensin1angiotensin1
in the liverin the liver
⇓⇓
Angiotensin 1 converted toAngiotensin 1 converted to angio 2angio 2 in kidneysin kidneys
⇓⇓
Angio 2 acts on glomerular blood vessels to causeAngio 2 acts on glomerular blood vessels to cause
vasoconstiction, tovasoconstiction, to maintain GFRmaintain GFR
⇓⇓
But at the same time activatesBut at the same time activates cytokines and causes fibrosiscytokines and causes fibrosis
of the Kidneys, if persistentof the Kidneys, if persistent

19. Intraglomerular Pressure
Arterial
Pressure
Angiotensin II Angiotensin II
Efferent
50 mmHg
Afferent
110 mmHg
Bowman’s
Capsule
↑ glomerular
pressure
Cytokine release
+
+ ++
60 mmHg

20. Main categories- RenalMain categories- Renal
Renal VascularRenal Vascular
– Large blood vesselsLarge blood vessels
Renal artery stenosis- atherosclerotic or other causesRenal artery stenosis- atherosclerotic or other causes
Benign NephronosclerosisBenign Nephronosclerosis
– Smaller Blood VesselsSmaller Blood Vessels
Malignant hypertensionMalignant hypertension
Vasculitis- eg Systemic lupus erythromatosis (SLE)Vasculitis- eg Systemic lupus erythromatosis (SLE)
HUS and TTPHUS and TTP

21. BL renal artery stenosis causing ischemicBL renal artery stenosis causing ischemic
nephropathy and severe Hypertensionnephropathy and severe Hypertension

22. Malignant hypertensionMalignant hypertension

23. Main categories- RenalMain categories- Renal
GlomerularGlomerular
– Nephrotic syndromeNephrotic syndrome
Primary GN eg: Membranous NephropathyPrimary GN eg: Membranous Nephropathy
Secondary glomerular disease: DM2, MultipleSecondary glomerular disease: DM2, Multiple
myelomamyeloma
– Nephritic syndrome: AGNNephritic syndrome: AGN
Primary eg: Membrano- proliferativePrimary eg: Membrano- proliferative
GlomerulonephritisGlomerulonephritis
Secondary: Systemic lupus erythromatosisSecondary: Systemic lupus erythromatosis
– Rapidly Progressive GN: ANCA related, anti-Rapidly Progressive GN: ANCA related, anti-

24. Diabetic NephropathyDiabetic Nephropathy
Diabetic glomerulosclerosis Normal Glomerulus

25. Diabetic NephropathyDiabetic Nephropathy
Advanced Diabetic Nephropathy Normal Glomerulus

26. Rapidly progressive glomerulonephritisRapidly progressive glomerulonephritis
(RPGN)(RPGN)

27. Main categories- RenalMain categories- Renal
Tubular and Interstitial disordersTubular and Interstitial disorders
TubularTubular
– Acute tubular necrosis which fails to recover completelyAcute tubular necrosis which fails to recover completely
Ischemic ATN- low BP and severe volume depletionIschemic ATN- low BP and severe volume depletion
Toxic ATN- Sepsis, Malaria etcToxic ATN- Sepsis, Malaria etc
Interstitial DisordersInterstitial Disorders
– Infections (chronic pyelonephritis), drugs- NSAIDSInfections (chronic pyelonephritis), drugs- NSAIDS
– Polycystic Kidney DiseasePolycystic Kidney Disease
– Autoimmune disordersAutoimmune disorders
– Renal Calculus diseaseRenal Calculus disease

28. Interstitial Nephritis- drugs andInterstitial Nephritis- drugs and
infectioninfection

29. Post RenalPost Renal
Obstructive NephropathyObstructive Nephropathy
– BL Renal Calculus DiseaseBL Renal Calculus Disease
– Prostatic enlargement- Benign or malignantProstatic enlargement- Benign or malignant
– Severe stricture urethraSevere stricture urethra
– Severe PhimosisSevere Phimosis

30. Obstructive NephropathyObstructive Nephropathy
BL Staghorn calculus Ureteric calculus on IVP

31. Obstructive NephropathyObstructive Nephropathy

32. Elevated Uric Acid Increases the Risk forElevated Uric Acid Increases the Risk for
Kidney DiseaseKidney Disease
The risk for kidney disease increased:The risk for kidney disease increased: 6 to 7 mg/dl6 to 7 mg/dl
in women andin women and 7 to 8 mg/dl7 to 8 mg/dl in menin men
Concluded that: elevated levels of uric acidConcluded that: elevated levels of uric acid
independently increase the risk for new-onset kidneyindependently increase the risk for new-onset kidney
diseasedisease
So Uric acid needs to be checked in high riskSo Uric acid needs to be checked in high risk
patients like DM and HT and treated if highpatients like DM and HT and treated if high
J Am Soc Nephrol 19: 2407–2413, 2008

33. Acute Kidney Injury Increases Risk of ESRDAcute Kidney Injury Increases Risk of ESRD
among elderlyamong elderly
Elderly individuals with AKI (ARF due toElderly individuals with AKI (ARF due to
ATN), particularly those with previouslyATN), particularly those with previously
diagnosed CKD, are at significantlydiagnosed CKD, are at significantly
increased risk for ESRDincreased risk for ESRD
suggesting that episodes of AKI maysuggesting that episodes of AKI may
accelerate progression of renal disease.accelerate progression of renal disease.
J Am Soc Nephrol 20: 223–228, 2009

34. Changes in Body Weight Predict CKDChanges in Body Weight Predict CKD
in Healthy Menin Healthy Men
increases in body weight are independentlyincreases in body weight are independently
associated with an increased risk for CKD.associated with an increased risk for CKD.
Risk remained significant even after otherRisk remained significant even after other
causes like DM, HT , metabolic syndrome etccauses like DM, HT , metabolic syndrome etc
were ruled out (adjusted)were ruled out (adjusted)
J. Am. Soc. Nephrol. 2008

36. PRESENTING MANIFESTATIONSPRESENTING MANIFESTATIONS
Signs and symptoms resulting directly fromSigns and symptoms resulting directly from
alterations in kidney function:alterations in kidney function:
– decreased or no urine outputdecreased or no urine output
– flank painflank pain
– EdemaEdema
– HypertensionHypertension
– discolored urine- Hematuria, pus in urinediscolored urine- Hematuria, pus in urine
– AnemiaAnemia

37. PRESENTING MANIFESTATIONSPRESENTING MANIFESTATIONS
Symptoms and/or signs of renal failure:Symptoms and/or signs of renal failure:
– weakness & easy fatigue (anemia & uremia)weakness & easy fatigue (anemia & uremia)
– Anorexia, Nausea & vomitingAnorexia, Nausea & vomiting
– mental status changes or seizuresmental status changes or seizures
– Anasarca- fluid overloadAnasarca- fluid overload
– Bone pains & fractures after minimum traumaBone pains & fractures after minimum trauma
– Burning feet, restless leg syndrome from uremicBurning feet, restless leg syndrome from uremic
polyneuropathypolyneuropathy

38. PRESENTING MANIFESTATIONSPRESENTING MANIFESTATIONS
Symptoms and/or signs of renal failure:Symptoms and/or signs of renal failure:
– Dyspnea, orthopnea or PND: fluid accumulating inDyspnea, orthopnea or PND: fluid accumulating in
the lungs andthe lungs and Uremic CardiomyopathyUremic Cardiomyopathy
– Acidotic breathing (Rapid and deep)- due toAcidotic breathing (Rapid and deep)- due to
acidosisacidosis secondary to renal failure.secondary to renal failure.
– Chest pain/ pericardial rubChest pain/ pericardial rub: uremic pericarditis: uremic pericarditis
– Severe itchingSevere itching due to Uremia and dry skindue to Uremia and dry skin
– MalnutritionMalnutrition in advanced renal diseasein advanced renal disease

39. PRESENTING MANIFESTATIONSPRESENTING MANIFESTATIONS
Systemic symptoms due to disease causingSystemic symptoms due to disease causing
renal failure:renal failure:
– eg fever, Joint pains, skin rash in vasculitis (egeg fever, Joint pains, skin rash in vasculitis (eg
SLE, ANCA vasculitis)SLE, ANCA vasculitis)
– eg high grade fever, low BP and shock ineg high grade fever, low BP and shock in
pyelonephritispyelonephritis

40. Vasculitic rashVasculitic rash

41. Vasculitic rashVasculitic rash

42. PRESENTING MANIFESTATIONS:PRESENTING MANIFESTATIONS: Lab findingsLab findings
CBC- normocytic normochromic anemiaCBC- normocytic normochromic anemia
HyperkalemiaHyperkalemia
Urea and creatinineUrea and creatinine
Low Ca, high P and uric acidLow Ca, high P and uric acid
UrinalysisUrinalysis- Proteinuria, hematuria, pus cells, casts- Proteinuria, hematuria, pus cells, casts
Sr Albumin- Nephrotic syndromeSr Albumin- Nephrotic syndrome
Sr Cholesterol- high in Nephrotic syndromeSr Cholesterol- high in Nephrotic syndrome

43. Urine analysis- poor mansUrine analysis- poor mans
biopsybiopsy

44. ProteinuriaProteinuria
Normal:Normal:
– Total protein < 150 mg/dTotal protein < 150 mg/d
– Urine albumin < 10 mg/dayUrine albumin < 10 mg/day
Proteinuria =Proteinuria = > 300 mg/d> 300 mg/d
– Microalbuminuria = 30-300 mg/dMicroalbuminuria = 30-300 mg/d
– The normalThe normal Urine Protein To Creatinine RatioUrine Protein To Creatinine Ratio is lessis less
thanthan 0.2 mg/mg0.2 mg/mg. (proteins and creatinine are measured. (proteins and creatinine are measured
in mg %)in mg %)
– Micral test for Microalbuminuria detectionMicral test for Microalbuminuria detection

45. IS microalbuminuria/
proteinuria bad?

47. Microalbuminuria and risk of progression of
kidney disease
An early decline in GFR occurred in
– 68% with progression of MA
– 32% with stabilization of MA
– 16% with regression
– and 9% with normoalbuminuria.
J Am Soc Nephrol. 2007 Apr;18(4):1353-61. Epub 2007 Feb 28.

48. Heme-granular casts- ATNHeme-granular casts- ATN

49. RBC Cast: AGN/ RPGNRBC Cast: AGN/ RPGN

50. Pus cells and pus cell castPus cells and pus cell cast
Pus cells White cell casts

51. Acute Vs Chronic: Disease DurationAcute Vs Chronic: Disease Duration
The distinction between acute, rapidly progressiveThe distinction between acute, rapidly progressive
(subacute), and chronic kidney disease is arbitrary(subacute), and chronic kidney disease is arbitrary
Rise in the plasma creatinine concentration or anRise in the plasma creatinine concentration or an
abnormality on the urinalysis that has developedabnormality on the urinalysis that has developed
– within hours to days: acute processwithin hours to days: acute process
– Over days to weeks- SubacuteOver days to weeks- Subacute
– Over Months- ChronicOver Months- Chronic
Arbitory: No previous valuesArbitory: No previous values

52. DiagnosisDiagnosis
Clinical manifestationsClinical manifestations
Blood biochemistryBlood biochemistry
Urine analysisUrine analysis
RadiologyRadiology
Kidney BiopsyKidney Biopsy

53. RadiologyRadiology
X- Ray KUB- Renal calculus diseaseX- Ray KUB- Renal calculus disease
USG and dopplerUSG and doppler
– Size: most important feature, EchogenesitySize: most important feature, Echogenesity
– Obstruction & other structural abnormalitiesObstruction & other structural abnormalities
– Renal vessels- Renal artery and venous lesionsRenal vessels- Renal artery and venous lesions
CT scan- Replaced IVP to a large extentCT scan- Replaced IVP to a large extent
– Accurate assessment of renal stonesAccurate assessment of renal stones
– Some structural abnormalities more clearlySome structural abnormalities more clearly::
Malignancy, cysts, abscessMalignancy, cysts, abscess

54. RadiologyRadiology
MRI and MR angiographyMRI and MR angiography
– More accurate assessment of the renal arteryMore accurate assessment of the renal artery
and veins forand veins for stenosis or thrombosisstenosis or thrombosis

55. Kidney BiopsyKidney Biopsy
The most specific diagnostic test for causeThe most specific diagnostic test for cause
and prognosisand prognosis
The kidneys should be normal sized onThe kidneys should be normal sized on
USG before you biopsy itUSG before you biopsy it
Provides adequate diagnostic informationProvides adequate diagnostic information
in 90 % of the casesin 90 % of the cases

56. Complications of renal failureComplications of renal failure
Cardiac:Cardiac:
– CMPCMP
– pericarditis & tamponadepericarditis & tamponade
Nervous system:Nervous system:
– Encephalopathy, seizuresEncephalopathy, seizures
– NeuropathyNeuropathy
HematologyHematology
– Anemia of CKDAnemia of CKD
Bone and jointsBone and joints
– Renal bone diseaseRenal bone disease
– Secondary hyper PTHSecondary hyper PTH
– GoutGout
EndocrineEndocrine
– Sexual dysfunctionSexual dysfunction
– Thyroid abnormalitiesThyroid abnormalities
VascularVascular
– Vascular calcificationVascular calcification
– Severe peripheralSevere peripheral
vascular diseasevascular disease
– PrematurePremature
atherosclerosisatherosclerosis
– Severe CADSevere CAD

57. Estimating Kidney function: GFR andEstimating Kidney function: GFR and
Creatinine clearanceCreatinine clearance
Sr Creatinine:Sr Creatinine:
– insensitive markerinsensitive marker
– Needs to be corrected for age, gender, weightNeeds to be corrected for age, gender, weight
and muscle massand muscle mass
Cockcroft-Gault equationsCockcroft-Gault equations
Cret Clearance = (140-age) X weight
72 X Sr Creat
Multiply this by 0.85 in case of females

58. Measurement of GFRMeasurement of GFR
CreatinineCreatinine
eGFR (Cockcroft-Gault, MDRD)eGFR (Cockcroft-Gault, MDRD)
Creatinine ClearanceCreatinine Clearance
Creatinine Clearance + CimetidineCreatinine Clearance + Cimetidine
Radionuclide MarkersRadionuclide Markers
Inulin ClearanceInulin Clearance
Cystatin CCystatin C

59. Cockcroft-Gault equationsCockcroft-Gault equations
70/F, weight 45 kgs and 35/M, weight 70 kg70/F, weight 45 kgs and 35/M, weight 70 kg
Both have Sr Creatinine of 2 mg %Both have Sr Creatinine of 2 mg %
– In the young man, creatinine clearance / GFRIn the young man, creatinine clearance / GFR
using the formula isusing the formula is 51.36 ml /min51.36 ml /min
– In the older lady, the creatinine clearance /In the older lady, the creatinine clearance /
GFR is……..GFR is……..
18.61 ml / min18.61 ml / min

60. Back to our caseBack to our case
So can we explain all the symptoms on theSo can we explain all the symptoms on the
basis of mild renal dysfunction??basis of mild renal dysfunction??
Lets calculate the GFRLets calculate the GFR
4 months before she presented to us, creat4 months before she presented to us, creat
was1.4 mg %was1.4 mg %
– eGFR = 29.9 ml/ mineGFR = 29.9 ml/ min
Now the creat was 2.4 mg %Now the creat was 2.4 mg %
– eGFR = 17. 4 ml / mineGFR = 17. 4 ml / min

61. Back to our caseBack to our case
USG of abdomenUSG of abdomen
– RK- 7 X 2.9 cms, LK- 7.3 X 3 cmsRK- 7 X 2.9 cms, LK- 7.3 X 3 cms
– Small and echogenicSmall and echogenic
ManagementManagement
– Anemia correction & bone protection,Anemia correction & bone protection,
– control of HT and hyperlipidemia: ACEIs,control of HT and hyperlipidemia: ACEIs,
– Diet and correct acidosisDiet and correct acidosis
– AV fistula and preparation for dialysisAV fistula and preparation for dialysis
– Sister as a potential kidney donor for transplantSister as a potential kidney donor for transplant

62. ManagementManagement
Aggressive control of risk factorsAggressive control of risk factors
Smoking cessationSmoking cessation
BP target: < 125/75 in proteinuricsBP target: < 125/75 in proteinurics
Lipid target- StatinsLipid target- Statins
DietDiet modification- as per the blood chemistry,modification- as per the blood chemistry,
fluid status and symptomsfluid status and symptoms

63. ManagementManagement
CardiacCardiac evaluation and protectionevaluation and protection
– Overlapping risk factorsOverlapping risk factors
Symptomatic treatmentSymptomatic treatment
– AcidosisAcidosis
– Bone protectionBone protection
– Correction of hyperphosphatemia, low calciumCorrection of hyperphosphatemia, low calcium
– Vitamin supplementsVitamin supplements
– Anemia management: erythropoitin and IV ironAnemia management: erythropoitin and IV iron

64. Management- Proteinuria reductionManagement- Proteinuria reduction
ACEI inhibitors:
– BP control + proteinuria reduction + cardiac protection
– Ramipril: Cardiopril
ARBs
– BP control + proteinuria reduction + cardiac protection
– Telmisartan: Telsartan
High dose statins: Atocor (Atorvastatin):
– Proteinuria reduction + endothelial protection

65. Management-Renal function preservationManagement-Renal function preservation
ACEI
– Ramipril ( Cardiopril) helps slow the progression
of renal dysfunction, in addition to decrease in
proteinuria
ARBs
– Telmisartan (Telsartan): slows progression of
renal disease
– Many trial supporting the same

66. ManagementManagement
Treatment of specific diseasesTreatment of specific diseases
– Eg Steroids for SLEEg Steroids for SLE
– Specific therapy of Nephrotic syndrome: steroids,Specific therapy of Nephrotic syndrome: steroids,
cyclophosphamide, cyclosporincyclophosphamide, cyclosporin

67. THANKS for you patience…..THANKS for you patience…..
X