CKD - Pearls for Diagnosis

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CKD - Pearls for Diagnosis

28 Apr, 3:30 PM

[Music] good evening to your doctors on behalf of team like this to all of you is joining us here tonight today we have the honor and privilege of having among us dr manisha who is professor and head of technology at australia medical college and hospital hyderabad mom is also executive member indian society of organ transplant editor-in-chief in the journal of transplantation vice president indian society of nephrology and chair of south asia regional board international society of metrology you dr manisha for joining us tonight it is truly an honor to be learning from you tonight so good evening everyone who is on the call who have spared their time to be here and today i will be talking about chronic kidney disease so we are starting with chronic kidney disease and in between i'll be asking few questions so do not think that chronic kidney disease uh has to be dealt with only by nephrologists i mean everyone whether we are mbbs or we are doing our md or we may be a gynic person or anybody for that matter we should have some awareness about the chronic kidney disease and that's why i have named the first topic in the series as ckd pearls chronic ebz some clinical pearls so i start with a question which of the following is correct 40 years old mean serum creatine is 2 urine protein is 2 plus he comes to your clinic which of the calling statements is correct he has aki acute kidney injury or he has ckt or the information given is not adequate or he has nephrotic syndrome with my renal failure so which of these you think is the correct answer the questions are simple so we have half the people voting that's good that's great so your vote is anyhow anonymous please vote okay so uh people have written aki ckb 38 have written that the information is inadequate so yes the third answer is correct because you cannot say aki or ckd because i have not even mentioned the duration of kidney problem so we need to ask how long he has been having this right so if it is more than three months then we make think of ckd if less than three months or less than a week or two weeks we have to think of aki right so that's important so the correct answer is information get given is inadequate now nephrotic syndrome see nephrotic syndrome you use the term then you have proteinuria plus low serum albumin and high cholesterol that information have not put so what's the correct answer it's cancer 3. so how do you define chronic kidney disease remember chronic kidney disease is defined as impairment of kidney function of equal to or more than three months so that three months period is compulsory to call it chronic and how we define the kidney impairment ra the gfr should be less than 60. so all of us get scared of gfry we have to calculate how we calculate i will tell you how do we do it so gfr should be less than 60 and if the gfr is more than 16 then look for other abnormalities whether the person is having proteinuria or small kidneys or fibrosis on biopsy so this is the complete definition of chronic kidney disease the first statement is three months and then you look at the gfr if gfr is less than 60 it's straight away chronic kidney disease if the gfr is more than 60 then see whether the patient has proteinuria or small kidneys or fibrosis on biopsy so this is what we need to know about chronic kidney disease okay then there are five stages of chronic kidney disease stage one to stage five you can see in the picture and they are mainly based on gfr as well as the urine albumin so based on gfr normal gfr generally i mean is more than 120 so if you have a gfr of more than or equal to 90 that is stage one between 60 to 90 with stage 2 3260 stage 3 15 to 30 stage 4 and less than 15 it's called last stage or stage 5 and each stage can further be divided on the level of albumin so if the urine albumin is less than 30 milligram per day it is a1 a2 is between 30 to 300 and more than 300 it's called a3 so remember that that we have three stages of albuminuria also so ckd staging even if you are an mbbs doctor or a general practitioner or a physician whenever patient comes to you with ckd try to write the stage of ckb as well so it's very simple i'll tell you how but first understand that staging is based on gfr and also the level of algorithm so now we have this patient with a gfr of 14 and urine albumin is 500 which stage will he fall into so stage g3 a3 g4 a3 g5 a2 or g5 a3 so just hazard yes you can give your answers there right or wrong doesn't matter we are here for the purpose of learning so 48 people great great going i encourage all of you to vote it's not an exam as are the guests otherwise we'll never learn we learn by making mistakes wow so majority voted that's great so let me see yes so again actually it is g five eight three that's the correct answer how it is g5 a3 because gfi were was less than 15 it was 14 so it becomes stage 5 and albumin is more than 500 it's 500 that's more than 300 so that is a3 so where does he fall into so this is called the heat map of ckd where on the left side you have gfr on the right side you have a1 a2 a3 that is the albumin so here where does he fall into you can see the cross there he falls into g5 a3 so in your prescription you should write that g5 a3 okay so albumin you can do it in the lab and gfr lab can give you or you are all smart doctors you can have the gfr app free download just calculate gfr calculator just click it you will get the gfr calculator you fill the creatine value h and you get the gfr it is that simple so always on your prescription try to stage the ckd okay why we should know about ckd people think that ckd is very uncommon diabetes is common and hypertension is common heart disease yes very common but ckd no we talks about poor kidneys because everybody feels that it's very uncommon but let us see so again another question for you that is if it's around 18 percent of indian population what is the percentage of indian people affected by ckd one percent five percent fifteen percent or twenty 25 can you make a guess yeah so you have 30 seconds to answer this 1 5 15 25 i told you diabetes is an 18 so how common is ckb wow great number of people answering it's really heartening for the for the person who's asking the questions if people are interested that's great so we have still eight seconds come down yeah so your audience is very fast with the fingers they are answering fine very good so now let us see what the results are so that's absolutely right so we'll go with the majority log kia ji 15 is the correct cancer so imagine diabetes is 18 and we all know so much about diabetes and ckd is almost as common i mean 15 and in one study in india they say it's around 17 percent so not far behind diabetes but we hardly know anything about it and that's the reason for the seminar on netflix to tell you that is quite common so chronic kidney disease is a global killer in plain sight but we do not recognize it in the global scenario it's around 1 in 10 but look at the figures in india it's roughly around 17 or 1 in 8 indians have ckd so we are now 146 people here so out of us how many would be having ckd i mean it's it's maybe around um if you say around 150 15 20 of us 20 members among us will be having ckd and we don't know about it so it's quite common remember that what are the common cause of ckd this is our study from india we have a pool of 5000 patients multicentric study and diabetes is the most common cause this is followed by chronic interstitial nephritis whether tubules and interstitium are involved it's become very common because of abuse of painkillers because of stones which are very common in india in the summer months then ckd unknown we do not know what the cause is maybe the herbal things or ayurvedic things what we take i mean without prescriptions or heavy metals we do not know so unknown cause is very common in india it's called ckdu ckd of undetermined origin then you have chronic glomerulonephritis hypertension polycystic kidney disease and others so calmness still remains liability kidney disease and we should all be aware of this now which of the following statements is correct we know that we are all scared of cardiovascular disease and we know diabetes is a risk factor for cardiovascular disease so which of the statements is correct diabetes is a stronger risk factor for um so which of the statements is incorrect i've framed this the question wrongly sorry for that so each of the following is incorrect so three are right one is incorrect so diabetes is the strongest risk factor for cbd as compared to ckt diabetic patients are 15 risk of cardiovascular death ckd patients are 30 risk of cardiovascular deaths and diabetic patients with ckb have 32 risk of cardiovascular death so which of the following statements is correct which of the following statements sorry it's incorrect three are right one is wrong so diabetes is the strongest risk factor the application is fifteen percent raised security patients thirty percent risk of cardiovascular death and last is combined diabetes and ckb they have 32 percent first so can you guess which of them is incorrect one is not correct okay so yeah uh first one is the correct cancer yeah and that has got maximum goods so ckd is a stronger risk factor than diabetes for cardiovascular disease and we worry so much about diabetes and heart and all that so this is the time start worrying about chronic kidney disease as well don't forget about diabetes i do not definitely mean that but remember cardiovascular ckd is an important risk factor for cardiovascular diseases so what about the ckd what does it cause on one hand it can lead to end-stage kidney disease patients go on dialysis and transplant on the other hand it is a very strong risk factor for heart disease as i already pointed out you can see that the risk of heart disease goes up and up with the chronic kidney disease so 15 in diabetic without ckd and almost 30 percent in non-diabetic with ckd and 32 percent in those patients who have both diabetes and ckb so remember this it's important and all sorts of cardiovascular diseases are increased you can see that you can have congestive heart failure or myocardial infarction or strokes peripheral vascular disease atherosclerotic vascular disease and that all causes of cardiovascular mobility and mortality are high so that's the important point fine now how many patients we talked about that around 15 to 17 percent of indian population of ckd how many of these progress to end stage kidney disease every year how many need dialysis how many need transplant every year ten thousand three thousand five black can you tell me what numbers does india need to dialyze every year ten thousand fifty thousand two lakhs or five lakhs these are the choices in front of you so which choice would you like so very interactive audience they are answering well many of them are getting the answers right unfortunately we don't have helplines unlike but i think this audience does not need help lines yeah that's great so two lakhs that's great so two lakhs is the correct answer so two lakhs every year is a huge number we have to do dialysis for two lakh people every year for that we need one lakh or 50 000 machines at least every a new machine because old people are surviving new people are getting added up so india cannot bear the burden of dialysis we have to prevent ckd that's important so remember that cure is not important prevention is important so we know that treatment of end stage kidney disease is dialysis and transplant are transplants available in india you are all aware they are available which are which types of transplant living kidney transplant transplant from disease donor transplant from cardiac death or xeno transplant all the following are available except so your time starts now living kidney transplantation from disease brain dead donor transplantation so we have lots of people voting yeah so time is over and we have most of the doctors have voted for xenotransplant that's absolutely right so xenotransplants the good thing is it has started in the world and uh transplant from pig has been done and pig's heart has been put into a human being and has functioned nicely so uh the all the other forms are available in india living transplant everywhere transplant from disease donor it's available everywhere most of the states have it from um transplant after circulatory death it's occurring now in pgi chamber for this we need a very good ambulance system the patient needs to be shifted immediately all those things are there but we are proud that in india this also has started india is doing very well in the field of transplantation uh zero transplant as of now is not available in india but soon it will be available because india does adapt to the new situations and gets the new innovations very quickly and um you would be happy to know that transplant from peak is possible uh and that model has worked successfully and how many kidney transplants are done in india every year ten thousand twenty thousand thirty thousand forty thousand so can anybody answer that let us see how much you are aware of the kidney transplant i know that's not your feel but we should have a general idea so yes can we have the audience full please yes ma'am 10 20 so india unfortunately does around 10 000 to 12 000 transplants per year and i told you two lakh people need a transplant so remember we are far away from meeting the demands by transplant prevention is that okay india is still the country which does a huge number of transplants i mean we are second only to america and the number of transplants but our population is so huge i mean 10 to 12 000 transplants are just peanuts we need to increase the rate of transplants and most of the transplants in india are from living donors and we need to increase the transplants from disease donors as well okay so now what are the transfer treatment available in india we have dialysis peritoneal dialysis hemodialysis and we have transplant living and disease donor transplant this i already said dialysis is costly you're all familiar with the dialysis machines if you have not seen this is the dialysis machine each dialysis costs around 2000 rupees per session and patient has to go to the hospital for three times in a week so four hours every time so monday then wednesday then again friday those patients go on tuesday then thursday then saturday like that so alternate day lifelong patient has to go for dialysis and dialysis is not only cumbersome it's costly as well it's four hours long patients fly on the bed and the machine cleans the patient's blood each dialysis also needs 150 liters of water can you imagine in a resource per country so dialysis is available in india but it is very very costly peritoneal dialysis can be done at home you can see bags are there the fluid is put in the abdomen and the bad fluid which grains of urea and creatine comes out in the drain bag as you can see in the picture this also is around 30 000 rupees per month so it is also not very cheap only thing is it can be done at home so people say modern dialysis is available transplant is available peritoneal everything is available why we should be scared of ckd as i said the treatment is very costly another thing is we cannot match the demand because now government is opening these dialysis centers the modi government and state commons every month so 50 000 machines they are providing all over india um but under these also we will we will not be able to dialyze all the patients we will be able to provide dialysis only to one-fourth of the patients who need dialysis so way with the other yeah so now what about transplants even the transplants are costly and um we are doing 10 000 to 12 000 per year and we need 2 lakh per year so it's just not possible okay so uh transplants are five lakhs five to seven lakhs we do it free in a government sector and after transplant patient has to take medicines those medicines pass around ten thousand rupees per month life long so it is also very difficult so these techniques are available but they are very costly and hence prevention is better so as i said those people who do not undergo dialysis or do those who do not undergo transplant what happens to them they die so out of two lakh people 1.5 lakh people are dying every year because of ckd and you definitely need to know about ckd so we have understood that ckd is common treatment is available but transplant and dialysis are costly good news is that ckd progresses to five stages and we can prevent progression from one stage to the other so how can you prevent ckb by preventing the progression from stage one to two to three like that so what are the risk factors so remember that there are many studies going on ckd how to prevent ckd we are also a part of that study global studies are going on and there are some modifiable risk factors and non-modifiable risk factors so male gender black race and genetic they are non-modified we can't do anything about that but diet control of hypertension diabetes proteinuria use of ace inhibitors arbs management of dyslipidemia stopping smoking adequate sleep do you know that sleep also causes ckd inadequate inadequacy and sedentary lifestyle also causes ckv so all these things are modifiable risk factors we keep on hearing about them all the time but the problem is when we are writing a prescription from the patient we do not write all these measures it's important to know that we ourselves don't follow these measures none of us sleeps adequately none of us it's a proper healthy diet so those things are important i'll be discussing that as well then ckd progression depends on the type of disease so diabetic kidney disease progresses very fast the polycystic kidney disease kidney disease they progress little bit slowly so how can we prevent the progression we can prevent the progression by controlling the risk factors but for that we need to identify the ckd early many of the times the patient comes to the nephrologist when they are in stage five already the tbs are gone so we have to identify ckd earlier and who identify ckd early all of us should know so what are the symptoms of ckd how will you identify ckd early so can you pick up what are the symptoms fractures anemia polyurea which of these is not a feature of ckd such as anemia polyuria wow 114 volts okay so actually the last one is not a feature of ckb active urine sediment and low complement generally occurs in rapidly progressive renal failure not in ckd fractures can occur because kidneys help in formation of active vitamin d anemia can occur because erythropoietin is produced from the kidney polyurea can occur patients are present with low urine output with a very high urine output also concentration defect so that's important those patients who tell you we get up three to four times at night to pass urine be on the lookout for ckd don't think that they're normal so many of the times the patients for enemy receive keep on receiving that transfusions nobody checks that reactant because nobody relates anemia to the kidney similarly fractures nobody thinks of fractures in kidney we think fractures orthopedic structures are repaired again the patient so that's important okay so fourth is the wrong answer all others are features of ckd so in the early stages ckd can be completely asymptomatic stage one stage two the patients will be like you and me normal good urine output no swelling nothing the second stage what happens is stage three four you can have symptoms which are not related to the kidney you may have anemia as i said cns symptoms severe symptoms appetite will be not epic peptide won't be there sometimes breeding problems teaching fluoritis so any of the organ systems can be involved so that is what what happens is many of the times it's missed so the main basic message of this slide is if somehow the patient is not well and you are not able to identify the cause at least get a reaction done proritus itching that may be a symptom of ckd we keep on writing some emollients or keep on giving some anti allergic drugs and all that patient doesn't respond so remember that could be a symptom of ckb generally these symptoms we all know decrease urine output and swelling of feet unfortunately the patient comes to us with these symptoms in the last stage so if we don't know that other symptoms can also be there we will miss ckd so it's important to know that ckd can manifest with all other symptoms because kidney function is not only formation of urine and removal of waste it helps in blood formation by producing electrocontin reduces vitamin d and is important for bone health it regulates the prostaglandins hormones and is responsible for maintenance of blood pressure so even high blood pressure in young age is a symptom of chronic kidney disease so always remember that okay so now i told you that cqb in stage one may be completely asymptomatic no symptoms so then what does it mean that 1.3 billion indians should be keep on checking them for ckb should we screen all indians for ctd so this gives us another question okay i think some okay so what whom should we screen and what are the tests so tell me which of the following is not for speeding test for ckd urine albumin statin serum creatinine and gfr in ultrasound your time starts now okay we both have been casted for option number b statement no so that's wrong answers the statement c is now included in the screening test for ckd ultrasound is not a screening test you do ultrasound later on screening test is only urine protein and during serum creatine and gfr so these are the two screening tests now systatin c has been added in cases where you have a doubt so ultrasound is not a screening test you can have ckd with a normal ultrasound also so ckd is that is not a screening test cleaning test are the first three urine albumin serum cleaning and gfr and if you have a doubt system c so as i said urine albumin and creatine and gfr are the standard test urine albumin is easy you can just send to the lab and as i said less than 30 is normal 30 to 300 is a2 and more than 300 is 83 that's high protein area and these albumen test should be repeated at least two or three times in a period of six months so don't believe only one report and label the patient as ckd and do not do the test if the patient is having urine infection fever or if the patient is pregnant or the sugars are uncontrolled or congestive so patients should be stable when you are asking for a urinal okay then what about the gfr so the moment we talk about gfr we keep our hand like this oh god gfr because we all remember our biochemistry days horrible gfr we used to hate that chapter never wanted to calculate it but now as i said we are all smart doctors and we have smartphones so the easy thing is just download a gfr calculator on your phone you have downloaded the medifix app it's easier than that download a gfr calculator fine so best method to calculate on that calculator is which one mdrd apgfr cockroft called formula or during platinum clearance so that brings us to the next poll and yes so your time starts now okay so maximum votes are for right okay creatinine clearance so that's not right that's an answer from 10 years ago now the latest answer is the second one gfr calculator and use the fp gfr calculator so you download the gfr calculator you can see this see this is the screenshot which you have taken so the first one ckdft calculator that's the best one and what you have to fill creatinine age gender and race so race all of us are at the race finish that's it and you get the gfr so so simple we need not remember any formula nothing that just download this uh national kidney foundation gfr calculator on your phone okay so please carry this message across and from now on your prescriptions you should always mention urine albumin and the gfr that's important okay and here you can see the third one the ckd fps starting creatine equation that is the latest so in case of confusion where the gfr is borderline you can get both the actinin and cystatin from the lab so statin is just like a blood test it costs around 1200 rupees it's expensive so don't do it for everyone but for whose gfr is borderline or where you have a doubt you can use the third equation where you have to fill the value of reactant and the value of state and c and again you get the same value of g part okay so remember this so starting c even if you don't do it it's fine just do the pre-admin and use the first formula so as i said now statement c has been added now so this is that this is starting to see the third formula that is the staten secret in the same calculator you can use so people who are interested they can check this out as well okay so now we have uh talked about the screening test albumin creatine and gfr finished very easy please do it now who should we screen 1.2 billion indians should we screen all of them which of the following statements is correct this uh i'm sorry the speech of the following statements is wrong screening should be done for all population screening should be done for all diabetics screening should be done for elderly people screening should be done for those females with a history of penal failure in pregnancy so which of the groups we need to screen yes ma'am by a large margin uh the doctors have voted for option one that the screening of ckd should be done for all indian population but that is wrong unfortunately yes so that's wrong because as of now india doesn't screen for everyone all the other three categories we should screen so they we should screen the messages we should screen only the high risk groups i will tell you what those high-risk groups are second third and fourth are all high-risk groups okay so those who have a history of aki in the past or those who who are elderly those who are diabetics screen them all population we don't do because we'll die our budget will get exhausted they're 1.3 billion india is a unique country a special country in japan they screen everyone in india we have not reached that stage it is better to screen the high risk groups like covet vaccine the first day for the high risk population something like that later on maybe for everyone but not now it is second three and four so these are the three groups where you should be uh i mean screening them we need not test the entire indian population the risk groups are apart from those three as i said hypertension all hypertensives all diabetes all people with heart attack those people you should screen and then these are the other important groups older age elderly people then sle hiv those who have a family history those who come from low socioeconomic status those who have environmental exposures pesticides those who have prior api so the fourth choice was pregnant lady who are they care in the past that's why pre-eclampsia those who have pregnancy induced hypertension those one on nephrotoxin some people may be on nss or joint pains and also we should screen them and obviously so these are important groups where we need to stream so you whenever you are sitting in the clinic whether mbbs gps or physicians or any other speciality whenever these patients whenever a patient comes think your mind should start thinking oh whether they belong to these groups if they belong to these risks please do a albumin and a creation it is mandatory okay because why do we need to do because you can start nephroprotection strategies and i call them the ten commandments ten commandments all our prescriptions we should write all these ten things and what are these ten things let us see physical activity more than 30 minutes walk per day that's important write that on the prescription it really makes a difference 30 minutes are you working daily at least i am working daily i complete 10 000 steps a day diet salt restriction low protein and less sugar i'll tell that in short while smoking succession uh glycemic control between 6.5 to 8 bp control now the targets are 120 in ckd new targets nephroprotection asmr beta's arb should be a part of prescription sglt2 inhibitors in both diabetic kidney disease non-diabetic kidney disease then statins then bicarbonate then avoid nephrotoxins painkillers don't write bluefame obram hemisolide all those things no an anemia connection maintain hemoglobin more than 11 and iron more than 100 so these are the 10 commandments and remember whenever you are treating a patient diabetic patient hypotensive patient they come to your clinics they don't come to the neurologist directly just remember that whether this patient is at risk for ckd if yes do albumin and creatinine calculate the gfr and that's it i mean just write these ten commandments that's very very important okay so now coming to all these commandments so when we ask the patient guide ask him to take a picture ask him or her to take a picture of diet plate and show so many of the times indian diets are becoming like the left side diet even if that is not the case we fill up plate with rice and chapati and carbohydrates that's not correct the plate should look like the right size plate half should be vegetable salads one should one food should be carbohydrate one food should be uh chicken and mutton so or any other for a veg non vegetarian avoid mutton lean meat or if you are not a non vegetarian good very good thing is use vegetable protein plant protein so avoid red meat avoid mutton egg can be taken egg white can be taken so if you are a vegetarian its fine no problem i mean you have dials you have rajma soya bean tofu paneer those things can be added so plate should look like this so from now on all of you whether you are having dinner or lunch think in your mind whether your plate looks like this or not what we do is we take this much of salad that is not correct fill half of your plate with salad fill your stomach with that and then have carbohydrate and protein and same thing applies for a ckd patient and as i said avoid animal proteins as far as possible go for plant proteins plant proteins are better then salt so if you ask anybody in india ckd or non ckb how much salt they say people come layering we take very little salt but what they do is even if they restrict the salt they are taking chips and pickles and paper and god knows what so you have to tell them that also and many of them say we are taking i mean rock salt we are taking this salt sodium is there in all the salts so remember to tell them that half teaspoon salt if you are hypertensive one teaspoon flat teaspoon salt if you are a normal tension meaning five gram of sodium chloride per day flat teaspoon and also tell them that the other things hidden in salt you can use lemon in your vegetables cooking instead of salt you can i mean avoid soya sauce avoid salad dressings so what is the point of having so much of salad with dressing on top of it mustard dressing and so many different different dressings all of them are very high in salt so it's important read the food labels as well so all these things are very important whenever you go for conferences outside india you will see one special thing indians take 10 gram of salt 2 teaspoons all of us because all indians will be around one table and they'll be pouring salt like this all of us do that that is wrong so and you look at the other people because we have been brought up like that we take a lot of salt even in our rotis and all we add salt and oil which should not be done so remember absolve in moderation only is acceptable not more than that exercise we keep on telling how much of how many of us do see no need for gym or swimming pool you do that if you want but half an hour walking is not too much to us same thing applies for ckd as well what about bp control initially we used to talk about 149t then 130 80 then 125.75 if proteinuria is there and all that now the standard guideline is target 120 you can individualize but most of the ckd patients are able to tolerate systolic 120 is the guideline now and that is the latest kdo guideline which has come in 2021 and as an erb should be the first drug of choice which all of us know we are using that but unfortunately we are using minor doses minimal pediatric doses tell me saturn what should be the dose 80 mg how much do we give 40 mg in april how much do we use 5 mg because we are so scared of hyperkalemia which is correct but we should modify hyperkalemia but try to go go for the highest dose for neptune protection okay so that's important so tell me satan 80 similarly for other saturns you can see you have something called maximum recommended dose and maximally tolerated those so try to increase the dose slowly uh till the patient i mean is able to reach the maximum labor days so you have started a arb still bp is high what is the next drug to add for a ckd patient second line is generally calcium channel blockers third line is diuretics many of the patients need all three grass blockers calcium channel blockers and diuretics the underused drug is mra mra's mineralocorticoid receptor antibodies spinal electron and now we have henry known they are good anterior potential drugs for resistant hypertension again be careful about the hypokalemia then after that still not controlled minoxidil can be used then still not controlled go for clonidine oxygen so this is the way you treat a patient of hypertension with chronic kidney disease it's important many of them need three drugs or drugs five drugs but if you concentrate on the salt many of the times we are able to get away with lesser drugs so we have controlled the blood pressure what about sugar targets if the patient is a diabetic so in ckd 6.5 to 8 you can individualize as per the patient previously we used to say insecurity patients don't go for a tighter target maintain it seven eight like that but now if the patient is young does not have any other comorbidities target is 6.5 for ckd patients also those who are older at high risk for hypoglycemia you can maintain around eight so the bottom line is individualized and how do you treat these patients so metformin metformin still remains the standard drug for ckd patients more than 30 gfr go with metformin less than 30 you have to stop midforming what is the next drug after metformin so those people who have a gfr of more than 30 do not forget about sglt2 inhibitors they are all new drugs on the horizon i'm sure all of you have heard multiple webinars we have had a pandemic of webinars on sglt2 inhibitors but it's important because they are neutral protective and renal protective for your diabetic ckd patients sglt2 should be used so you can see that they act on the proximal tubule unfortunately the ammunition is not working so what they do is they cause the glucose loss in urine and they also cause sodium loss and urine and they reduce the intraglobular pressure so these are very wonderful drugs they are called smart drugs because they reduce blood pressure they reduce heart problems they reduce the kidney work they reduce hyper filtration they are smart diuretics reduce albumin so they have eight benefits not only renal protection not only sugar control so many other benefits so always remember that prescription should contain sglt2 especially in patients who have diabetic with kidney disease some albumin urea is there also gfr is low gfr more than 30 sgat2 should be a part of prescription now next question is only for diabetic ckd should we use sglt2 we know that it is an anti-diabetic drug but now studies are coming which have shown that this drug sgld2 drug is special it is different from all other diabetic medicines because it can be used in non-diabetic kidney disease also and it helps in renal protection so they are very important drugs and we should all be aware it would be wrong it would be unethical if the patient comes to you most of your patients will have a gfr of more than 50. they'll be on metformin you have done an albumin albumin is present in urine and if you forget to add sglt2 it would be a gross negligence so add israel to inhibitor whether you add diaper glucose and organoglucosin or any other glyphosate ampaguy frozen doesn't matter but these should be a part of prescription metformin then second drug should be sglg2 inhibitor these are various studies i am not even going into that but i am just telling you that many trials are there we were a part of these global trials credence trial dapper ckd trial and they have shown 30 percent renal risk reduction so no other drug has shown so much of any risk reduction apart from the grass blocking so rash blockade plus sglt to the effect gets combined so it's important not only in diabetic ckd even in non-diabetic ckd also so diabetic ckd you are using metformin and sglt2 in non-diabetic ckd methamine is obviously not used but you can use sql inhibitors and in addition to improving the reading outcomes they bring down the incidence of cardiovascular deaths as well and as i already told you that cardiovascular drugs are an important cause of deaths in ckd patients so glt2 have double advantage so which of the following statements is incorrect regarding license control in ckb so can we so can we go to the so strict control of blood sugar that is hba1c should always be maintained at 6.5 second is hbm1c is not very accurate in ckd and may give falsely high value or low value third is time in range can be an important test for glycemic control and the last one is that in persons with diabetic kidney disease on sglt2 inhibitors when the gfr falls less than 30 we should not discontinue sdl3200 so which of the following statements is not correct like many of these mcq tongue twisters they they even twist your brain and all that so don't worry it's fine it's okay so strict control of blood sugar that is six point five hbo and see not accurate yeah so first one okay second one thirty two nine and last one yeah but the first one is incorrect that street control i already told that you have to individualize so 6.5 for younger people older people you can go up to eight hvac second is correct because hbm1c is not very accurate uh in ckd patients you can have high value low value so it's not very accurate time in range is a new concept you know in continuous glucose monitoring systems you have time in range so for ckt also it's becoming important and last question is a bit tricky so as i said sdlt2 inhibitors we start when the gfr is more than 30 we do not start them when the gfr is less than 30 but after you have started it suppose the gfr was 32 and then later on the gfr becomes less than 30 still you do not discontinue you can continue it till the patient goes for dialysis so sdlt2 have to be started when the gfr is more than 30 but they can be continued even when the gfr falls down below 13 long term because they are so much radio protective and so protected so the say this shows the same thing as glt2 should be a part of your prescription only thing do not use sdlt2 and the patient is sick so sick day rules we have for ace inhibitors metformin similarly for sglt2 patient is dehydrated vomiting high fever diabetic ketoacidosis such patients we do not use sdlt do we use them when the patient is stable or sick patients we generally use insulin and then another important thing is when we are using sglt2 they cause a good amount of diuresis i told they are smart directly so many of the times we have to reduce the dose of primary thing otherwise the patient is going to dehydration so a double advantage i mean the diuretic dose also needs to be stopped patients become completely edema free and the last point we already discussed that if the gfr falls down below 30 after starting sg82 in the long [Music] what are the other inner protective drugs in diabetic ckb except so meaning uh one of these drugs is not pheno protective all others are in your protective gear so can we have the pole now it's question extreme little bit wrongly except what is not there so which one is not reno protective can we have the pole yeah so glk known which of these is not reno protected in diabetic ckb so still you have around 15 seconds to go half of the people have voted others are now getting active we have 75 volts that's right yes clock is ticking four more three two one and that's it so you know protected yes so the last one last one is not reno perfected there is no trial showing reno protection it is renal safe you need not modify the dose cotton glypton you can use the same dose but it does not cause reduction in albuminuria or stabilization of gfr all others are good drugs and what this audience should know is we have used metformin we have used sglt2 still you have proteinuria and all that what do you do next you can add glp one receptor economist and a new important drug which is coming now is spin re-known you'll be happy to know that when you known is becoming available in the indian market soon uh 10 mg and 20 mg tablets are available and this would be a great value addition for the treatment of diabetic ckbrt at least trials for non-diabetic security with tendinone are also going on linagliptin also has been found to reduce albumin and family natural to the tune of around uh say 14 so all three have demonstrated renal protection one two and three chemical is renal safe but whether it's renal beneficial that we don't know probably we need more trials on that so this is the same thing those patients who are not controlled on midform and sdlt2 glp1 receptor ignis are the drugs of next choice fine so what else what else can we do for renal protection so remember those 10 commandments statins so when should we add a starting for a patient with ckd so generally can we go to the poll again because this is an important question because this all physicians and gps need to know when do we need a starting should we start at statin for all diabetic cpps after the age of 18 years even if they have a normal lipid profile all ckds after 50 years of age despite normal lipid profile only those who have a past history of cardiovascular disease or cerebrovascular accident or we should not add satin in ckd because it causes rhabdomyolysis so three are correct one is incorrect which one pick up the incorrect one all diabetics after 18 years with ckb started if it profile is normal after 50 years all ckd electric profile is normal should you add or only those have cardiovascular history or ckd no no no no abdominalises which one is incorrect the last one absolutely the last one is encouraged so people are very i think uh very much driven about starting saturn so the point what i want to make is even if the lipid profile is normal diabetic security after 18 years are you adding starting many of us are not so remember statin should be there to reduce the cardiovascular risk and all ckd even with normal profile after the age of 50 adders stacked in do not forget it should be a part of your prescription the ten commandments and anyone those who have a past history we are all adding so the first two was what i wanted to highlight so this is the same guideline this is uh from the heart association guideline there diabetic ckd after 18 starting should be there and for all ckd after 50 starting should be there now what are the renal protection measures the ten commandments again so which one is useful bicarbonate uricosium drugs probiotics prebiotics and aspirin so many of these drugs are found in the prescriptions gps general practitioners metrologists endorse cardios everyone so which one is the correct answer it should be there the others should not be there which one is mandatory the others may be there not be there fine but which one is mandatory 13 seconds to go 12 seconds to go age 7 down down absolutely so very good so it's uh bicarbonate so you should maintain a serum by cabinet level of how much 22 milligrams per liter that's important europe acidity drugs when should be at if the uric acid is very high and the patient is symptomatic otherwise we have pearl trial feather trial fixed trial which have shown that routine use of irritations is not very beneficial just to reduce the level of uric acid about then you may add otherwise any level of uric acid if the patient is symptomatic joint pains loud then probiotics biotics they are costly and many of the times we end up adding that they are not mandatory there are some studies which show that they remove little bit urea in the uh stools via the git but obviously they are not mandatory and aspirin should not be a part of every prescription aspirin only if there's a past history of cv event so it is used for secondary flow fluxes not for primary products especially in ckd high risk for being so don't keep on adding aspirin for all hypertensive patients this is a trial which is shown that by carbonated adding prevents the progression of cqb so you may ask okay ten commandments madam is telling we all know this but what's new there is a study which we were also part of this study it's a multicentric study from ames pgi chandigarh and ten institutes across india from our institutes as well and what does it show a horrible finding we are not proud of the study so we have studied 3009 people where we had all the complete data out of 4056 who were included in the study and ras blockers were used only in what percentage 50 horrible we should have been using them in 100 and iron was given only 31 percent even those who needed iron and erythropoieting in three percent so this is horrible figures we are not doing whatever we can to prevent the ckd and this is center uh the the study is from reputed centers across india in urban population so i don't know what's happening at the ground level so this highlights that it is the small small things that matter remembering the ten commandments rather than street focusing on some molecular mechanism molecular target some costly medicine prevention is better than cure a stitch in time saves nine so remember these ten commandments that would be the purpose i mean i would think that this is successful if we are all able to follow these uh precautions so this slide emphasizes the same testing screening for ckd picking it up early it's just 300 rupees and treatment is 3000 rupees per month even if you use sglt2 and all whatever drugs i mentioned and treatment look at the treatment it's 10 times as costly dialysis 30 000 per month transplant is 5 lakh so which is cheaper for india and which is beneficial and what would you do if you were a diabetic patient hypertensive patient many of us on this call are hypertensive diabetics obese may be on painkillers maybe maybe elderly more than 65 are we feeding ourselves we are not do you know your gfr no do you know urine albumin no when we are not doing for ourselves what we will be doing for our patients we won't do it so remember whosoever yourself patient anybody if they fall into those risk groups please scream it's important and treat using the ten commandments which many of us many of them are very simple so physicians practitioners nephrologists all are trying their best indian doctors i respect a lot because we work a lot under adverse circumstances all of us are doing a great job whether in the periphery i mean u.s doctors uk doctors you cannot compare they work with so many facilities with so many investigations to help them here we work sometimes one doctor sees hundred patients and people criticize us for not giving time i mean 100 patients in two hours three hours it's very difficult we have to see them we can't just see ten patients for one hour and send the rest of them we cannot so we i believe we are working well we are trying our best but one mistake we are committing we need to collaborate all of us need to work together so the early patients the early patients ckd patients whose responsibility physician gp please pick them up please treat them use the ten commandments and if the gfr keeps on falling down below 30 refer to the nephrologist so it's a part of the team each cog in the wheel is important we need to collaborate for 1.2 billion population of india number of nephrologists do you know how many in the country 2 000 number of physicians and gps 10 lakhs we have dietitians also working so if we put all together all of us need to work together to prevent ckd and the commandments are simple identify early urine albumin all of us can ask the lab to do it and gfr we can either calculate or ask the lab to do that they'll do it but you should know that you have to do it in that highest group and after that also if you have a doubt just refer to the next row or position whosoever is available if your albumin is more than 300 or more than 30 and we read that we can if gfr is less than 90 can't we understand that all of us can whatever be the level of education so together i believe we can make a difference the physicians the post graduates the students the gps nephrologists all working together and this is what our country means so what is the message all doctors advice cleaning diabetes hypertension obesity and all the other race groups these are the three major risk groups physicians what is your job identify early and nephrologists you may know everything in theory but implement it use all those ten commandments which i showed in the study from india that even the nephrologists are not doing it so all of us should implement all those ten commandments so this is i think my final message to the crowd security management is a comprehensive security is very common pick it up early and identify early start the ten commandments the last last part the so these are the interventions to slope ckd progression so one patient who might have ended up with dialysis at 45 years if we treat the diabetes we push him to 55 years without dialysis if we control bp he can live for 65 years without dialysis we use raspberry we prolong the need for dialysis sglt2 we may give him a dialysis free life so that's what the management of ckd is and this was the theme of this world he needed to increase awareness among all sections of society and that is the purpose of this netflix baby so thank you all that was the last slide and thank you for a very patient hearing and i'll be happy to take any question again thank you so much i speak for everyone in the audience you've so beautifully and meticulously explained every aspect of diagnosis tonight we're just giving a moment to our doctors we already have a good number of questions yeah just giving a moment doctor you can also ask a question directly to mom by touching with the raised hand teacher one this thing that some person was asking i got the name that the race is not a part of the gfr calculator absolutely right so in the new uh calculating equations the race has been removed so very good i'm so happy that people are aware of that so great so yeah raise now necessarily in the new calculators it's not there yeah so can i ask my question yes sure please yeah i'm doctor secretary of diabetes from tane uh how do you interpret the high gfr with people with low create 9 so it is hyper filtration by kidney how do you interpret so that's a very great question so first of all let me converse in indian scenario it's not very common but it is seen so one thing is that if the gfr is very very high if the patient's muscle mass everything is normal if the patient is not malnourished if the patient does not have i mean say amputation and all that and the gfr is very high then it might be a sign of hyperfiltration injury so that is one thing the other thing is um the hyperfiltration that sort of a gfr comes when the cream is very low as you yourself said and creatine sometimes is falsely low in certain settings one thing is if the patient is malnourished muscle mass only is not generated from the muscles then those who undergo amputation so whole muscle one month one limb is lost reacting may be falsely low so in those cases sometimes the gfr formally do not work and you may have to i mean resort to other measures but hyper filtration um you whenever you are commenting about hyperfiltration be sure that patient is adequately nourished and has i men does not have a loss of limb and all that in those situations still if you have hyper filtration then uh check for the sugars because they are one important causes of hyper filtration injury and if still in doubt my patients are diabetic yeah okay and in such cases you can always confirm using a systatin based equation so i showed you that treatments start in combination so cistatin does not get influenced by many of the factors which change the treatment so that's a great question so if in doubt you can use the and how do you address that if i find it uh hyper filtration then should i use ac inhibitors or something absolutely yes so such patients you can use asymptotes and you also know that the hdlt2 inhibitors they how do they cause renal protection they reduce hyperfiltration so there are other drugs in such a situation thank you madam hello good evening mom first of all yeah first of all madam congratulations and you have covered practically all the questions are routinely faced by the physicians uh i am adding one more that normally what we see in our practice is that so many people are using the alternative medicines with heavy metals and then that also need to be required when we ask about routinely because we have seen so many patients with the drugs especially the heavy metals laid in arsenic and mercury so that's a great point so if you remember those 15 risk conditions i was showing the pesticides and all those things you know so all those things uh nephrotoxins the nephrotoxins so the ayurvedic medicines and the herbal medicines and all those things see i'm not saying that the indian system of ayush is bad i'm not saying that iu stands for ayurveda yoga and yunnani siddha and homeopathy but the problem is here uh unmonitored ayush is practiced so some packets and all those things see every system has to be followed in a proper manner and i usually not work for everyone and i use again you need expertise and all that so which ones are good and bad and all those things so if you are not going for proper medications and generally ckd patients ayush does not play much role so the point what you've made is very important so you should specifically ask the patients and many of our patients are on those systems of medicine and nowadays that trend is somehow increasing so i mean they fight with you they say that your medicines alopathy has so many side effects and all that but we always say that a known devil is better than an unknown angel at least what we are giving we know the composition the ingredients the side effects in other things where they get it from a cracks in some packet or bottle we don't even know what they contain so that's an absolute early great point always ask whether they are on any individual distance right before before i stay away i would like to ask one more question that is about you sowed the plate and you saw fruits and vegetables but in an established security do we not have to keep in mind the potential potassium low absolutely so i was talking about the early ckd so vegetables fruits can be continued stage one stage two stage three be mount mindful of the potassium even in a stage four and five if the potassium is okay we continue using them only thing uh we tell them to avoid the high potassium fruits generally banana contains a lot of potassium coconut water contains a lot of compassion so we tell them you have all vegetables don't stop everything stop all vegetables and then have all vegetables and fruits practice leeching and we know what leaching is that we cut all the vegetables put them in water warm water keep them for one hour throw away the water the whole potassium goes off and you can still fill your plate half with all the reds and the greens and all those things provided you are practicing so that can be done but as you said i mean uh be mindful of the potassium generally what we have observed stage one two and three the hyperkalemia is not a major problem um provided you stop you avoid the juices and coconut water and banana generally you are okay the point is because we they are already on using this inhibitor so we have to be very careful about the height absolutely absolutely so we should be careful and uh we monitor the potassium until so many of our patients are still on green vegetables and all that but they practice leaching so even potatoes and green vegetables and all we put them to put them in water uh for around one hour warm water and throw away the water but as you said see potassium and all we should always monitor and try to have the current happen many of the times without the fiber in the diet constipation is another big problem so we do all this but obviously i mean during uh today the craft was on prevention early identification but management of advanced ckb you will be seeing ckd stage 3 maybe 3 b 4 and all that then all these points also have to be discussed so those things i have not discussed because that comes under treatment of cjd today we talked about network protection strategies right thank you thank you thanks man thank you for the fantastic presentation actually i am alone so i am 41 years old and i am hypertensive for the past few years i am on tablet remember 10 milligram pd so my pressures are usually around 130 i was thinking that 131 is very acceptable but if i have to hike up should i change the drug or should we increase those or which of these as well because there are certainly important developments in abtk so control of hypertension you know is very important try to maintain around 120 you can hike up the dose check your urine osmolality the urine hospitality ideally less than 200 is really good uh serum hospitality as the urinary be below 200 and then again look at the size and all that you know knew what drugs are available for regarding the progression is available it's not useful in all the cases but in certain cases because guidelines of adp management have changed drastically and it would be nice i mean if you can meet the neurologist because there are so many uh strategies where you can remove adp from your family from your next generation so those things you need to be aware of you are in medical and i mean you know that this disease is autosomally dominant and your generations next generation will keep on getting unless you go for certain interventions which are now available so grass blocked it you have to optimize that maintain the urine osmolality level optimize that as well look at the cyst volume every year and then um you we have to check whether you need uh as well so there are so many i mean developments in the field of polycystic meet any of the nephrologists they'll be able to guide you uh better look at your exercise and advise accordingly okay thank you thanks for your question dr narayana i'm just taking a few questions in the comment section yeah okay so dr anurag asked if serum should be included in the screening no not this why because gets altered by variety of factors by hydration by your protein intake by antibiotics by infection so urea urea is not a part of your screening okay role of cystitis in kidney function ma'am ah so i told you if the gfr by creatinine is between 45 to 60 confirm it doing a statin as one of the senior doctors asked if you have a confusion you are getting a very high gfr and all that you can always confirm with system so nowadays it's starting people are able to afford it and you are having a doubt and all that if you really want an accurate gfr the combination of creatine and cystatin gfr is the best okay mom can we give stl to inhibitors in non-diabetic kidney disease yes yeah so uh the the hdlt2 are indicated for diabetic as well as non-diabetic kidney disease it's important you have dapper ckd trial which is shown that they are very neutral protective in patients with non-kidney disease and they do not cause hypoglycemia that's the main problem everybody is worried about so they cause losses in the urine and all that only when you have hyperglycemia and all that otherwise i mean there is there is something kidney mechanism there it prevents the further loss of glucose if the sugars are falling down and all that so israel inhibitors do not cause hypoglycemia in a non-diabetic individual and should be used if they are protein especially yeah okay uh we have a question ma'am could you please enlighten on the status of lupus nephritis with respect to transplant indication okay so eucalyptus is an important cause of chronic kidney disease not very common around five percent of chronic kidney disease is uh because of people's nephritis so lupus nephritis you can take for transplant provided you have treated the lupus nephritis properly there are so many drugs available steroids microfinance you have the taxi map psychophosphate so many drugs are available most important thing is the patient should be completely free of lupus meaning the dsd and complement levels should be normal for at least six months before you take the transplant okay so you should not take the transplant when the patient is high uh is having high type rates of antibody so dsdna and complement should be negative for a period of six months when you are trying to transplant the patient and the patient should be completely treated with immunosuppression the urine protein should become normal i mean the urine protein and all the hematuria all those things should subside activity should not be there meaning dstna complement should be numbered at least for six months okay uh thank you mom uh we have a question uh proton pump inhibitors are nephrotoxic so which should we opt for in patients with ckd that's a very difficult question and one which nephrologists keep on getting all the time now so as of now that thing the cause and effect is not very well proven because more than half the population in the world is on proton pump inhibitors and um we have so many cause of ckd where we are not able to identify the cause so many of the time some studies say that proton pump inhibitors have just been blamed because everybody is on them but uh having said that there are other papers which show a relation so uh it's not that we stop the ppis completely uh use them on judiciously it's easier said than done but try to use them for four weeks or at least less than eight weeks not more than that and then you can use the ranitidine and other drugs so it's very difficult to get the patient off ppi once they are so much used to it but you have to explain to them because not only the ckd because other heart problems as well those are some of the stupides as if now so my message would be use them if you really have to but try to limit for four weeks not more unless it's absolutely indicative and try managing with the other drugs for example that i'm interviewing some of the you have so many others as well mom could we take a few more questions i hope it's all right we will be on the side uh dr shivani who came on stage a while ago her question was what is dose of pnodosis and duration in ckd okay so nodosis is bicarbonate and the dose is it depends on the level of bicarb generally one gram twice daily is given you start with that dose and can go up and down do not start no doses or so disease or whatever i mean all these are bicarbonate in patients who are already hypertensive or who are overloaded control the hypertension first and uh make the patient edema free and then start using target about my cup of 22 many of the times you need to continue using them because in ckd patients once you stop them again the acidosis um increases and if the patient is able to alter the diet and consume more of plant production all that the acidosis may get controlled and you may stop their use so there is no hardened password the target is maintained by cup 22 in case of my cup is again falling below that you again have to reintroduce these medicines okay thank you mom we have a lot of questions here thank you doctor excellent informative uh great session madam um we just uh have a question just a minute man how to calculate dialysis doors and patients is there one fit for all okay so actually i mean um it's not the one fit for all uh there are formulae to calculate the dialysis dose but the thing is simply what we do is we start for i mean uh start generally i mean first analysis we do for a short duration of time uh it's called decremental dialysis so first jesus generally is done for one hour and after that you subsequently uh do four hours and these four hour sessions are done twice a week but this is the standard most of the times 90 prescriptions would be like this but you can always move up and down nowadays the latest concept is patient-centric approach previously we used to uh advise dialysis four times a week or three times a week four hours that is 12 hours per week we used to tell the patient kidney works for 24 hours a day so dialysis minimum has to be done for four times for three times or four hours at 12 hours 12 hours a week but now the concept is if the patient is having a good urine output if the patient is very comfortable with twice a week analysis you can manage the twice a week dialysis that's called patient-centric approach so if the patient wants if a patient is comfortable good urine output the creatine and all is fine twice a week dialysis is also okay so that is the latest concept but generally most of the patients would be on price of heat dialysis you can go up and down because you can calculate the pre-dialysis urea post alice's urea and there are formally which can help you determine the exact number of hours and all that but that's very cumbersome practically what's done is 90 of the times it's 12 hours per week that's four hours per dialysis three sessions a week that's for hemodialysis for peritoneal dialysis it's the continuous therapy so you do four backs per day so i hope that uh answers your question thank you so much ma'am we have a question from dr misak how to differentiate between acute kidney sorry aki and cki in the first visit criteria an indication for dialysis okay excellent question so see sometimes it is very difficult to differentiate akia and ckd because you have to look at the overall picture so if the patient is um i mean already previous reports are there and all that it's fine i mean six months three months back the patient had the same problem and all ckd but sometimes i'm um understand that you might just be asking nothing is available i create protein is there and what do you think so if the ultrasound report is available in ultrasound is small size generally ckd but sometimes they are not that lucky the ultrasound kidney size is also normal and you can have uh ckt sometimes with normal ultrasound also like in some patients of diabetes hiv amyloid those patients the kidney size may be normal also even in uh ckd so sometimes that also doesn't work but ninety percent of the times the ckd the ultrasound shows small kidney size so that is one way other things are if the hemoglobin is low if the patient is hypertensive it's generally ckd now again exceptions are always there medicine is not that simple so uh suppose when there is a rule we have an exception so most of the times if the anemia is there we call ckd but then you should know that you may have aka with anemia important causes are hus or bleeding bleeding volume depletion and um aki so those are two conditions where you can have uh anemia even in aki but generally anemia is a feature of ckd then apart from that if the patient is having uh hypertension hypertension is unusual in aki generally uh again hus may have hypertension but otherwise if hypertension is there mostly it is i mean ckd mostly now third important thing is uh the bone diseases bone diseases clinically you may not be able to see but raised alkaline phosphate is a feature of ckd high pth is a feature of ckd calcium and phosphorus does not differentiate between ak and ckd calcium may be low in aki may be low in ckd phosphorus may be high in both but alkaline phosphatase is high in ckd normally in akin pth is high in security normally nature so these are some few points the level of creatinine does not differentiate level of proteinuria does not differentiate so that's why i mean um it takes some time before are able to identify understand and as you work more and more with the kidney patients you can make out that shallow complexion all those things they help but these are the few practical points again sometimes if everything is normal and the patient is not improving finally the biopsy comes to your health so biopsy helps in differentiating if you get a lot of fibrosis and all in biopsy it's generally ckd aki fibrosis is minimal so these are some of the features of uh i mean how you differentiate and the other thing indication for dialysis so creatinine alone is not an indication generally creating more than 6.57 we take for dialysis but having said that remember a e i o u a e i o u the vowels a stands for acidosis incorrectable oscillators you are given bicarbonate patient not responding e stands for electrolyte disturbances hyperkalemia you have tried everything you have given salvation all you have given bicarb you have given insulin destroys calcium glutamate not working intractable hyperkalemia is an indication so electrolyte disturbance i is inorganic phosphorus poisoning inorganic poisoning suppose poisoning barbiturate poisoning some poison then you have to do dialysis even if the creatine is normal o is overload overload means pulmonary edema and u is uremia uremic uric pericarditis so these are the five indications where you take for emergency dialysis irrespective of the level of free abdomen otherwise as i said creatine more than six six point five is an indication for dialysis in pregnancy creatine of four itself is an indication for dialysis okay so it's not only creatine alone remember the a e i o u yes thank you just a couple of more questions if that's all right it's okay okay promise one couple more uh dr kaushik asked why hypervolume with hypertensive should not be given bicarbonates of the last question yeah so that is because like it's not a rule but the thing is if the patient is already having hypertension sodium bicarbonate it again adds to the sodium in the body so to i mean prevent uh further increase in hypertension and all that you avoid giving more sodium load to the patient sodium bicarbonate along with bicarbonate gives sodium as well so remember that that's why we avoid it if the patient is overloaded or um uncontrollably hypertension thank you so much ma'am for taking all these questions we still have a lot of questions can you take a short one my best painkiller in ckb just like a corbin when i see it again and again easy none so the thing uh the thing is keep up having said that pain is a universal phenomena so best painkiller is salinda unfortunately not a level in india so we use generally paracetamol or we use chana doll most of the times dramatic uh you can use local painkillers though they also get absorbed but painkiller or infants and all can be used and i mean sometimes you have to go for mn patients what terminal and other different forms of opioids are also given most of the times practically speaking we use paracetamol and chamomile thank you so much ma'am all the pending questions we can perhaps redirect them to you over mail and then you could we could let the doctor thank you so much for your time you've given us more time than initially planned we do have plan to have mom again we have loved every part of the session it has been meticulous and interactive and we'll definitely have mom again doctors and we could uh perhaps ask more questions in that session absolutely okay thank you very much we enjoyed having you here okay same here bye thank you again good night


Renal function is essential for homeostasis. Early diagnosis of renal dysfunction and institution of appropriate therapy are vital to survival. Renal function testing has a wide range of indications, ranging from acute emergencies to chronic conditions. A variety of clinical laboratory tests have utility in identifying the presence of renal disease, monitoring the response of kidneys to treatment, and determining the progression of renal disease. Let's hear from Dr. Manisha Sahay, Professor and Head of Nephrology at Osmania Medical College & Hospital, Hyderabad, for more expert perspectives on this subject!

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