Understanding Chronic Kidney Disease and Management

Namaskar, I am Dr. Nitesh Raj, today we will talk about CKD i.e. Chronic Kidney Disease It's also called Chronic Renal Failure so let's start, Chronic Kidney Disease like It is known from the name that chronic is added, chronic means continuation of a disease. There is a disease in the kidney, there is damage in the kidney, there is injury in the kidney, but it is occurring slowly, from many days and if it is more than 3 months then it comes under chronic kidney disease now it means that if it happens for less than 3 months and it gets cured then it comes under acute kidney injury or acute kidney disease what happens is Kidney injury happens, but if treated properly, it reverses, as you must have seen in a patient whose creatinine has gone up to 5-6, he is admitted to the hospital and gradually you'll see that in 10-15 days normal creatinine starts coming within 1 to 2 days, this is also the reason, as you know in the studies that if someone has hypertension, low blood pressure or excessive bleeding from the body, dehydration, or injury on the kidney, or any kind of obstruction in the way of urine, then it is due to all these things acute kidney injury can happen, why does acute kidney injury happen, as soon as you see, there is a lot of dehydration, if the blood loss is too much, if heart is not pumping well, or if a certain person has a heart attack, then it is hard to pump. If not doing so then over all the quantity of water or blood is reduced or the heart is not pumping well then all the consequences will be that the kidney will get less blood supply then there will be deficiency of nutrients, oxygen & glucose to the kidney. All this will be less and there is injury to the kidney, drugs also play a major role in this, such as some nephrotoxic drugs, such as aminoglycosides, amphotericin B then tacrolimus there are some medicines which I have named here, you will see them. Due to this, whatever happens to the kidney then if we stop those medicines, then their kidney starts recovering, then you will see that the creatine comes back normal, but what we will talk about now is chronic kidney disease. For more than 3 months , we are seeing that there is injury in the kidney, there are some parameters in the kidney, such as if the eGFR (estimated glomerular filtration rate) then the rate, the water in our body, the toxins, whatever they filter if we see all these things, then chronic means more 3 months the disease has happened, what is the cause of chronic kidney disease, you should know that it is diabetes and other is hypertension and many more, such as polycystic kidney disease, glomerular nephritis, drug induced, especially pain killer drugs then it emerges as chronic kidney disease. There is a difference in the Chronic Kidney disease from acute kidney injury which is irreversible once the damage is done which you are seeing that it is reported from above 3 months creatinine is not reducing your GFR rate is low it means that it has been reversible and it will continue to progress slowly, now it will continue to progress slowly, so what will we do with medicine and why will we need to give medicine when we know that it is a kidney disease which Will keep on progressing then Yes if you give the medicine then the speed at which Chronic kidney disease was progressing will slow down or stop to a large extent Many people claim that chronic kidney disease is completely curable or reversible on YouTube which is completely false so let us see point by point what are the symptoms, what will be the treatment, how will be the diagnosis, so if we focus on the treatment part and we know a little about Pathology Pathophysiology of kidney then it will be easier for us to know so one by one we can see here in this picture that the staging of kidney has been done on the basis of glomerular filtration rate and On the basis of kidney damage, how much damage will be done, then for that we have the most important thing that we will investigate that how much kidney damage has happened, what level it has happened, that is albumin creatinine ratio, so on the basis of these two, we have found The staging which you see here now see why this happened overall so you should know that I want to say again and again that diabetes and hypertension are the reason for this. Many people say that we have diabetes, also they have sugar or high blood pressure. but we don't have any problem, I want to say this again and again that sugar and pressure, which are silent killer, silent killer that means they will kill you slowly you'll not get to see the consequences in one day Not like acute kidney Injury happens, you will see that kidney damage will not happen in these diseases, gradually, every day some n some injury is happening, that's why people control the sugar and pressure by taking Medicines, And the rest of the people who give logic that we are not having any problem, but the problem will be that like a termite, it will keep damaging the organs of your body, which you will see proof here in the form of CKD. I have already told you that it is irreversible, so after all it is irreversible, so at least we can control its progress or slow down the speed of progress, what to do for it ...If we know that little bit of pathophysiology for this, then it will be very easy for us to know, what kidney do, if we know this, then the treatment will also be very easy for us. how much water should be there in the body, how much blood level, what is the blood level, how much blood should be, how much plasma will come out of blood, water will be filtered, all these decisions are Taken by the kidney, if the filtration capacity of the kidney is hampered, if there is kidney damage, then the level of water which should be removed From the body will not be able to exit through the urine and because of that, you will get the symptoms of volume overload. What will happen if there is too much water in the body, then you will see Puffy eyes, water around heart, pulmonary edema around lungs and so on These are the symptoms found cuz of water Therefore you can't able to excrete urine properly and water is retained Next thing is If we talk about sodium and potassium, water does not come out well, then there are things for sodium, sodium can be too much in the body, it can be too little, how; if there is less urine, then the quantity of water in the body will be more then what will happen that due to fix sodium and high water capacity the sodium will get diluted with water Level of water keep on increasing and level of sodium get decreased Which is called dilutional hyponatremia. Thirdly we'll talk about potassium remember in the case of CKD we'll see that potassium Excretion is less and there is a high amount of potassium in the body, which we call hyperkalemia there is another reason for hyperkalemia which l will tell further, due to metabolic acidosis, hyperkalemia also occurred, so you should know here that potassium excretion is Less, more is Retained in the body, due to this, hyperkalemia happen, the thing you have to pay attention to for hyperkalemia is that what I think is the most damaging complications and the most dangerous complications in CKD is is hyperkalemia because it don't give any chance to patient, doctor to get time to manage and sudden cardiac arrest; arrhythmia which will get to see the irregularity of heart and sudden death of patient. So we have to be conscious regarding potassium level especially in CKD related patients. Next is H+ and HCO3 balance How much acid is there in your body and how much bicarbonate is there in your body so you have to remember that in the patient of chronic kidney disease ,the acid which is more retained, the H+ goes on increasing, then the quantity of H+ is also more, so this is why we called it acidosis i.e. acidic condition. There is another condition and the one which is bicarbonate excrete, it should have also absorbed but it is being removed, so the bicarbonate i.e base is removed and H+ i.e. acid being absorbed, so overall we will see that metabolic Acidosis occurs in blood and when metabolic acidosis occurs, it increases hyperkalemia, how does it increases hyperkalemia, h+ is more in the blood, then you know that the majority of the potassium that remains inside the cells and the outside You see that h+ is more, which is proton, which is acid if it is more, then this exchange happens between H+ and Potassium and potassium comes out of the cell So, this is called hyperkalemia Potassium comes out of the blood cells, it comes into the plasma, then its quantity will be more So it will be hyperkalemia. So basically there are two reasons for hyperkalemia. First is no excretion of potassium The body is retaining and the second is because of acidosis. Next we will talk about calcium and phosphate metabolism in the case of chronic Kidney Disease. Let's talk about calcium but before that I've made a video on Vitamin-D in which the 7-d hydro cholesterol changed into skin in the presence of Sunlight in cholecalciferol and then this cholecalciferol changes into liver in 25 hydroxy cholecalciferol and after that it goes to kidney and changes into 1, 25 hydroxy cholecalciferol 1,25 hydroxy cholecalciferol is the active Vitamin-D Now, if someone has CKD someone's kidney is damaged, or injured cholecalciferol is made in body and skin It will also be taken in the liver and 25 hydroxy cholecalciferol will be made but it'll not be converted into 1,25 hydroxy cholecalciferol because the person's kidney is damaged and the enzyme that is needed in the kidney to convert 25 hydroxy cholecalciferol into 1, 25 hydroxy cholecalciferol which is the active form of Vitamin D which is not done So overall, there is a deficiency of Vitamin D, then what will happen if there is a deficiency of Vitamin D. We need to know what Vitamin D does, so whatever food we eat If there is calcium in it, then it helps in absorption of calcium from our intestine. so if vitamin D remains adequate in the body, calcium will also remain adequate in the body. The excretion of calcium from the body is to be stopped because of Vitamin-D then the calcium will remain in our blood, that means it balances it positively on calcium, next we come to the option of phosphate, if extracting the level of phosphate becomes very low, then the level of phosphate is very much flooded in the blood And as soon as the level of calcium goes down, the body being very sensitive, on low calcium level, a hormone is released from parathyroid gland, i.e. parathyroid hormone is released and gives orders to the bones that we have calcium deficiency, so that calcium can be extracted from the bones, hence, the bones overall becomes weak, calcium is taken out from there and comes in blood which fills you with vitamins. There is already lack of Vitamin-D , calcium is already less in the body, the higher amount of phosphate is going to combine with calcium, then ionizes calcium in the body is low, then the parathyroid hormone secreted from parathyroid gland and give order to bones to remove both calcium and phosphate from the bones, then what will happen overall; bones will become demorph and weak and remodeling will be done. This is called renal osteodystrophy. It is said that it also absorb calcium from gut but it is mainly seen in the bone. next we come to the blood cells, if any person has kidney injury and is damaged, then his RBC, which is hemoglobin, becomes very less, because the hormone erythropoietin which is secreted from kidney stimulate bone marrow to make blood. Now that your kidney is damaged damaged the erythropoietin hormone is not extracting then in this condition Person will have anemia due to loss of blood and toxins have accumulated inside such patients, now toxins have accumulated, I have already told you that the filter is not being done properly, the dirt which should be removed is not being removed, the level of urea in the body has increased, creatinine level has increased, then patient will have vomiting tendency, nausea or not feeling hungry, there are many complications, then the food intake also decreases, due to which the chances of getting nutritional anemia also increases. And together with this, there is another cause of anemia, so you are seeing that in this condition, i.e. is the erythropoietin hormone which plays a major role, now come to another thing that you know that kidney injury in chronic kidney disease protein is excreted from our body normally protein excretion is not okay, but the protein which are so important for the body such as in immunoglobulin and maintaining immunity of the body, it is also helpful in body building. Protein and albumin starts excreting from our body and causes albuminuria albumin comes out through urine and which we measure through albumin creatinine ratio so when too much protein is removed from the body, a signal is given to the liver that protein is coming out of the body, it should not have been removed, but it is still being removed because there is damage to the kidney. As soon as the signals come in the liver, the liver will start making protein and a lipoprotein is also produced in this process. I've already made a video on lipoprotein and cholesterol, in that you will see that LDL cholesterol, VLDL cholesterol, all these triglyceride, starts to build up too much. Overall, It can affect your heart as well because liver will make protein and it will also make lipoprotein, and because of that you will see that all of these is related to your cholesterol hence, the quantity of cholesterol is also increased in our body, the most important thing is that the dirt which should be filtered, such as your creatinine, urea All of these toxins which should have been removed from the body, but the body is retaining all of these And so the patients will have so many complications. Many people think that CKD means increased level of creatinine , which is wrong! Creatinine comes as a by product through metabolism of muscles from creatine and it should be removed from the body, which is not removed by the damaged kidney, and The quantity of creatinine which is coming in our blood, through which we calculate the glomerular filtration rate, and find out the filter capacity, do not think that chronic kidney disease means creatinine is increased , creatinine will definitely increase and cuz of that Due to this, the glomerular filtration rate will be affected and many metabolic abnormalities will be seen. in laboratory parameters, what will be found in lab testing, more h+ will be found, less bicarbonate will be detected, more creatinine, it will not be able to filter, high urea quantity will be found you will get a less amount of calcium because phosphate combines with calcium Hence calcium will be less, phosphate will be more things uric acid will be more. Uric acid should also be an excreted this is also not happening. Blood Parameters means in blood parameter what will be seen in CBC then there will be Anemia. if you get lipid profile done you can see that you'll get high amount of Triglyceride, LDL, VLDL. now we come directly on its treatment now we know that kidney damage has happened you have never paid attention to blood pressure and sugar and did not control adequately, due to this, kidney has been damaged slowly, it is in your mind that creatine has been increasing again and again And the real thing is that creatinine is increasing And GFR i.e. glomerular filtration rate has been low Now what should we do in these? Are we able to reduce our creatinine level? Will our kidney be normal or not? In CKD please give attention That it is impossible to make reversible changes in kidney. But the speed at which the damage has been happening will be reduced. With proper medicines and consultation of your nephrologist, then what medicines are given in this, then first of all you see what are the abnormalities, which I told, then if we start one by one, see, you know that acidosis occurs in which high amount of H+ is retained in our body and bicarbonate loss occurs, metabolic acidosis occurs. If metabolic acidosis occurs then we mainly focus on the diet of the patient First, we will say, do protein restriction, from this three-four things, you will get to know why to restrict high protein diet, especially animal protein diet. Amino acids will break down into urea, creatinine High Nitrogenous waste in blood is called azotemia Produced only after the breakdown metabolism of protein, so the amount of protein will be less, especially in animals protein will be better. but now you don't have to take that much less because your body mass will be malnutritioned, you have to take protein in a proper balanced way, especially vegetable protein, you have to eat more and The catabolism of the animal protein that you take from the animal protein and the product that is formed is acidic , then the quantity of H+ will increase, and acidosis will increase, that's why you are told to take vegetable protein because vegetables Catabolism is basic. The patient have to give attention on their diet. Second thing is that if acidosis is more, Quantity of h+ is more, you get the blood test done, the mark of h+ is more and Bicarbonate is low, then how did you understand that it is metabolic acidosis, which is called ABG, Atrial blood gas analysis, then the quantity of h+ is high, then the patient will obviously be in pain, because I have told that h+ exchange with potassium and can cause hyperkalemia h+ acidity is high and acute condition is high means less pH acidic medium means pH decrease from normal range which is 7.34 and 7.24 If acute condition happened then give injection of bicarbonate if it is chronic condition normal well stable patient then we give tablets sodium bicarbonate. sodium bicarbonate tablet very commonly prescribed You must have heard the name nodosis, next we talk about phosphate, so as I said, the excretion of phosphate decreases and the quantity of phosphate is very high in blood and this is phosphate combines with calcium. when it combines with calcium, then the quantity of calcium which is ionized, will be less, And the parathyroid hormone is released. So the level of phosphate in which the excretion is decreasing hence phosphate is increased in our body, for that we have to avoid phosphate Rich diet. Next we'll give phosphate binders If food we are eating, if there is more phosphate in it then it will get bind with it and it is removed from the way of excretion then phosphate which is absorbed from intestine will be less, then its level in blood will be less, then we can do two things, first, we can reduce phosphate rich diet and the second one is to take phosphate binders are two interventions which I have given here, you will see that we will also do it. Thirdly if the calcium level is low i.e. hypocalcaemia, we get to see a lot of hypocalcemic tetany and other things, then how can we fill the calcium level which is low, then we will have to give vitamin supplements for the calcium level in active form of Vitamin-D The vitamin which is usually given to normal patients Whose kidney is normal such as uprise- D3 which comes in the form of capsules which we advised to take weekly Is cholecalciferol means that 7d-hydrochloric acid has been formed and is in the body and when sun light acts on it then it formed........ After Cholecalciferol is formed it goes to the liver, then 25 cholecalciferol is made from hydroxy cholecalciferol and then it goes to the kidney, so you know that Kidney of the patient is already damaged, so 125 which is the active form of Vitamin which is 125 Hydroxy cholecalciferol will not be able to become, therefore giving them the capsules of Vitamin D is of no use because then it will remain as 25 Hydroxy cholecalciferol in the liver till the kidney will not be able to activate it. Enzyme is not present in it, because the kidney is damaged then in this condition you will have to give exact 125 hydroxy cholecalciferol. you will have to give 0.25, 0.5 which is in micrograms, it will be run. then I told that the most dangerous consequences that will happen will be due to hyperkalemia, neither will it give a chance to the patient nor to the doctor for treatment, because sudden arrhythmia , its level you will see very narrow range, if you see in blood test the report will be 3.5 to 5 where it is more hyperkalemia occured and this sudden arrhythmia , tall T waves which is seen in ECG and can cause cardiac arrest then how do we treat it so in this condition most initially we do that where we see that the patient has Hyperkalemia, Potassium level has increased in this condition if we have to do immediate treatment then first of all we give calcium gluconate, calcium gluconate in the formula of 10, 10, 10 i.e 10%, 10ml, for 10 mins. We give calcium gluconate because you know that The most dangerous effect of hyperkalemia will be on the heart and if there is a sudden death, then to stabilize the heart, we give calcium gluconate for the stability of the heart and then our target is to reduce the potassium level, how will we reduce it..so by giving insulin and dextrose means Insulin will help in entering of potassium in blood cell So it will be not in the plasma, it will come in the blood cells, so there is decreased in the level of hyperkalemia If we are giving insulin to someone for the treatment of hyperkalemia, then it should not be such that his sugar will fall , that's why medicines are given in a calculated way, Hence, give him dextrose as well and give insulin along with it and insulin Will reduce potassium and what is the way to reduce potassium by nebulization. Through nebulization the beta-agonist drug such as salmeterol, terbutaline All these reduce potassium and what else can be done we also give potassium binding raisins to drink it. In CKD patients we also Restrict potassium rich diet such as potatoes, banana , spinach, coconut juice, normal fruit juice Next we'll talk about patients who has anemia such patients have less amount of erythropoietin hormone Kidney is damaged and erythropoietin hormone is made up from kidney, erythropoietin give signal to bone marrow to make RBs, red blood cells were formed, so now that signal is not available, what will we have to give directly, we will have to give erythropoietin hormones directly .This hormone therapy which is given in the skin just like insulin, I will give here how much it is given weekly, along with that iron supplement will also be given, because if you are giving erythropoietin hormone, it is stimulating the bone marrow to make more RBC and if there is a deficiency of iron in the body then no matter how much we stimulate and if iron is also less then from where it will be made then we will add iron along with it. Next if the patient is suffering from albuminuria in which the albumin Protein is released from urine due to which liver was getting signal and trying to make more and more protein and lipoprotein is also being made and lipoprotein is related to LDL cholesterol, VLDL Cholesterol, triglyceride will also become more, due to which there will be effect on heart, the chances of getting cardiovascular disease will increase and there is more chance of getting cardiovascular disease, because all these phosphate is more, then phosphate is also very often, get precipitated in our blood and Urea causes uremic pericarditis in the vessel and makes it hard, due to that cardiovascular diseases will be more seen in CKD patients. even then he will either be a diabetic patient or a blood pressure patient. In majority of the cases , CKD patients have stronger chances of having cardiovascular diseases In complications during CKD there will be higher chances of having Cardiovascular disease. Blood pressure and sugar should be keep in Adequate control anyhow. the most important medicine which has been seen is Angiotensin Receptor Blockers or angiotensin Converting Enzyme inhibitors i.e. ramipril or enalapril or ARBs receptors blockers i.e. losartan, telmisartan Now why only this because it has been seen in many studies that it reduces BP and the most important thing is that it reduces the albuminuria that occurs, it reduces the albumin which is coming out of the urination, which is a very bad thing that the protein is coming out of the urine, so that too It reduces and BP is also controlled, one thing is the same, if we give any medicine then many people will have side effects. It works very well in some conditions, you see, this medicine itself gives a little potassium, it can also increase creatinine that's why whenever you give an AC inhibitors or ARB inhibitors ,keep monitoring the potassium and creatinine level of patients. AC inhibitors and ARB inhibitors work greatly in proteinuria. These inhibitors work effectively in diabetes and high blood pressure in case of proteinuria. If the person is having problem with these inhibitors we have to stop these medicines by proper monitoring. For adequate sugar control especially SGLT 2 inhibitors which I've already made a video on this topic such as Empagliflozin, canagliflozin, dapagliflozin control albuminuria upto some extent in addition, it has also been seen that it will control sugar and also it has been seen that it also reduces cardiovascular events, which are cardiovascular diseases reduces to a great extent, especially empagliflozin that it comes in the market with the name jardiance etc. It's found as vicra, gibtulio, empaone etc. You must have to make restriction in your diet such as protein and salt restrictions. Mainly salt restriction is done because it increases blood pressure Potassium rich diet should be avoided to prevent hyperkalemia and phosphate rich diet should also be avoided. Take a help from the dietician and they will make a chart, eat accordingly and regularly. Keep consulting with nephrologists, now here I will talk about two more medicines, people who say that creatinine will reduce, Many people claim on YouTube, but since the time these two medicines have come, creatinine is reduce to a great extent. Till now it has been seen that there is an effect on the progression of kidney disease, which is quite slow or halted. On both these medicines, a research is still going on. First one is N-Acetyl Cysteine (NAC) In Paracetamol, overdose N-Acetyl Cysteine is also given here too, the system gives results like your antioxidant, especially Glutathione which is the major antioxidant in our body. It replenishes the store of glutathione Many companies have started making N-Acetyl Cysteine and many nephrologist suggest this drug. it has been seen to a great extent that, creatinine is reduced, it has been seen in many that GFR will also be controlled to a great extent, that leads to slow down the kidney damage. Taurine also works like antioxidant which is a Amino acid. and we give medicines which are being given too much these days, this is Alpha-ketoanalogues(KA). It is a mixture of those amino acid Which remove nitrogen from amino acid Animal protein is a mixture of amino acids which contains Nitrogenous waste such as urea, creatinine etc. And the same nitrogen creates Nitrogenous waste in our body . Nitrogenous waste is the main problem in our kidney, so if protein is also found, And no Nitrogenous waste is there, this is obviously a good sign. is very good that you take protein or if you do not have nitrogen group, then the nitrogen waste which is yours will be very less, then it is equal to alpha ketu, people are being given a lot of space . Bar if post teachers do then I location protein deficiency then protein will be filled like I have given here you will see how alphablock reduces and what is the dose and how it reduces everyday and also give along There are also combinations with similar tablets which is homocysteine which levels roll in blue and homosis team which is cardiovascular events for hut and very dangerous for our blue vessels blue plots and many more Events are art attack strokes, all these things are controlled by Homosis, we also add parade option in these things, it has been seen that there is a lack of pilot option and if there is a lack of pilot option, then Homosis team If there is no one to control it, then the homosis team level will increase and can cause many problems in the heart, that's why we take supplement of parade option, then you will remember this thing by alpha ki tu analog nsc tiles system and then These four are being given too much right now, just like this one is a vitamin, it is a nutritional supplement. Antioxidants are given, so these are given, the side effects are very less, although the strength of it is the major factor and if you control the rest of the complications, then if this progress stops, it will be slow, then you will not have to do dialysis in the future. It should not be that the kidney which is completely damaged, its GG will be reduced to a very low level and then you may have to do dialysis, after that a real transplant will also be done, I hope this video is a little It's big but you share as much as possible and if you haven't subscribed then kindly subscribe my YouTube channel Dr. Nitesh Raj. thank you so much Jai Hind

Namaskar, I am Dr. Nitesh Raj, today we will talk about CKD i.e. Chronic Kidney  Disease  It's also called Chronic Renal Failure so let's start, Chronic Kidney Disease like It is known from the name that chronic is added, chronic means continuation of a disease. There is a disease in the kidney, there is damage in the kidney, there is injury in the kidney, but it is occurring slowly, from many days and if it is more than 3 months then it comes under chronic kidney disease now it means that if it happens for less than 3 months and it gets cured then it comes under acute kidney injury or acute kidney disease what happens is Kidney injury happens, but if treated properly, it reverses, as you must have seen in a patient whose creatinine has gone up to 5-6, he is admitted to the hospital and gradually you'll see that in 10-15 days  normal creatinine starts coming within 1 to  2 days, this is also the reason, as you know in the studies that if someone has hypertension, low blood pressure or excessive bleeding from the body, dehydration, or injury on the kidney, or any kind of obstruction in the way of urine, then it is due to all these things acute kidney injury can happen, why does acute kidney injury happen, as soon as you see, there is a lot of dehydration, if the blood loss is too much, if heart is not pumping well, or if a certain person has a heart attack, then it is hard to pump. If not doing so then over all the quantity of water or blood is reduced or the heart is not pumping well then all the consequences will be that the kidney will get less blood supply then there will be deficiency of nutrients, oxygen & glucose to the kidney. All this will be less and there is injury to the kidney, drugs also play a major role in this, such as some nephrotoxic drugs, such as aminoglycosides, amphotericin B then tacrolimus  there are some medicines which I have named here, you will see them. Due to this, whatever happens to the kidney then if we stop those medicines, then their kidney starts recovering, then you will see that the creatine comes back normal, but what we will talk about now is chronic kidney disease. For more than 3 months  , we are seeing that there is injury in the kidney, there are some parameters in the kidney, such as if the eGFR (estimated glomerular filtration rate)  then the rate, the water in our body, the toxins, whatever they filter if we see all these things, then chronic means more 3 months  the disease has happened, what is the cause of chronic kidney disease, you should know that it is diabetes and other is hypertension and many more, such as polycystic kidney disease, glomerular nephritis, drug induced, especially pain killer drugs then it emerges as chronic kidney disease. There is a difference in the Chronic Kidney disease  from acute kidney injury which is irreversible once the damage is done which you are seeing that it  is reported from above 3 months creatinine is not reducing your GFR rate is low it means that it has been reversible and it will continue to progress slowly, now it will continue to progress slowly, so what will we do with medicine and why will we need to give medicine when we know that it is a kidney disease which Will keep on progressing then Yes if you give the medicine then the speed at which  Chronic kidney disease was progressing  will slow down or stop to a large extent Many people claim that chronic kidney disease is completely curable or reversible on YouTube which is completely false  so let us see point by point what are the symptoms, what will be the treatment, how will be the diagnosis, so if we focus on the treatment part and we know a little about Pathology Pathophysiology of kidney then it will be easier for us to know so one by one we can see here in this picture that the staging of kidney has been done on the basis of glomerular filtration rate and On the basis of kidney damage, how much damage will be done, then for that we have the most important thing that we will investigate that how much kidney damage has happened, what level it has happened, that is albumin creatinine ratio, so on the basis of these two, we have found The staging which you see here now see why this happened overall so you should know that I want to say again and again that diabetes and hypertension are the reason for this. Many people say that we have diabetes, also they have sugar  or high blood pressure. but we don't have any problem, I want to say this again and again that sugar and pressure, which are silent killer, silent killer that means they will kill you slowly you'll not get to see the consequences in one day  Not like acute kidney Injury happens, you will see that kidney damage will not happen in these diseases, gradually, every day some n some injury is happening, that's why people control the sugar and pressure by taking Medicines, And the rest of the people who give logic that we are not having any problem, but the problem will be that like a termite, it will keep damaging the organs of your body, which you will see proof here in the form of CKD. I have already told you that it is irreversible, so after all it is irreversible, so at least we can control its progress or slow down the speed of progress, what to do for it ...If we know that little bit of pathophysiology for this, then it will be very easy for us to know, what kidney do, if we know this, then the treatment will also be very easy for us.  how much water should be there in the body, how much blood  level, what is the blood level, how much blood should be, how much plasma will come out of blood, water will be filtered, all these decisions are Taken by the kidney, if the filtration capacity of the kidney is hampered, if there is kidney damage, then the level of water which should be removed  From the body will not be able to exit through the urine and because of that, you will get the symptoms of volume overload. What will happen if there is too much water in the body, then you will see  Puffy eyes, water around heart, pulmonary edema around lungs and so on These are the symptoms found cuz of water Therefore you can't able to excrete urine properly and water is retained  Next thing is If we talk about sodium and potassium, water does not come out well, then there are things for sodium, sodium can be too much in the body, it can be too little, how; if there is less urine, then the quantity of water in the body will be more then what will happen that due to fix sodium and high water capacity the sodium will get diluted with water  Level of water keep on increasing and level of sodium get decreased  Which is called dilutional hyponatremia.  Thirdly we'll talk about potassium remember in the case of CKD we'll see  that potassium Excretion is less and there is a high amount of potassium in the body, which we call hyperkalemia there is another reason for hyperkalemia which l will tell further, due to metabolic acidosis, hyperkalemia also occurred, so you should know here that potassium excretion is Less, more is Retained in the body, due to this, hyperkalemia happen, the thing you have to pay attention to for hyperkalemia is that what I think is the most damaging complications and the most dangerous complications in CKD is is hyperkalemia because it don't give any chance to patient, doctor to get time to manage and sudden cardiac arrest; arrhythmia which will get to see the irregularity of heart and sudden death of patient. So we have to be conscious regarding potassium level especially in CKD related patients. Next is H+ and HCO3 balance  How much acid is there in your body and how much bicarbonate is there in your body so you have to remember that in the patient of chronic kidney disease ,the acid which is more retained, the H+  goes on increasing, then the quantity of H+ is also more, so this is why we called it acidosis i.e. acidic condition. There is another condition and the one which is bicarbonate excrete, it should have also absorbed  but it is being removed, so the bicarbonate i.e base is removed and H+ i.e. acid being absorbed, so overall  we will see that metabolic Acidosis occurs in blood and when metabolic acidosis occurs, it increases hyperkalemia, how does it increases hyperkalemia, h+  is more in the blood, then you know that the majority of the potassium that remains inside the cells and the outside You see that h+ is more, which is proton, which is acid if it is more, then this exchange happens between H+ and Potassium and potassium comes out of the cell So, this is called hyperkalemia  Potassium comes out of the blood cells, it comes into the plasma, then its quantity will be more So it will be hyperkalemia. So basically there are two reasons for hyperkalemia.  First is no excretion of potassium   The body is retaining and the second is because of acidosis. Next we will talk about calcium and phosphate metabolism in the case of chronic Kidney Disease. Let's talk about calcium but before that I've made a video on Vitamin-D in which the 7-d hydro cholesterol   changed into skin in the presence of Sunlight in cholecalciferol  and then this cholecalciferol changes into liver in  25 hydroxy cholecalciferol and after that it goes to kidney and changes into 1, 25 hydroxy cholecalciferol  1,25 hydroxy cholecalciferol is the active Vitamin-D  Now, if someone has CKD  someone's kidney is damaged, or injured cholecalciferol is made in body and skin It will also be taken in the liver and 25 hydroxy cholecalciferol will be made but it'll not be converted into 1,25 hydroxy cholecalciferol   because the person's kidney is damaged and the enzyme that is needed in the kidney to convert  25 hydroxy cholecalciferol into 1, 25 hydroxy cholecalciferol which is the active form of Vitamin D which is not done  So overall, there is a deficiency of Vitamin D, then what will happen if there is a deficiency of Vitamin D. We need to know what Vitamin D does, so whatever food we eat If there is calcium in it, then it helps in absorption of calcium from our intestine. so if vitamin D remains adequate in the body, calcium will also remain adequate in the body. The excretion of calcium from the body   is to be stopped because of Vitamin-D then the calcium will remain in our blood, that means it balances it positively on calcium, next we come to the option of phosphate, if extracting  the level of phosphate becomes very low, then the level of phosphate is very much flooded in the blood And as soon as the level of calcium goes down, the body being very sensitive, on low calcium level,  a hormone is released from parathyroid gland, i.e. parathyroid hormone is released and gives orders to the bones that we have calcium deficiency, so that calcium can be extracted from the bones, hence, the bones  overall becomes weak, calcium is taken out from there and comes in blood which fills you with vitamins. There is already lack of Vitamin-D , calcium is already less in the body, the higher amount of phosphate  is going to combine with calcium, then ionizes calcium in the body is low, then the parathyroid hormone secreted from parathyroid gland and give order to bones to remove both calcium and phosphate from the bones, then what will happen overall; bones will become demorph and weak and remodeling will be done. This is called renal osteodystrophy. It is said that it also absorb calcium from gut but it is mainly seen in the bone. next we come to the blood cells, if any person has kidney injury and is damaged, then his RBC, which is hemoglobin, becomes very less, because the hormone erythropoietin which is secreted from kidney  stimulate bone marrow to make blood. Now that your kidney is damaged damaged the erythropoietin hormone is not extracting then in this condition  Person will have anemia due to loss of blood and toxins have accumulated inside such patients, now toxins have accumulated, I have already told you that the filter is not being done properly, the dirt which should be removed is not being removed, the level of urea in the body has increased, creatinine level has increased, then patient will have vomiting tendency, nausea or not feeling hungry, there are many complications, then the food intake also decreases, due to which the chances of getting nutritional anemia also increases. And together with this, there is another cause of anemia, so you are seeing that in this condition, i.e.  is the erythropoietin hormone which plays a major role, now come to another thing that you know that kidney injury in chronic kidney disease protein is excreted from our body normally protein excretion is not okay, but the protein which are so important for the body such as  in immunoglobulin and maintaining immunity of the body, it is also helpful  in body building.  Protein and albumin starts excreting from our body and causes albuminuria  albumin comes out through urine and which we measure through albumin creatinine ratio so when too much protein is removed from the body, a signal is given to the liver that protein is coming out of the body, it should not have been removed, but it is still being removed because there is damage to the kidney. As soon as the signals come in the liver, the liver will start making protein and a lipoprotein is also produced in this process. I've already made a video on lipoprotein and cholesterol,  in that you will see that LDL cholesterol, VLDL cholesterol, all these triglyceride,  starts to build up too much. Overall, It can affect your heart as well because  liver will make protein and it will also make lipoprotein,  and because of that you will see that all of these is related to your cholesterol hence, the quantity of cholesterol is also increased in our body, the most important thing is that the dirt which should be filtered, such as your creatinine, urea All of these toxins which should have been removed from the body, but the body is retaining all of these And so the patients will have so many complications. Many people think that CKD means increased level of creatinine    , which is wrong! Creatinine comes as a by product through metabolism of muscles from creatine   and it should be removed from the  body, which is not removed by the damaged kidney, and  The quantity of creatinine which is coming in our blood, through which we calculate the  glomerular filtration rate, and find out the filter capacity,  do not think that chronic kidney disease means creatinine is increased , creatinine will definitely increase and cuz of that Due to this, the glomerular filtration rate will be affected and many metabolic abnormalities will be seen. in laboratory parameters, what will be found in lab testing,  more h+ will be found, less bicarbonate will be detected, more creatinine, it will not be able to filter, high urea quantity will be found you will get a less amount of calcium because phosphate combines with calcium Hence calcium will be less, phosphate will be more things uric acid will be more. Uric acid should also be an excreted this is also not happening. Blood Parameters means in blood parameter what will be seen in CBC then there will be Anemia. if you get lipid profile done you can see that you'll get high amount of Triglyceride,  LDL, VLDL.   now we come directly on its treatment now we know that kidney damage has happened you have never paid attention to blood pressure and sugar and did not control adequately, due to this, kidney has been damaged slowly, it is in your mind that creatine has been increasing again and again And the real thing is that creatinine is increasing
And GFR i.e. glomerular filtration rate has been low   Now what should we do in these? Are we able to reduce our creatinine level? Will our kidney be normal or not? In CKD please give attention  That it is impossible to make reversible changes in kidney. But the speed at which the damage has been happening will be reduced. With proper medicines and consultation of your nephrologist, then what medicines are given in this, then first of all you see what are the abnormalities, which I told, then if we start one by one, see, you know that acidosis occurs in which high amount of H+ is retained in our body   and bicarbonate loss occurs, metabolic acidosis occurs. If metabolic acidosis occurs then we mainly focus on the diet of the patient  First, we will say, do protein restriction, from this three-four things, you will get to know why to restrict high protein diet, especially animal protein diet. Amino acids will break down into urea, creatinine  High Nitrogenous waste in blood is called azotemia  Produced only after the breakdown metabolism of protein, so the amount of protein will be less, especially in animals protein will be better.  but now you don't have to take that much less because your body mass will be  malnutritioned, you have to take protein in a proper balanced way, especially vegetable protein, you have to eat more and The catabolism of the animal protein that you take from the animal protein  and the product that is formed is acidic , then the quantity of H+ will increase, and acidosis will increase, that's why you are told to take vegetable protein because vegetables Catabolism is basic. The patient have to give attention on their diet. Second thing is that if acidosis is more, Quantity of h+ is more, you get the blood test done, the mark of h+ is more and Bicarbonate is low, then how did you understand that it is metabolic acidosis, which is called ABG, Atrial blood gas analysis,   then the quantity of h+ is high, then the patient will obviously be in pain, because I have told that h+ exchange with potassium and can cause hyperkalemia  h+ acidity is high and acute condition is high means less pH  acidic medium means pH decrease from normal range which is 7.34 and 7.24 If acute condition happened then give injection of bicarbonate if it is chronic condition normal well stable patient then we give tablets sodium bicarbonate. sodium bicarbonate tablet very commonly prescribed You must have heard the name nodosis, next we talk about phosphate, so as I said, the excretion of phosphate decreases and the quantity of phosphate is very high in blood and this is phosphate combines with calcium. when it combines with calcium, then the quantity of calcium which is ionized, will be less, And the parathyroid hormone is released. So the level of phosphate in which the excretion is decreasing hence phosphate is increased in our body, for that we have to avoid phosphate  Rich diet. Next we'll give phosphate binders If food we are eating, if there is more phosphate in it then it will get bind with it and  it is removed from the way of excretion then phosphate which is absorbed from intestine will be less, then its level in blood will be less, then we can do two things, first, we can reduce phosphate rich diet  and the second one is to take phosphate binders are two interventions which I have given here, you will see that we will also do it. Thirdly if the calcium level is low  i.e. hypocalcaemia, we get to see a lot of hypocalcemic tetany  and other things, then how can we fill the calcium level which is low, then we will have to give vitamin supplements for the calcium level in active form of Vitamin-D  The vitamin which is usually given to normal patients Whose kidney is normal such as uprise- D3 which comes in the form of capsules which we advised to take weekly  Is cholecalciferol  means that 7d-hydrochloric acid has been formed and is in the body and when sun light acts on it then it formed........ After Cholecalciferol is formed it goes to the liver, then 25 cholecalciferol is made from hydroxy cholecalciferol and then it goes to the kidney, so you know that  Kidney of the patient is already damaged, so 125 which is the active form of Vitamin which is 125 Hydroxy cholecalciferol will not be able to become, therefore giving them the capsules of Vitamin D is of no use because then it will remain as 25 Hydroxy cholecalciferol in the liver till the kidney will not be able to activate it. Enzyme is not present in it, because the kidney is damaged then in this condition you will have to give exact 125 hydroxy cholecalciferol. you will have to give 0.25, 0.5 which is in micrograms, it will be run.  then I told that the most dangerous consequences that will happen will be due to hyperkalemia, neither will it give a chance to the patient nor to the doctor for treatment, because sudden arrhythmia , its level you will see very narrow range, if you see in blood test the report will be 3.5 to 5 where it is more hyperkalemia occured and this sudden arrhythmia , tall T waves which is seen in ECG  and can cause cardiac arrest then how do we treat it so in this condition most initially we do that where we see that the patient has Hyperkalemia, Potassium level has increased in this condition if we have to do immediate treatment then first of all we give calcium gluconate, calcium gluconate in the formula of 10, 10, 10 i.e 10%, 10ml, for 10 mins. We give calcium gluconate because you know that The most dangerous effect of hyperkalemia will be on the heart and if there is a sudden death, then to stabilize the heart, we give calcium gluconate for the stability of the heart and then our target is to reduce the potassium level, how will we reduce it..so by giving insulin and dextrose means Insulin will help in entering of potassium in blood cell So it will be not in the plasma, it will come in the blood cells, so there is decreased in the level of hyperkalemia  If we are giving insulin to someone for the treatment of hyperkalemia, then it should not be such that his sugar will fall , that's why medicines are given  in a calculated way, Hence, give him dextrose as well and give insulin along with it and insulin Will reduce potassium and what is the way to reduce potassium by nebulization. Through nebulization the beta-agonist drug such as salmeterol, terbutaline All these reduce potassium and what else can be done we also give potassium binding raisins  to drink it. In CKD patients we also Restrict potassium rich diet such as potatoes, banana , spinach, coconut juice, normal fruit juice  Next we'll talk about patients who has anemia such patients have less amount of erythropoietin hormone  Kidney is damaged and erythropoietin hormone is made up from kidney, erythropoietin give signal to bone marrow to make RBs, red blood cells were formed, so now that signal is not available, what will we have to give directly, we will have to give erythropoietin hormones directly .This hormone therapy which is given in the skin just like insulin, I will give here how much it is given weekly,  along with that iron supplement will also be given, because if you are giving erythropoietin hormone, it is stimulating the bone marrow to make more RBC  and if there is a deficiency of iron in the body then no matter how much we stimulate and if iron is also less then from where it will be made then we will add iron along with it. Next if the patient is suffering from albuminuria in which the albumin  Protein is released from urine due to which liver was getting signal and trying to make more and more protein and lipoprotein is also being made and lipoprotein is related to  LDL cholesterol, VLDL  Cholesterol, triglyceride will also become more, due to which there will be effect on heart, the chances of getting cardiovascular disease will increase and there is more chance of getting cardiovascular disease, because all these phosphate is more, then phosphate is also very often, get precipitated in our blood and Urea causes uremic pericarditis in the vessel and makes it hard, due to that cardiovascular diseases will be more seen in CKD patients.  even then he will either be a diabetic patient or a blood pressure patient. In majority of the cases , CKD patients have stronger chances of having cardiovascular diseases  In complications during CKD there will be higher chances of having  Cardiovascular disease. Blood pressure and sugar should be keep in  Adequate control anyhow. the most important medicine which has been seen is  Angiotensin Receptor Blockers or angiotensin  Converting Enzyme inhibitors i.e. ramipril or enalapril or ARBs receptors blockers i.e. losartan, telmisartan  Now why only this because it has been seen in many studies that it reduces BP and the most important thing is that it reduces the albuminuria that occurs, it reduces the albumin which is coming out of the urination, which is a very bad thing that the protein is coming out of the urine, so that too It reduces and BP is also  controlled,   one thing is the same, if we give any medicine then many people will have side effects. It works very well in some conditions, you see, this medicine itself gives a little potassium, it can also increase creatinine  that's why whenever you give an AC inhibitors or ARB inhibitors ,keep monitoring the potassium and creatinine level of patients.   AC inhibitors and ARB inhibitors work greatly in proteinuria. These inhibitors work effectively in diabetes and high blood pressure in case of proteinuria. If the person is having problem with these inhibitors we have to stop these medicines by proper monitoring.   For adequate sugar control    especially SGLT 2 inhibitors which I've already made a video on this topic such as  Empagliflozin, canagliflozin, dapagliflozin control albuminuria upto some extent  in addition, it has also been seen that it will control sugar and also it has been seen that it also reduces cardiovascular events, which are cardiovascular diseases reduces to a great extent, especially empagliflozin that it comes in the market with the name jardiance etc. It's found as vicra, gibtulio, empaone etc. You must have to make restriction in your diet such as protein and salt restrictions. Mainly salt restriction is done because it increases blood pressure  Potassium rich diet should be avoided to prevent hyperkalemia and phosphate rich diet should also be avoided. Take a help from the dietician and they will make a chart, eat accordingly and regularly. Keep consulting with nephrologists, now here I will talk about two more medicines, people who say that creatinine will reduce,  Many people claim on YouTube, but since the time these two medicines have come, creatinine is reduce to a great extent. Till now it has been seen that there is an effect on the progression of kidney disease, which is quite slow or halted. On both these medicines, a research is still going on. First one is N-Acetyl Cysteine (NAC) In Paracetamol, overdose N-Acetyl Cysteine is also given here too, the system gives results like your antioxidant, especially Glutathione which is the major antioxidant in our body. It replenishes the store of glutathione  Many companies have started making N-Acetyl Cysteine and many nephrologist suggest this drug. it has been seen to a great extent that, creatinine is reduced, it has been seen in many that GFR will also be controlled to a great extent, that leads to slow down the kidney damage. Taurine also works like antioxidant which is a Amino acid. and we give medicines which are being given too much these days, this is  Alpha-ketoanalogues(KA). It is a mixture of those amino acid  Which remove nitrogen from amino acid  Animal protein is a mixture of amino acids which contains Nitrogenous waste such as urea, creatinine etc. And the same nitrogen creates Nitrogenous waste in our body . Nitrogenous waste is the main problem in our kidney, so if protein is also found,  And no Nitrogenous waste is there, this is obviously a good sign. is very good that you take protein or if you do not have nitrogen group, then the nitrogen waste which is yours will be very less, then it is equal to alpha ketu, people are being given a lot of space . Bar if post teachers do then I location protein deficiency then protein will be filled like I have given here you will see how alphablock reduces and what is the dose and how it reduces everyday and also give along There are also combinations with similar tablets which is homocysteine which levels roll in blue and homosis team which is cardiovascular events for hut and very dangerous for our blue vessels blue plots and many more Events are art attack strokes, all these things are controlled by Homosis, we also add parade option in these things, it has been seen that there is a lack of pilot option and if there is a lack of pilot option, then Homosis team If there is no one to control it, then the homosis team level will increase and can cause many problems in the heart, that's why we take supplement of parade option, then you will remember this thing by alpha ki tu analog nsc tiles system and then These four are being given too much right now, just like this one is a vitamin, it is a nutritional supplement. Antioxidants are given, so these are given, the side effects are very less, although the strength of it is the major factor and if you control the rest of the complications, then if this progress stops, it will be slow, then you will not have to do dialysis in the future. It should not be that the kidney which is completely damaged, its GG will be reduced to a very low level and then you may have to do dialysis, after that a real transplant will also be done, I hope this video is a little It's big but you share as much as possible and if you haven't subscribed then kindly subscribe my YouTube channel Dr. Nitesh Raj. thank you so much Jai Hind

Transcript for:Understanding Chronic Kidney Disease and Management

Transcript for:
Understanding Chronic Kidney Disease and Management