Chronic Kidney Disease

Dr. Kevin T JohnMedicine PG (PIMS)

DEFINITION OF CKD

• CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health.

Classification of CKD

Evaluation of CKD

EVALUATION OF CKD

• In people with GFR <60 ml/min/1.73m2 (GFRcategories G3a-G5)

• markers of kidney damage• review past history • previous measurements to determine

duration of kidney disease• duration is >3 months

• CKD IS CONFIRMED

EVALUATION OF CKD

• urinalysis to detect hematuria or pyuria , urine microscopy to detect RBC casts or WBC casts.

• Ultrasound to assess kidney structure for kidney shape,size, symmetry and evidence of obstruction

• Serum and urine electrolytes to assess renal tubular disorders

DEFINITION AND IDENTIFICATION OF CKDPROGRESSION

• Define CKD progression based on one of more of the following

• drop in GFR category accompanied by a 25% or greater drop in eGFR from baseline

• Rapid progression is defined as a sustained decline in eGFR of more than 5 ml/min/1.73 m2/year

• confidence in assessing progression is increased with increasing number of serum creatinine measurements and duration of follow-up.

FOLLOWUP

• Assess GFR and albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression

• The AER is one of the best indicators of diabetic nephropathy risk in both type 1 and type 2 diabetes

Management of CKD

PREVENTION OF CKD PROGRESSION

• BLOOD PRESSURE• diabetic and non diabetic adults with

CKD and urine albumin excretion < 30mg/24 hours treated with BP-lowering drugs to maintain a BP that is consistently<140mm and diastolic <90.

• CKD and with urine albumin excretion of >30mg/24 hours maintain a BP <130/80mmhg

• Use of ARB or ACE-I in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours

• If diabetic, albuminuria 30-300mg /24 hrs is indicated for ACE/ARBI

• electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and drug side effects has be given close attention in CKD to prevent adverse effects of antihypertensive therapy.

CKD and risk of AKI• All CKD patients are at risk for AKI• All reversible precipitating factors has to

be avoided

Protein intake in CKD• protein intake restriction to 0.8

g/kg/day in adults with diabetes or without diabetes and GFR <30 ml/min/ 1.73 m2.

• avoid high protein intake (1.3 g/kg/day) in adults with CKD at risk of progression

Diabetic control• Glycemic control improves outcomes in people

with diabetes with or without CKD• In people with CKD and diabetes, glycemic control

should be part of a multifactorial intervention• Blood pressure control and cardiovascular risk,

ACE-I,ARBS,Statins and antiplatelet therapy to be used where clinically indicated

• Recommended target (HbA1c)at 7.0% and not less to prevent hypoglycaemia and to delay progression of the microvascular complications of diabetes, including diabetic kidney disease

Salt intake• Salt lowering intake to <2 g per day of

sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated.

• Individuals with CKD should receive expert dietary advice and information as a education program, based on severity of CKD and the need to intervene on salt,phosphate, potassium, and protein intake where indicated.

• Patients with CKD be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30minutes 5 times per week),

• BMI - 20 to 25, and• Stop smoking

COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEYFUNCTION

• CKD are prone to develop a variety of complications which reflect loss of endocrine or exocrine function of the kidney.

Anaemia Diagnose anemia in adults and children >15 years

when the Hb concentration is • <13.0 g/dl in males• <12.0 g/dl in females.

Blood Hb monitoring in CKD• when clinically indicated in people with GFR

>60 ml/min/1.73 m2 • at least annually in people with GFR 30-59 ml/min/1.73 m2 • at least twice per year in people with GFR<30 ml/min/1.73

m2

Anaemia (Cont)

• Work-up for anemia in CKD • Iron replacement therapy if indicated• ESA therapy is not recommended in those

with active malignancy• ESAs should not be used to increase the

Hb concentration above 11.5g/dl

CKD METABOLIC BONE DISEASE

• Changes in bone mineral metabolism and alterations in calcium and phosphate homeostasis occur early in the course of CKD and progress as kidney function decline

• serum levels of calcium,phosphate, PTH, and alkaline phosphatase activity at least once in adults with GFR o45 ml/min/1.73 m2.

• Aluminium hydroxide, Calcium citrate, Magnesium carbonate,calcium acetate phosphrus binders are used

Vit D hypovitaminosois

• As CKD progresses, levels of 1,25(OH)2D progressively fall

• Deficiency of 25(OH)D increases fracture risk and is associated with increased mortality

• In vitamin D-deficient subjects supplementation with vitamin D increases BMD and muscle strength, reduces risk for fractures reduces, and reduces PTH.

Acidosis• Severity of metabolic acidosis in people with

CKD progressively rises as GFR falls.• Chronic metabolic acidosis is associated

with increased protein catabolism, uremic bone disease, muscle wasting, chronic inflammation, impaired glucose homeostasis, impaired cardiac function, progression of CKD, and increased mortality

• In CKD with serum bicarbonate concentrations <22 mmol/l ,oral bicarbonate supplementation be given to maintain serum bicarbonate within the normal range

Cardiovascular disease

• Heart Outcomes Prevention• Evaluation (HOPE) study demonstrated

that any degree of albuminuria is a risk factor for cardiovascular events in individuals with or without diabetes

• 1. Smoking cessation• 2. Exercise• 3. Weight reduction to optimal targets• 4. Lipid modification recognizing that the risk reduction

associated with statin therapy in adults with CKD• 5. Optimal diabetes control HbA1C o7% (53 mmol/mol)• 6. Optimal BP control to o140/90 mm Hg or o130/80• mm Hg in those with CKD and depending on the degree• of proteinuria (see Recommendations 3.1.4 and 3.1.5)• 7. Aspirin is indicated for secondary prevention but not• primary prevention• 8. Correction of anemia to individualized targets

Peripheral arterial disease

• CKD patients are at high risk of developing PAD• Regularly examined for signs of peripheral arterial

disease• Patients with CKD and diabetes are offered regular

podiatric assessment

MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD

• All adults with CKD should be annually vaccinated with influenza vaccine,unless contraindicated.

• They should receive vaccination with polyvalent pneumococcal vaccine and hepatitis B.

TIMING THE INITIATION OF RRTDialysis be initiated when one or more of the following are present: • serositis, pericarditis• acidbase or electrolyte

abnormalities • Pruritus• Inability to control volume status

or blood pressure• a progressive deterioration in

nutritional status refractory to dietary intervention

• cognitive impairment

TIMING THE INITIATION OF RRT• Living donor preemptive

renal transplantation in adults

• GFR is <20 ml/min/1.73 m2,

• evidence of progressive and irreversible CKD over the preceding 6-12 months

THANK YOU