A direct and focused management of CKD

1. MANAGEMENT OF CHRONIC
KIDNEY DISEASE (CKD)
Dr A.Maphane

2. OUTLINE
• Definition
• Classification
• Epidemiology
• Overview of Kidney function
• Pathophysiology
• Clinical Features
• Diagnostic approach
• Management
• References

3. DEFINITION
KDIGO has defined CKD as abnormalities of kidney structure or
function present for >3 months with implications for health.
Such abnormalities may include 1 or more markers of kidney damage:
• albuminuria >30 mg/g of creatinine,
• urine sediment abnormalities,
• electrolyte and other abnormalities due to tubular disorders,
• abnormalities detected by histology,
• structural abnormalities detected by imaging,
• history of kidney transplantation)
• presence of glomerular filtration rate (GFR) <60 mL/ min/1.73 m2

4. CLASSIFICATION OF CKD
Based on cause of disease:

5. Based on GFR:
• G1 − GFR >90 mL/min per 1.73 m2
• G2 − GFR 60 to 89 mL/min per 1.73 m2
• G3a − GFR 45 to 59 mL/min per 1.73 m2
• G3b − GFR 30 to 44 mL/min per 1.73 m2
• G4 − GFR 15 to 29 mL/min per 1.73 m2
• G5 − GFR <15 mL/min per 1.73 m2 or treatment by dialysis
Based on Albuminuria:
• A1 − ACR <30 mg/g (<3.4 mg/mmol)
• A2 − ACR 30 to 299 mg/g (3.4 to 34.0 mg/mmol)
• A3 − ACR ≥300 mg/g (>34.0 mg/mmol)

7. EPIDEMIOLOGY
• According to NHANES (2014) the prevalence of CKD in USA was
approx. 14.8% and by stages: - G1: 4.7%
- G2: 2.9%
- G3: 6.6%
- G4: 0.4%
- G5: 0.2%
• Overall prevalence has been relatively stable over the years but
there’s a in prev of ESRD due to increased lifespan because of
advancement in renal therapy
• Other countries: ranges from 1-30% and global prev at present is @
13.4%
• In a retro cohort over 5.5yr period est. annual incidence is approx.
1700 per million

8. CONT’D
• NRH medical wards: CKD patients make up approx. 35-40%
IMPACT OF CKD & ESRD on GENERAL MORBIDITY:
• Approx. 50% dialysis patients have ≥3 comorbid conditions (HTN, DM,
CVD, PVD) and quality of life is far lower in dialysis patients.
• Age and presence of cardiac disease were associated with higher
rates of hospitalisation.
IMPACT on MORTALITY:
• CKD/ESRD patients are increased risk of mortality particularly from
CVD
• Survival rates for dialysis patients are: @ 1yr (85%), 2yr (65%) and 5yr
(34%)

9. BACK TO THE BASICS

12. PATHOPHYSIOLOGY

13. CLINICAL MANIFESTATIONS

14. DIAGNOSTIC EVALUATION
Blood
• CBC with diff
• Urea, Creatinine and
Electrolytes with Ca2+ and
phosphorous
• PTH
• HBA1c
• LFTs
• Uric acid
• Fe2+ studies
Urine
• Urinalysis with
microscopy
• Spot urine for
microalbumin
• 24-urine collection for
protein and creatinine
(if needed)
Renal biopsy-if
significant proteinuria,
hematuria or sterile
pyuria

15. Urine albumin & protein to creatinine ratio
Albumin-to-creatinine ratio
• Normal to mildly increased <30mg/g
• Moderately increased 30-300 mg/g
• Severely increased >300 mg/g
Protein-to-creatinine ratio
• Normal to mildly increased <150mg/g
• Moderately increased 150-500 mg/g
• Severely increased >500 mg/g

16. CONT’D
Ultrasound
• For hydronephrosis, cysts, and stones
• To assess echogenicity, size, kidney symmetry
If indicated by history or by findings:
• Antinuclear antibody to evaluate for lupus and other autoimmune dis
• Serologies for HBV, HCV, and HIV
• Serum antineutrophil cytoplasmic antibodies for vasculitis
• Serum and urine protein immunoelectrophoresis for multiple
myeloma

17. ESTIMATING GFR

18. MANAGEMENT
The general management of the patient with CKD involves the
following issues:
• Treatment of reversible causes of renal failure
• Preventing or slowing the progression of renal disease
• Treatment of the complications of renal failure
• Adjusting drug doses when appropriate for the level of estimated
glomerular filtration rate (eGFR)
• Identification and adequate preparation of the patient in whom renal
replacement therapy will be required

19. TREATMENT OF REVERSIBLE RENAL CAUSES
• AKI on CKD due to decreased renal perfusion:
- Hypovolemia: give a trial of fluid repletion
-Hypotension 2o to Myocardial dysfunction/pericardial disease:
treat cause
• STOP and avoiding use of nephrotoxic drugs e.g. Aminoglycosides,
NSAIDs, radiographic contrast materials
• Relieving any underlying urinary tract obstruction e.g. BPH, Stones

20. PREVENTING OR SLOWING PROGRESSION OF
RENAL DISEASE
• Antihypertensive therapy
-With proteinuria: ACEi or ARBs +/- CCB
-No proteinuria: one or two of; ACEi/ARBs OR CCB OR Thiazide
• Target BP 125-130/<80mmHg
• Proteinuria goal <1000mg/d
• ACEi: Benazepril 30mg, Captopril 100mg, lisinopril 20mg
• ARBs: candesartan 16mg, valsartan 160mg
• CCB: Amlodipine, Nifedipine

22. CONT’D
Other targets for renal protection
• Protein restriction: 0.6-0.8g/kg/d
• Smoking cessation
• Treatment of chronic metabolic acidosis: supplemental sodium
bicarbonate 650mg oral
• Glycaemic control: SGLT 2 inhibitors (Canagliflozin, Dapagliflozin)

23. TREATMENT OF COMPLICATION OF RENAL FAILURE
• Volume overload: - dietary Na restriction (<2g/d)
-Diuretics: Furosemide 40mg-200mg IV
• Hyperkalemia: -Dietary; low K diet 1.5-2.7g/d
- avoiding meds that K e.g. NSAIDs
• Metabolic acidosis: supplemental sodium bicarbonate
• Mineral and Bone disease: -PO4 restriction or PO4 binders (calcium
carbonate, Mg salts, Al3 salts)
-Calcitriol (1.25 dihydroxyvitamin D)

24. CONT’D
• Anaemia: - EPO 80-120u/kg SC 3x/wk or darbepoetin 0.45μg/kg q wk
- Iron supplementation: FeSO4 200mg PO
• Dyslipidaemia:- statin therapy; atorvastatin 20mg OD or simvastatin
20-40mg OD

25. TREATMENT OF COMPLICATIONS OF ESRD
• Malnutrition: secondary to anorexia, decreased intestinal digestion
and absorption and metabolic acidosis.
- diet should include Protein, Fat, Mineral and Water providing
approx. 30-35kcal/kg per day
• Uremic bleeding, Pericarditis and uremic neuropathy: initiation of
dialysis
• Infection and Vaccination:
- Adults with all stages of CKD should be offered annual vaccination
with influenza virus
- Adults with stage 4 and 5 CKD who are at high risk of progression of
CKD should be immunized against hepatitis B
- Adults with CKD stages 4 and 5 should be vaccinated with polyvalent
pneumococcal vaccine

26. Indications for renal replacement therapy
• Pericarditis or pleuritis (urgent indication).
• Progressive uremic encephalopathy or neuropathy, with signs such as
confusion, asterixis, myoclonus, wrist or foot drop, or, in severe,
cases, seizures (urgent indication).
• A clinically significant bleeding diathesis attributable to uremia
(urgent indication).
• Fluid overload refractory to diuretics.
• Hypertension poorly responsive to antihypertensive medications.
• Persistent metabolic disturbances that are refractory to medical
therapy. These include K, Na, metabolic acidosis, / Ca, and PO4.

27. CONT’D
• Persistent nausea and vomiting.
• Evidence of malnutrition.

28. Haemodialysis Vs Peritoneal dialysis
• Selection of dialysis modality is influenced by:
-Availability and convenience
-Comorbid conditions
-Dialysis centre factors
-Pt’s home situation and comfort with home therapies.
• Recent USRDS of 2018 showed a sustained survival advantage with
PD among pts who started dialysis in 2011 with an adjusted 5 yr
survival of 52% compared with 42% for those on HD.
• BUT from different studies conclusion is that survival on HD and PD is
similar with perhaps a slight advantage favouring PD

29. WHEN TO REFER TO A NEPHROLOGIST
• Acute kidney injury or abrupt sustained fall in GFR
• GFR <30mL/min/1.73m (GFR categories G4-G5)
• Persistent albuminuria >300 mg/g)
• Atypical Progression of CKD
• Urinary red cell casts, RBC more than 20 per HPF sustained and not
readily explained
• Hypertension refractory to treatment with 4 or more antihypertensive
agents
• Persistent abnormalities of serum potassium

30. CONT’D
• Recurrent or extensive nephrolithiasis
• Hereditary kidney disease
• No clear aetiology of CKD
• Type 2 diabetes with proteinuria w/o coexistent retinopathy or
neuropathy
• Rapid decline in kidney function (>5 mL/min per 1.73 m2 per year)

31. • NB: Kidney transplantation is the treatment of choice for ESRD
Have an idea of what this is?

32. REFERENCES
• Uptodate
• Pocket medicine
• NEJM
• KDIGO 2012 Guidelines

33. QUESTIONS…COMMENTS…SUGGESTIONS
THANK YOU!!!