3. Staging (As per eGFR)
๏ต 1) Stage 1 : more than 90
๏ต 2) Stage 2 : 60 to 90
๏ต 3) Stage 3 : a) 45 to 60 b) 30 to 45
๏ต 4) Stage 4 : 15 to 30
๏ต 5) Stage 5 : below 15
๏ต **** First symptom appears at stage 3B (Anaemia); electrolyte abnormalities
appear at stage 4 with eGFR below 20 usually ****
4. Investigations
๏ต FBC, CR, UREA, eGFR
๏ต S.Electrolytes
๏ต Urine Analysis
๏ต Urine ACR/ PCR ( ACR preferred now)
๏ต 24 hr urinary protein
๏ต USS
๏ต If Stage 3B and higher : Ca, phosphate, ALP, Vit-d3, PTH
๏ต Renal Biopsy
6. Indications Of Referral To Renal Clinic
๏ต ACR 70mg/m.mol or more
๏ต eGFR below 30
๏ต ACR 30mg/m.mol with haematuria
๏ต Hypertension not responding to 4 anti-htn drugs
๏ต Rare or genetic causes of CKD
๏ต Suspected Renal Artery Stenosis
7. Indication of Treating Renal Anaemia
๏ต Indications of therapy :
1) Hb below 100 (10mg/dl) with TSAT below 30 & Ferritin below 500
2) TSAT below 20
3) ferritin below 200 if haemodialysis, below 100 if peritoneal dialysis,
below 100 for non-dialysis
**** If patient is not on haemodialysis,consider a trial of oral iron & if intolerant or no response
after 3months switch into parenteral iron therapy. Patient on dialysis should start from parenteral
iron therapy****
8. Renal Anaemia
๏ต **** Renal anaemia occurs after stage 3B ; if stage 1,2,3A then it is not due to
ckd****
๏ต Diagnosed by : 1) FBC (Hb,MCV,MCH,MCHC)
๏ต 2) Iron profile including TSAT, Ferritin
๏ต 3) Reticulocyte Hb ( less than 29pg)
๏ต 4) % HRC (Hypochromic Red Blood Cells) (above 6%)
9. Oral Iron Therapy
๏ต Non Dialysis patient can be given oral iron for at least 3 months and later if
intolerant or no improvement switch into parenteral therapy. If tolerates and
improves can be continued. Dose is different than usual.
๏ต Dose : 325mg Ferrous Sulfate TDS
10. Parenteral Iron Therapy
๏ต Indications of Parenteral iron therapy :
1) Hb below 70 (7mg/dl)
2) TSAT below 12
3) Oral iron contra-indicated
4) Oral iron not tolerated
5) Risk of ongoing blood loss
Options are : Ferric Carboxymaltose, Iron Isomaltoside, ferumoxytol, Iron
Sucrose, Ferric Gluconate in sucrose complex,iron dextran(not preferred).
12. Erythropoetin Therapy
๏ต Checklist (Before starting Erythropoetin)
๏ต Hb : 100-120 (10-12mg/dl)
๏ต Ferritin above 200 for haemodialysis & 100 above peritonela dialysis
๏ต TSAT above 20
๏ต Folate & Vit B12 levels within normal limit
๏ต BP stable
13. Complications Of Erythropoetin Therapy
๏ต Hypertensive crisis
๏ต Seizure
๏ต Pure red cell aplasia
๏ต Thrombo-embolism
๏ต Viral Illness
๏ต Arthralgia
14. Failure Of Erythropoetin Therapy??
๏ต Rule out following reasons :
๏ต Chronic Infection
๏ต Chronic Inflammation
๏ต Malignancy
๏ต IDA
๏ต Hyper-parathyroid bone disease
๏ต Aluminium Toxicity
15. Detecting ESA Resistance
๏ต Suspect if: Target hb not achieved despite treatment with 300IU/kg/wk or if
continued need for administration of high doses of ESA to maintain target hb
range.
๏ต Pure red cell aplasia is indicated by low reticulocyte count with anaemia and
presence of neutralizing antibodies. ( Anti-erythropoietin Ab)
๏ต If suspected aluminium toxicity perform a desferrioxamine test
๏ต Consider referring to ESA resistance patients to haematology clinics.
17. Statin
๏ต Atorvastatin : 20mg OD
๏ต Simvastatin : 40mg OD
๏ต Rosuvastatin : 20mg OD
๏ต Pravastatin : 40mg OD
๏ต Combination therapy : Simvastatin 20mg OD plus ezetimibe 10mg OD
๏ต **** Most renal friendly amongst all is atorvastation****
18. Renal dose for anti-diabetic drugs
๏ต Metformin : can be used in full dose till stage 3A,half the usual dose in stage 3B and contra-indicated in stage 4
๏ต DDP4 Inhibitors : A) Linagliptin 5mg ( no dose adjustment required)
๏ต B) Sitagliptin 25mg to 100mg OD if eGFR over 60, 50mg if eGFR 30 to 60, and 25mg if eGFR
below 30
๏ต C) Vildagliptin 50mg bd if renal function normal otherwise 50mg once daily if any degree of
renal impairment
๏ต
19. Renal Dose Of Anti-Diabetic Drugs
๏ต SGLT2 Inhibitors : A) Canagliflozin 100mg OD upto 300mg OD, no dose
adjustment if eGFR above 60, upto 100g OD if eGFR 45 to 60, C/I if eGFR
below 45
๏ต B) Dapagliflozin 5mg OD upto 10mg OD if eGFR above 60,
do not initiate if eGFR below 60
๏ต C) Empagliflozin 10mg OD upto 25mg OD if eGFR above 60,
C/I if eGFR below60
20. Treating Metabolic Bone Disease In CKD
๏ต Principle of managing :
๏ต 1) Bisphosphonate
๏ต 2) Calcium
๏ต 3) Vitamin D supplementation
21. Treating Metabolic Bone Disease In CKD
๏ต A) Bisphosphonate :
๏ต 1) Upto eGFR 30 : Risedronate 35mg 2 week interval
๏ต 2) eGFR below 30 : Denusumab
๏ต B) Calcium supplementation : Calcium 1g daily if eGFR above 30 & 500mg
once daily if eGFR below 30 ( Due to risk of hypercalcemia casuing calcification
of the arteries)
๏ต C) Vitamin D Correction : Ergocalciferol or colecalciferol can be sued till
correction of vitamin d3 and after that calcitriol can be used ( .25mcg to 1mg on
alternate days or daily)
22. Treating Hypocalcemia in CKD
๏ต If eGFR above 30 : calcium 1g per day
๏ต If eGFR below 30 : calcium 500mg OD ( High intake of calcium causes
risk of calcification; specially calcification of coronary arteries raises
risk of IHD)
๏ต Options available are : calcium carbonate, calcium gluconate.
23. Treating Hyper Phosphatemia in CKD
๏ต 1) Calcium containing drugs : calcium carbonate, calcium acetate
๏ต 2) Non-Calcium containing drugs : Sevelamir
๏ต Indication : If phosphate above 6mg
๏ต Target ( Maintainence of phosphate level) : A) Dialysis patient 3.5mg to 5.5mg
๏ต B) Non-dialysis patient below 4.5mg
24. Treating Hyper-parathyroidism in CKD
๏ต Indicated if PTH 2 to 4 times higher than normal
๏ต Target keep PTH level between 2 to 4 times than normal ( If higher than 4
times then risk of osteititis fibrosa and if too low adynamic bone disease)
๏ต A) Dialysis patient : Calcitriol with cinacalcet
๏ต B) Non-dialysis patient : Calcitriol
๏ต C) Surgical management : Parathyroidectomy
25. Indications of Parathyroidectomy
๏ต 1) Calcium more than 2.85m.mole/l or 11.4 mg/dl
๏ต 2) Complication of hypercalcemia( bone disease,pancreatitis,renal stone)
๏ต 3) Age less than 50 years
๏ต 4) Symptoms of hypercalcemia
26. Treating Metabolic Acidosis in CKD
๏ต Sodi-bi-carbonate 500mg/600mg bid/tds extending upto 1g bid/tds (Max 4g
per day)
