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Diagnosis & medical management of ckd


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chronic kidney disease

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Diagnosis & medical management of ckd

  1. 1.  General Considerations  Clinical Findings  Complications  Management options  When to Refer  When to admit
  2. 2. General Considerations  Classification Stage 1: Normal GFR;GFR >90 mL/min/1.73m2 with *other evidence of chronic kidney damage. Stage 2: Mild impairment; GFR 60- 89mL/min/1.73 m2 with *other evidence of chronic kidney damage Stage 3: Moderate impairment; GFR 30-59 mL/min/1.73 m2 Stage 4: Severe impairment: GFR 15-29 mL/min/1.73m2 Stage 5: Established renal failure (ERF): GFR<15 mL/min/1.73 m2 or on dialysis *The “other evidence of chronic kidney damage” may be one of the following: • Persistent microalbuminuria • Persistent proteinuria • Persistent haematuria (after exclusion of other causes, e.g. urological disease) • Structural abnormalities of the kidneys demonstrated on ultrasound scanning or other radiological tests, eg. polycystic kidney disease, reflux nephropathy • Biopsy-proven chronic glomerulonephritis (most of these patients will have microalbumuria or proteinuria, and/or haematuria)
  3. 3. Clinical Findings  Symptoms & Signs  Laboratory Findings  Imaging
  4. 4. Symptoms & Signs
  5. 5. Laboratory Investigations Investigations in Categories Graded in Different Levels  Grade X – very basic  Grade Y – desirable  Grade Z – optional Grade Y  Urinary microalbumin  Urinary protein: creatinine ratio  Urinary alb:creatinine ratio Grade Z  PTH assays  25 – hydroxyvitamin D  Cystatin C Grade X  Blood urea  Creatinine  Serum electrolytes  Urinary sediment  Serum calcium  Serum phosphate  Acid base  Anion gap  Creatinine clearance  Estimated GFR by equations or  By using tables
  6. 6. Imaging USS-small echogenic kidneys bilaterally (< 10 cm) supports a diagnosis of chronic kidney disease, though normal or even large kidneys can be seen with adult polycystic kidney disease, diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, and obstructive uropathy. Radiologic evidence of renal osteodystrophy is another helpful finding, since radiographic changes of secondary hyperparathyroidism and chronic kidney disease mineral and bone disorder do not appear unless parathyroid levels have been elevated for at least 1 year. Evidence of subperiosteal reabsorption along the radial sides of the digital bones of the hand can confirm hyperparathyroidism.
  7. 7. Complications  Hyperkalemia Potassium balance generally remains intact in chronic kidney disease until the GFR is < 10–20 mL/min. However, an increased risk of hyperkalemia at higher GFRs.  Acid–Base Disorders  Cardiovascular Complications Long-term complications of chronic kidney disease include a high risk of morbidity and mortality of cardiovascular disease in comparison to the general population. 1. Hypertension 2. Pericarditis—With uremia, pericarditis may develop but is uncommon 3. Congestive heart failure—Patients with ESRD tend toward a high cardiac output.  Hematologic Complications 1. Anemia—The anemia of chronic kidney disease is characteristically normochromic and normocytic. 2. Coagulopathy—The coagulopathy of chronic kidney disease is mainly caused by platelet dysfunction  Neurologic Complications Uremic encephalopathy does not occur until GFR falls below 5–15 mL/min.  Disorders of Mineral Metabolism  Endocrine Disorders
  8. 8. Management  A. Medical Management  B. Management of complications  C. Dietary Management  D. Dialysis  E. Kidney Transplantation
  9. 9. Management  A. Medical Management Renoprotection ? The multidrug approach -an international protocol Goals of treatment BP <120/80 Proteinuria <0.3 g/24 h Treatment Patients with chronic kidney disease and proteinuria >1 g/24 h: ACE inhibitor increasing to maximum dose Add angiotensin receptor antagonist if goals are not achieved (In type 2 diabetes start with angiotensin receptor antagonist.) Add diuretic to prevent hyperkalaemia and help to control BP Add calcium-channel blocker (verapamil or diltiazem) if goals not achieved. Additional measures Statins to lower cholesterol to <4.5 mmol/L Stop smoking (three-fold higher rate of deterioration in CKD) Treat diabetes (HbA1c <7%, 53 mmol/mol) Normal protein diet (0.8–1 g/kg bodyweight)
  10. 10. Management C. Dietary Management 1. Protein restriction—Experimental models have shown that protein restriction slows the progression to ESRD 2. Salt and water restriction—In advanced chronic kidney disease, the kidney is unable to adapt to large changes in sodium intake. 3. Potassium restriction—Restriction is needed once the GFR has fallen below 10–20 mL/min. 4. Phosphorus restriction—The phosphorus level should be kept in the ‘normal’ range (below 4.6 mg/dL) predialysis, and between 3.5 and 5.5 mg/dL when on dialysis, with a dietary restriction of 800–1000 mg/d 5. Magnesium restriction—Magnesium is excreted primarily by the kidneys.
  11. 11. Management D. Dialysis When conservative management of ESRD is inadequate, hemodialysis, peritoneal dialysis, and kidney transplantation are alternatives. According to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; dialysis should be started when a patient has a GFR of 10 mL/min or serum creatinine of 8 mg/dL. A diabetic patient should start when the GFR reaches 15 mL/min or serum creatinine is 6 mg/dL. Other indications for dialysis include (1) uremic symptoms, such as pericarditis, encephalopathy, or coagulopathy; (2) fluid overload unresponsive to diuresis; (3) refractory hyperkalemia; (4) severe metabolic acidosis (pH < 7.20); and (5) neurologic symptoms, such as seizures or neuropathy
  12. 12. Management E. Kidney Transplantation Up to 50% of all patients with ESRD are suitable for transplantation. Age is becoming less of a barrier. Two-thirds of kidney transplants come from deceased donors, with the remainder from living related or unrelated donors. Immunosuppressive drugs include corticosteroids, azathioprine, mycophenolate mofetil, tacrolimus, cyclosporine, and sirolimus.
  13. 13. Prognosis  Mortality is higher for patients undergoing dialysis than for those receiving a kidney transplant and versus healthy age-matched controls. In general, uremia develops and patients lose consciousness prior to death. Arrhythmias can occur as a result of electrolyte imbalance.  The most common cause of death is cardiac dysfunction (45%).  For those who require dialysis to sustain life but elect not to undergo dialysis, death ensues within days to weeks  survival for as long as 25 years is seen depending on the disease entity
  14. 14. When to refer  A patient with stage 3–5 chronic kidney disease should be referred to a nephrologist for management in conjunction with the primary care provider.  A patient with other forms of chronic kidney disease should have an initial visit with a nephrologist to discuss future co-management needs.
  15. 15. When to admit  Admission should be considered for patients with decompensation of problems related to chronic kidney disease, such as worsening of acid-base status, electrolyte abnormalities, volume status that cannot be appropriately treated in the outpatient setting.  Admission is appropriate when a patient needs to start renal replacement therapy, and is not stable for outpatient initiation.
  16. 16. Summary  General Considerations  Clinical Findings  Complications  managements  Admitting and referring of patients