CKD refers to irreversible deterioration of renal function over a period of years . It is characterized by biochemical abnormalities( raised BUN and creatinine) to loss of excretory, endocrine and metabolic functions which leads to clinical manifestations (called uremic syndrome). Linked to #GFR and amount of #albuminaemia. Learn/Recall : 1.CLINICAL and LABORATORY MENIFESTATIONS 2.STAGING 3.INVESTIGATIONS 4. MANAGEMENT 5. DIET for CKD PATHOPHYSIOLOGY Common etiologies- Diabetes mellitus Glomerular diseases( primary, secondary, hereditary- IgA nephropathy most common. Hypertension Interstitial diseases( AKI due to toxins or ischemia; tubule-interstitial nephritis due to inflammation) Congenital/hereditary ( Polycystic kidney disease Systemic inflammatory diseases( SLE, vasculitis) Idiopathic There’re two underlying mechanisms: Inheritary mechanism (abnormality in kidney development/integrity, immune mediated, inflammation, toxins) Hyper filtration and hypertrophy of remaining viable nephrons. EPIDEMIOLOGY AND RISK FACTORS Mostly over the age of 65 yrs HTN, DM, vascular diseases Childhood obesity Low birth weight Advanced age Family history of kidney diseases May be symptomatic( usually until GFR falls below 30ml/min/1.73 m2. When GFR is less than 15-20, symptoms and signs are common involving multiple systems. Renal anemia and fatigue Fluid overload Pruritus Anorexia, weight loss Nausea, vomiting, hiccups Kussmaul breathing due to metabolic acidosis Muscular twitching , fits Drowsiness, coma Abnormality in calcium, phosphorus, calcitriol, PTH,sodium, potassium, water and acid-base homeostasis( metabolic acidosis). CALCIUM AND PHOSPHATE DISORDERS Bone manifestations (Osteodystrophy)- Osteitis fibrosa cystica ( classical of hyperparathyroidism) Osteomalacia ( low calcitriol) Adynamic bone disease (low/ normal PTH) CVS – vascular calcification ( calcification of media of coronary arteries and even heart valves. Others - Calciphylaxis STAGING OF CKD By: US National Kidney Foundation Kidney Disease Quality Outcomes Initiative, 2002 ( G1 to G5) Kidney Disease Outcomes Quality Initiative, 2013 ( A1, A2, A3) Based on : eGFR Amount of albuminuria( helpful in assessment of nephron injury. Stage 1&2- asymptomatic Stage 3& 4- prominent clinical and laboratory findings involving virtually all systems (Figure). Stage 5 aka ESRD (End Stage Kidney Disease)- which causes the death of patient due to accumulation of toxins, fluid and electrolytes unless removed by RRT(Dialysis or Renal transplant).

1. CHRONIC KIDNEY DISEASE(CKD)
Medical MADE EASY

2. CHRONIC KIDNEY DISEASE(CKD)
Irreversible deterioration of renal function over a period of years .
Characterized by biochemical abnormalities( raised BUN and creatinine) to loss of
excretory, endocrine and metabolic functions which leads to clinical manifestations
(called uremic syndrome).
Linked to GFR and amount of albuminaemia.

3. PATHOPHYSIOLOGY
Common etiologies-
 Diabetes mellitus
 Glomerular diseases( primary, secondary,
hereditary- IgA nephropathy most common.
 Hypertension
 Interstitial diseases( AKI due to toxins or
ischemia; tubule-interstitial nephritis due to
inflammation)
 Congenital/hereditary ( Polycystic kidney disease
 Systemic inflammatory diseases( SLE, vasculitis)
 Idiopathic
There’re two underlying mechanisms:
1. Inheritary mechanism (abnormality in kidney
development/integrity, immune mediated,
inflammation, toxins)
2. Hyper filtration and hypertrophy of remaining
viable nephrons.
EPIDEMIOLOGY AND RISK FACTORS
 Mostly over the age of 65 yrs
 HTN, DM, vascular diseases
 Childhood obesity
 Low birth weight
 Advanced age
 Family history of kidney diseases

4. CLINICAL AND LABORATORY MENIFESTATIONS OF CKD
1. May be symptomatic( usually
until GFR falls below
30ml/min/1.73 m2.
2. When GFR is less than 15-20,
symptoms and signs are
common involving multiple
systems.
3. Renal anemia and fatigue
4. Fluid overload
5. Pruritus
6. Anorexia, weight loss
7. Nausea, vomiting, hiccups
8. Kussmaul breathing due to
metabolic acidosis
9. Muscular twitching , fits
10. Drowsiness, coma
Abnormality in calcium,
phosphorus, calcitriol,
PTH,sodium, potassium, water and
acid-base homeostasis( metabolic
acidosis).
CALCIUM AND PHOSPHATE DISORDERS
Bone manifestations (Osteodystrophy)-
1. Osteitis fibrosa cystica ( classical of
hyperparathyroidism)
2. Osteomalacia ( low calcitriol)
3. Adynamic bone disease (low/ normal
PTH)
CVS – vascular calcification ( calcification of
media of coronary arteries and even heart
valves.
Others - Calciphylaxis
ANEMIA IN CKD
Due to-
 Low erythropoietin
 Diminished red cell
survival
 Iron deficiency due to
poor dietary absorption
and GI blood loss
 Chronic inflammation,
etc.

5. STAGING OF CKD
By:
 US National Kidney Foundation Kidney Disease Quality Outcomes Initiative, 2002
( G1 to G5)
 Kidney Disease Outcomes Quality Initiative, 2013 ( A1, A2, A3)
Based on :
1. eGFR
2. Amount of albuminuria( helpful in assessment of nephron injury.
Stage 1&2- asymptomatic
Stage 3& 4- prominent clinical and laboratory findings involving virtually all systems
(Figure).
Stage 5 aka ESRD (End Stage Kidney Disease)- which causes the death of patient
due to accumulation of toxins, fluid and electrolytes unless removed by RRT(Dialysis
or Renal transplant).
Stages GFR in ml/min/1.73 m2
G1 ≥ 90 (Normal or high)
G2 60-89 (Mildly decreased)
G3A 45-59 (Mildly to moderately decreased)
G3B 30-44 (Moderately to severely decreased)
G4 15- 29 (Severely decreased)
G5 < 15 (Renal failure)
A1 A2 A3
Normal to
mildly
increases
Moderately
increased
Severely increased
< 30 ml/g
< 3
mg/mmol
30-300
mg/g
3-30
mg/mmol
300 mg/g
>30 mg/mmol
Persistent albuminuria - categorization, description and
range ( KDIGO 2013)

6. INVESTIGATIONS FOR CKD
 Serum urea and creatinine (increased)
 Urine analysis (for proteinuria and hematuria)
 Serum electrolytes (to identify hyperkalemia, acidosis)
 Calcium, phosphate, PTH
 Plasma albumin (to exclude malnutrition, inflammation, nephrotic syndrome)
 Full blood count (for anemia)
 Lipid profile
 Blood glucose (HBA1c)
 Renal ultrasound (If obstructive features, hematuria and suspicious family history of renal disease)
 Other tests based on history and examination.

7. CKD : MANAGEMENT PRINCIPLES
Aim to –
 Monitor renal function
 Prevent/ slow further renal damage
 Limit complications
 Treat risk factors for CVS diseases
 Prepare for RRT ( Renal Replacement Therapy) by dialysis or renal transplant
Monitor renal function
Estimation of GFR
Every 6 monthly with
stage 3 CKD
More frequently incase of
stage 4/5 CKD cases
Prevent further renal damage
 Tight blood pressure control –
-To prevent CVS disease and stroke
-In case of CKD patients with
diabetes/proteinuria > 1g/24 hrs., BP
should be maintained < 130/80 mm Hg
1st line of therapy- salt restriction
Anti-hypertensive drugs( ACEIs and
ARBs; see ADRS related to these drugs)
 Reducing proteinuria ( ACEIs, ARBs
and diuretics
Fluid and electrolyte balance
 Dietary salt restriction (< 100 mmol/24 hrs)
 Use of loop diuretics ± metolazone
 Water restriction only if there is problem with hyponatremia
 Dietary restriction of potassium below 70 mmol/24 hrs, use of kaliuretic
diuretics, avoidance of potassium supplements (including occult sources
such as dietary salt substitutes), reduction/avoidance of potassium retaining
medications.
 Low protein diet
Acid base balance
#CKD leads to metabolic acidosis due to inability of
kidney to excrete organic acids.
#Causes increased tissue catabolism, decreased
protein synthesis and bone diseases
#Plasma HCO3 should be maintained above 22mmol/liter
with NaHCO3 supplements.
Rx for calcium & phosphate
disorders
Preventive measures-
1. Low phosphate diet
2. Use of phosphate binding agents (
calcium acetate, calcium
carbonate)
3. PTH level should be maintained
between 150-300 pg./ml

8. Medicines and Other Substances to
AVOID when you have kidney disease:
1. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
such as Ibuprofen, Naproxen, Aspirin (unless
prescribed by your heart doctor); Often included
in over-the-counter (OTC) cold and cough
remedies
2. Decongestants used for cold symptoms such as
Pseudoephedrine if you have high blood
pressure/hypertension
3. Antacids and laxatives with magnesium,
phosphorus and aluminum such as Mylanta, Milk
of Magnesium, Amphogel, Fleets products
4. Alka Seltzer or baking soda/”bubbling” products
for indigestion
5. Herbal medicines and remedies
6. Vitamin and diet/food supplements
7. Contrast dye studies such as CT scans or MRI
scans with contrast – Doctors and nurses should
be alert in Emergency Room.
8. Salt substitutes since they contain potassium .
Chronic Kidney Disease
Medicines to Avoid/ Okay to Take/ Antibiotics
Medicines and Other Substances that
are OKAY to take when you have kidney
disease:
1. For pain: Acetaminophen (Tylenol) or products
containing Tylenol (as long as you do not
exceed the recommended total daily dosage
listed on the medicine label)
2. For stuffy nose/cold symptoms: try saline nose
drops/spray
3. For indigestion, try Prilosec OTC (over the
counter)
4. For constipation, start with stool softeners, can
use Miralax if needed
5. For seasoning of foods, can use fresh herbs,
pepper, onions, garlic or lemon or lime juice.
Antibiotics with Kidney Disease:
Patients should be advised to take Antibiotics only under doctors’ prescription because
some antibiotics may be required at adjustable dose while some are not safe to take.

9. FUNCTIONAL ANATOMY OF KIDNEY & CLINICAL
EXAMINATION OF KIDNEY AND URNARY TRACT