The document provides a comprehensive overview of chronic kidney disease (CKD), including its definition, stages, symptoms, and management strategies. It highlights the importance of early referral to nephrologists, treatment of underlying conditions, and monitoring of kidney function, with a focus on hypertension and proteinuria management. The document also outlines dietary modifications, lifestyle changes, and potential complications associated with CKD, emphasizing the need for a multidisciplinary approach.

1. CHRONIC KIDNEY DISEASE INFO & TEMPLATE
OVERVIEW
CPG = an irreversiblelossof renal functionforatleastthree months.
Oxford= kidneydamage >= 3 monthsbasedon findingof abnormal structure
or GFR <60 mL/min/1.73m2
for>= 3months withorwithoutevidenceof kidneydamage.
UM express= 1. Azotemia– accum of nitrogenousproduct(chieflyurea) inblood –raisedU & C
2. Uremia – manifestationof organdysfunctiona/w azotemia
3. CRF – permanentGFRreduction/ GFR sufficienttoproduce detectablealterations
inwell-being&organ fx
4. ESRF –final stage of CKD whenptcan’t survive w/otransplant@longtermdialysis
   
[NKF-KDOQIClassification]
basedon three factors:
1. GFR (level of kidneyfunction)
2. pathological changes(kidneydamage)
3. presence of the abnormalityforatleast
three months.
- MildCKD. Asymptomatic.
- Moderate CKD.Usually
asymptomatic.
- Anemiainsome ptat 3B.
- Most are non-progressive or
progressveryslowly.
- Severe CKD.Firstsymptom
usuallyatGFR <20.
- ElectrolytesproblemsasGFRfalls
- Kidneyfailure.Significant
symptoms& complications.
- Dialysisinitiationvariesbut
usuallyatGFR <10
The kidneydamage isdefinedaseither:
a. Persistentmicroalbuminuria
b. Persistentproteinuria
c. Persistenthaematuria
d. Radiological evidence of structural
abnormalitiesof the kidneys
e.Biopsyprovenglomerulonephritis
Asymptomatic.Only
biochemical abn.
Loss of excretory,
metabolic & endocrine fx
of kidney.Leadstosx & sx
(referred as uremia)
ESRD/ESRF = when death
is likely w/o RRT

2. HISTORY
 If has prresentingcomplaint,elaborate dulu.Eg: thrombosedIJCwhile HD...
 Onset– CKD >= 3months
 Symptomsof CKD
o Usuallyassypmtomaticuntil GFR< 30 (stage 4)
o Sometimesfoundatroutine examination(raisedurea&creatinine +HPT,anemia,
proteinuria)
o Nocturia – earlysymptom–d2 lossof concentratingability&increasedoncoticload
pernephron
o Polyuria,increasedthirst
o Tiredness
o Breathlessness
 Symptomsof ESRF (uremicmanifestation)
o Metabolicacidosis:
 Proteinenergymalnutrition
 Loss of leanbodymass (anorexia)
 Muscle weakness
 Kussmaul’srespiration(unusuallydeeprespirationrelatedtometabolic
acidosis)
o Alteredsalt&waterhandling – fluidoverload:
 Peripheral edema(ankle swelling)
 Pulmonaryedema(SOB)
 Ascites(Abdominal distension)
 Hypertension (headache)
o Anemicsymptoms d2 decreasedrenal synthesisof erythropoietin:
 Fatigue
 Reducedexcercisecapacity
 Impairedcognitive& immune function
 Newonsetheartfailure/more severe heartfailure
o Othermanifestations(more likelyif inadequatelydialysed)
 General - Fatigue,increasedsomnolence,FTT
 Neuro- altered consciousness,fits,Drowsiness,Coma– Encephalopathy;
hemiparesis– stroke
 CVS- chest pain,SOB – Pericarditis &can be complicatedwithcardiac
tamponade; Coronaryarterydisease;reducedefforttolerance,orthopnea-
- symptomsof heartfailure; intermittentclaudication --peripheral vascular
disease
 GI – anorexia(malnutrition), hiccups,metallictaste (?), N& V,diarrhea
 Skin– dry skin,pruritus, ecchymosis
 Erectile dysfunction,decreasedlibido,amenorrhea,impotence/infertility
 Bone pain -- Renal osteodystrophy
 Restlesslegsyndrome/muscular twitching
 bleedingtendency-- Plateletdysfunction

3.  Identifycauses/riskfactorsforCKD
o CommoninMalaysia: long standingDM,HPT
o h/oautoimmune disorders (IgA nephropathymostcommon), systemicinfections,
drugs,neoplasia------[Glomerulardiseases]
o h/orepetitive urinarytractinfection,stones,drugtoxicity,autoimmune,
nephrocalcinosis ----- [Tubulointerstial disease]
o h/olarge vessel disease,hypertension,microangiopathy,vasculitis ----[ Vascular
diseases]
o h/oStones (lointogroinpain,dysuria,etc) oranatomical problemsof the urinary
tract --- [Urinarytract obstruction]
o Symptomsof SLE (malarrash, arthritisetc) & vasculitis ----- [systemicinflammatory
disease]
o Previousepisode of acute renal failure
o Historyof transplantedkidney –can have chronicrejection,drugtoxicity,transplant
glomerulopathy
o HereditaryKidneyDiseases, egPCKD
 inchronic cases,alsoask about:
o Course & progression
 Progressionof symptoms
 Progressionof markers.Egproteinuria,creatinineetc(espeducatedpt)
 Additionof medication, fluidrestrictions..
o Detailsaboutdialyisis
 HD/CAPD,frequency,done at..,compliance
 Int jugularcatheter/femoral catheter/AV Fistula/peritoneal dialysiscatheter
 Complicationsof hemodialysis:
 Hypotension,cardiacarrythmias,hemorrhage,airembolism, dialyser
hypersensitivity,pulmonaryedema,systemicsepsis
 Complicationsof peritoneal dialysis:
 CAPDperitonitis,catheterexitsite infection,sclerosingperitonitis
o Anyotherinterventionsdone:
 Renal transplant,lagi..?
 Functional impairment/status
o Change inqualityof life (espif starteddialysis)
o Psychosocial aspect
 PMH
o Comorbids,eg:
 DM - Glucose control,....
 HPT - Strict bloodpressure control (understandtargetBPinCKD)...
 Illnessleadingtochronicuse of NSAIDs& analgesics
o All followups&medications:
 Currentlistof medications prescribed.Eg: ace-I,ARB,etc
 OTC drugs – worsenCKD

4.  Familyhx
o Hereditaryrenal conditions
o DM, HPT,Systemcillness,etc
 Social hx
o Smoking
o Diet
PHYSICAL EXAMINATION
General – sallow(dirtybrown),Kussmaul’sbreathing,cushingoid,myoclonicjerks,hiccups
Vital signs– BP,pulsusparadoxus(inpericardialtamponade),arrythmia
Hands – palmar pallor,“half-and-half”nails(distalbrown/red,prox pink/white) @brownline
pigmentation,leukonychia,asterixis,tinel’ssign(carpal tunnelsynd)
Forearm– scratch marks(pruritus),bruising,hypertrichosis,vasculitis,AVFthrill
Face- anemia,bandkeratopathy (Cadepositbeneathcorneal epith),gumhypertrophy,
hypertensive/diabeticretinopathy
Neck– increasedJVP (fluidoverload@pericardial tamponade),Dual/triple-lumenIJC,
CVS – pericardial rub, cardiomegaly, galloprhythm, bibasal crept
Respi – Pleural effusion,,pulmonaryedema
Abdomen –tenchkoff catheter,transplantscar,ballotable kidneys, hepatosplenomegaly,loin
tenderness,prostatomegaly
Bone - vertebral tenderness
Legs– ankle edema,areflexia&reducedsensation (peripheral neuropathy) ,restlesslegs
DDX
All statedcauses of CKD

5. INVESTIGATIONS
Urine dipstick(proteinuria/hematuria)
Urine PCR / ACR
24 hr urine protein&albumin
FBC – normochromicanemia; + anemicworkup
RP – raisedurea & creatinine,hyperK+
Ca low,POhigh;PTH high
LFT – albuminlow –malnutrition
ABG – metabolicacidosis
Lipidprofile
FBS, HbA1C
Hepatiis&HIV serology –if dialysisisplanned
ECG – if hyperK/ elderly/riskfactorsforCVD
Renal ultrasound –shrunkenkidneys(kidneysenlargedinDM,PCKD,amyloidosis,myeloma,
systemicsclerosis,asymetricrenal vasculardisease)
CXR – cardiomegaly,pleural/pericardialeffusion,pulmoedema
Bone xrays – if indicated –renal osteodystrophy;considerDTPA scan
Renal biopsy – if cause isunclear& normal sizedkidneys
Othertests – to exclude ddx/causesaccordingly(if indicated).Eg:ESR,complement,
autoantibodies
MANAGEMENT
Referearlytonephrologist
Treat reversible causes:relieve obstruction,stopnephrotoxicdrugs,…
Aim: - retardprogressionof renal disease,
- reduce CVDrisk
- manage CKD-relatedcomplications
1. Treatmentof HypertensionandProteinuria inCKD
a. Can use any type of anti-HPTInHPT w/oproteinuria(choice dependsonco-morbid)
b. ACE-I/ARB(renoprotective&cardioprotective) is1st
line in:
i. non-diabeticCKD+ proteinuria ≥0.5g/day + HPT
ii. non-diabeticCKD + proteinuria≥1.0g/day irrespective of HPT
iii. DM + albuminuria(micro- ormacroalbuminuria) irrespective of CKDstage or
HPT
c. Optimal BloodPressure Range
i. <140/90 (SBP range 120-139) mmHg.
ii. <130/80 (SBP range 120 - 129) mmHg:
- inpatientswithproteinuria ≥1gram/day
- inpatientswithdiabetickidneydisease.
d. Optimal ProteinuriaReduction
i. <1 g/dayfor non-diabeticCKD
ii. NormoalbuminuriaforDKD

6. 2. Monitoringof Renal Function
a. RP at 2 wksafterstart/adjustACE-I/ARB
b. reduce or discontinue ACEi/ARBif:
i. sustained rise increatinine levelsabove 30% frombaseline
ii. or eGFR reduces>25% from baseline
iii. or serumpotassiumis>5.6 mmol/l duringthe firsttwomonthsafter
commencementof ACEi/ARB
**after excludingotherprecipitatingfactorsandrefertoa nephrologist/physician.
3. Optimal GlycaemicControl
a. Target HbA1c ≤7% inDM but thisshould be individualisedaccordingtoco-
morbidities.
4. Preventionof CoronaryArteryDisease
a. Statinfor 1o
& 2o
prevention (startterusawal2)
b. Aspirinfor2o
prevention(avoidcombinationclopidogrel +aspirininCKDunless..)
5. DietaryIntervention
a. Referdietitian
b. Low proteindiet(0.6- 0.8 g/kg/day) withadequateenergyintake (30– 35
kcal/kg/day) forCKDStage 3 – 5
c. Sodiumrestriction(notmore than 1 level teaspoonof salt addedtofood/day)
6. Lifestyle Modification !!!
a. exercise,reduceexcessweightandavoidsmoking
7. Special Precautions
a. Reviewall prescribedmedicationregularlytoensure dose is appropriate
b. AvoidNSAIDsincludingCOX-2Inhibitors(such asmefenamicacid, diclofenac,
ibuprofen,naproxen,indomethacin,ketoprofen,salicylic acid[highdose],
meloxicam, celecoxibandetoricoxib)
c. Avoidradio-contrastagentsif possible(use alternativesmethod@contrasts)
d. AvoidFleet(oral NaPO) incolono forCKDstage 4-5 (use macrogol)

7. 8. Others:
a. Anemia
i. exclude IDA &chronicinfection.
ii. considererythropoietin
b. Renal osteodystrophy
i. Treat if PTH high:RestrictdietaryPO(milk,cheese,eggs)
& give binders(Calcichew) ----bindPOingut– reduce absorption
ii. VitD analogues &Ca supplements(willreduce bone disease&hyperPTH)
c. Edema
i. highdose loopdiuretics.Eg:Frusemide 250mg-2g/24hr
ii. Restrictionof fluid&sodium
d. Restlesslegs
i. Clonazepam(0.5– 2 mg daily) orGabapentin
e. Pregnancy
i. Can considerif mildrenal impairment(creatinine <124 μmol/L) &well
controlled BP
ii. Avoidif moderate tosevere renal impairment
iii. All pregnantwomenwithCKDshouldbe co-managedbyamultidisciplinary
team
9. Prepare forrenal replacementtherapy
a. Options:
i. HD
ii. CAPD
iii. Transplant
b. Indications fordialysis (AEIOUutkAKIsbnrnya..)
i. Acidemia
ii. Electrolytes –resistanthyperK
iii. Intoxication
iv. Overload– fluidoverloadnotresponsive todiuretics
v. Uremia– symptomaticuremiadespite optimal treatment
vi. Significantimpairmentinqualityof life
10. Manage depression&otherpsychosocial aspects
a. Supportgroup
b. Refersocial/welfarebodies
c. If developsdepression,considerreferpsychiatrist/counsellors