Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for at least three months. CKD is staged from 1-5 based on glomerular filtration rate. Common causes include diabetes, hypertension, glomerulonephritis and polycystic kidney disease. Treatment focuses on slowing progression, managing complications like anemia and bone disease, and preparing for renal replacement therapy with dialysis or transplantation as kidney function declines. Dialysis modalities include hemodialysis and peritoneal dialysis (continuous ambulatory, intermittent, or continuous cycler-assisted). A kidney-friendly diet limits protein, phosphorus, potassium, sodium and may restrict fluids in later stages to slow CKD

1. CHRONIC KIDNEY
DISEASE
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Topics
• What is CKD
• Stages of CKD
• Common Causes of CKD
• Pathogenesis of CKD
• Risk factors for CKD
• Symptoms of CKD
• CKD: Complications
• Diagnostic criteria for CKD
• CKD: Treatment
• When to start Dialysis?
• Dialysis
• General Principles of Dialysis
• Dialyser
• Semipermeable Membrane
• Dialysate
• Hemodialysis
• Peritoneal Dialysis
1. Continuous Ambulatory Peritoneal Dialysis (CAPD)
2. Intermittent peritoneal dialysis
3. Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)
• Benefits of peritoneal Dialysis vs Hemodialysis
• Conservative Management
1. Management of hypertension
2. Management of glycemic control
3. Management of hyperphosphatemia
4. Management of Anemia
o KDIGO Clinical Practice guidelines for Anemia in CKD
5. Management of Hyperkalemia
6. Diet in CKD
• End Of Life Care (EOL)
• Do’s & Don’ts for CKD patients
• Do's & Don’ts for Dialysis patients

3. Chronic Kidney Disease
Definition:
Structural or functional abnormalities of the kidneys for ≥3months,
as manifested by either:
1. Kidney damage, with or without decreased GFR, as defined by:
• pathologic abnormalities
• markers of kidney damage, including abnormalities in
the composition of the blood or urine or abnormalities in
imaging tests
2. GFR of less than 60 ml/minute per 1.73m2
per body surface area
(normal is 125ml/min) .

4. Stages of Chronic Kidney Disease
Stage Description GFR
(ml/min/1.73m²
Action plan
1 Kidney Damage
with Normal or
↑GFR
>90 Diagnose and treat CKD,
treat comorbid conditions,
slow progression of CKD,
reduce cardiovascular risk
2 Mild ↓ GFR 60-89 Estimate progression
3 Moderate ↓ GFR 30-59 Evaluate and treat
complications
4 Severe ↓ GFR 15-29 Prepare for kidney
transplant
5 Kidney failure <15 or Dialysis Kidney transplant if uremia
present
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5. Common Causes of CKD
CVD and its related risk
factors
(e.g. obesity, smoking)
CVD and its related risk
factors
(e.g. obesity, smoking)
Chronic glomerulonephritis
Chronic pyelonephritis
Chronic glomerulonephritis
Chronic pyelonephritis
Renal stones &
Obstructive
uropathy
Renal stones &
Obstructive
uropathy
Acute Kidney InjuryAcute Kidney Injury
Analgesics abuseAnalgesics abuse
Diabetes Mellitus
Hypertension
Diabetes Mellitus
Hypertension
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Risk Factors for CKD

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9. CKD- Complications
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12. Treatment of Chronic Kidney Disease
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When to start Dialysis?
 Dialysis should be instituted whenever the glomerular filtration rate (GFR) is
<15 mL/min and there is one or more of the following:
• Symptoms or signs of uraemia.
• Inability to control hydration status or blood pressure.
• Progressive deterioration in nutritional status.
 In any case, dialysis should be started before the GFR has fallen to 6
mL/min/1.73m2 , even if optimal pre-dialysis care has been provided and
there are no symptoms.
KDIGO 2012 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease

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• High-risk patients e.g. diabetics may benefit from an earlier start.
• To ensure that dialysis is started before the GFR is 6mL/min, clinics
should aim to start at 8–10 mL/min.
KDIGO 2012 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease
When to start Dialysis?

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Dialysis

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General Principles of Dialysis

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• Device by which waste products are removed from the patient's blood.
• Two main compartments of any dialyser -
1. blood compartment
2. dialysate compartment
• They are separated by a semipermeable membrane.
Dialyser

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Semipermeable Membrane

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Dialysate
• Mixture of water and salts which is used for the process of dialysis.
• Identical in concentration to those found in normal blood.
• Contains very little potassium so that potassium will be removed from the
patient during dialysis across the semipermeable membrane.
• Contains no urea or any other waste product so that their removal during
dialysis is rapid.
• water used to make dialysate contains very little calcium.
• water softener is used to prepare the water for dialysis fluid.

20. Hemodialysis
Procedure
-A fistula or graft is created to access the
bloodstream
-Wastes, excess water, and salt are removed
from blood using a dialyzer.
-Hemodialysis required approx. 3 times per
week, each treatment lasting 3-5 hrs
-Can be performed at a medical facility or at
home with appropriate patient training. Complications
-Infection at access site
-Clotting, poor blood flow
- Hypotension
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21. Peritoneal Dialysis
Procedure
- Dialysis solution is transported into the
abdomen through a permanent catheter
where it draws wastes and excess water
from peritoneal blood vessels. The
solution is then drained from the
abdomen.
Three Types of Peritoneal Dialysis
 Continuous Ambulatory Peritoneal
Dialysis (CAPD)
 Intermittent peritoneal dialysis
 Continuous Cycler-Assisted Peritoneal
Dialysis (CCPD)
Complications
- Peritonitis
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Continuous ambulatory peritoneal
dialysis: Advantages
Equipment: system of dialysis is very simple and a patient does not have to learn to use
any complicated machinery.
Training: Two or three weeks is sufficient for anyone to master the system of connecting
and disconnecting the lines from the bags.
Home life: Because there is no machinery used, no modification of the patient's home is
needed. Also the patient need depend very little upon a partner to help in dialysis, thus less
strain upon the family.
Life style: avoids travel to and from a hospital or dialysis centre for haemodialysis and
gives more time to spend with family and friends.
Contd…

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Continuous ambulatory peritoneal
dialysis: Advantages
Food and drinks: more pleasant than the small quantity of fluid
possible for the haemodialysis patient.
Drugs: Often only calcium carbonate is needed.
Health: greater improvement in the anaemia of renal failure is seen in patients on CAPD
than in those treated by haemodialysis or intermittent peritoneal dialysis.
Diabetes: CAPD is the best treatment for diabetics who develop permanent renal failure.
Insulin is added to each bag so that the diabetes is very well controlled

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Intermittent peritoneal dialysis(IPD):
Advantages
• Gentle : waste products are removed much more slowly than by haemodialysis.
• IPD doesn’t cause a patient to feel 'washed out' the day after treatment as is caused by
haemodialysis.
• Easier to learn than that of haemodialysis.
• No need to gain the skill of inserting needles into a fistula.
• 'Alarms' are less frequent and hence a dialysis is less stressful.
• Can be used for virtually all patients except for those who previously have had a number of
abdominal operations.
• Patient is able to drink more fluid than a patient who receives chronic haemodialysis.

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Continuous cycle peritoneal dialysis:
Advantages
1. Gentle and the technique easy to learn.
2. Like CAPD and IPD, fluid and diet allowances are more generous than for the patient
receiving haemodialysis. The gap between each CCPD treatment is approximately 14
hours.
3. patient is able to treat himself at home without the help of a partner.
Contd…

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• Machine used is considerably smaller than that necessary
for IPD and requires little space.
• Little or no modification of a patient's home is required to perform
CCPD.
• Chance of peritonitis is very small.
• Machine is portable
Continuous cycle peritoneal dialysis:
Advantages

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Benefits of peritoneal Dialysis vs
Hemodialysis

28.  Hypertension Control
Goal: Lower Blood Pressure To <130/80 mmhg
Antihypertensive Agents
 Glycemic Control
Pre-prandial Plasma Glucose 90-130 Mg/Dl
A1c <7.0%
Peak Postprandial Plasma Glucose <180 Mg/Dl
Self-monitoring Of Blood Glucose (SMBG)
Medical Nutrition Therapy
Restrict Dietary Protein To RDA Of 0.8 G/Kg Body Weight Per Day
Conservative Management
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29. Hyperphosphatemia Management
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30. Treatment options for Anemia in patients with CKD
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 IV IRON THERAPIES
• Iron replacement
- Iron dextran
- Iron sucrose
- Sodium ferric gluconate
- Ferumoxytol
 ESA THERAPIES
o epoetin alfa
o epoetin beta
o Darbepoetin alfa
o continuous erythropoietin receptor activator (CERA)
 RED BLOOD CELL TRANSFUSION
- For severe anemia
- For acute anemia
 CORRECTION OF NUTRITIONAL DEFICIENCIES
Contd…

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Treatment options for Anemia in patients with CKD

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Hypoxia-inducible factor (HIF) gene targets

35.  Hyperkalaemia and Metabolic Acidosis :
- managed with low-potassium dietary advice, medication adjustment and sodium
bicarbonate tablets
 Regular dietetic input- Supplementation with Low protein diet (Ketoanalogues)
 Physiotherapy
 Occupational therapy
 Social work input as they become less able to care for themselves at home
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Diet in CKD

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What is a chronic kidney disease diet?
•A chronic kidney disease diet limits protein, phosphorus, sodium, and potassium.
•Liquids may also need to be limited in later stages of chronic kidney disease.
• This diet helps slow down the rate of damage to kidneys.
• Diet may change over time as health condition changes.
•Also there may be need to make other diet changes if you have other health
problems, such as diabetes.

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What kind of diet changes are needed?

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• Protein intake of 0.6-0.75 grams of protein per kilogram of body weight per day
(g/kg/d) for patients in stages 1-4 of CKD.
• In stage 5, when patients are receiving dialysis, increased protein intake is suggested
(approx. 1.2 g/kg/d).
• The average healthy person consumes the amount of protein equivalent to 1.2 g/kg/d.
• On basis of current K/DOQI recommendations, CKD patients in stages 1-4 need
dietary counselling to reduce their protein intake by about half.
What are the recommendations about dietary protein
in CKD?

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Proteins With Lower Fat and Cholesterol
Original Food Substitute Food
Regular ground beef 90% lean or greater ground
beef
Whole eggs Egg whites or egg substitute
Fried fish Fresh or frozen fish
Large portions of red meat Reduce to 3 oz (size of deck of
cards)
or leaner cuts of meat
Chicken breast to replace fatty
cuts of meat

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CARBOHYDRATES
If you do not have a problem eating carbohydrates, these foods are a good source of energy. If
your provider has recommended a low-protein diet, you may replace the calories from protein
with:
•Fruits, breads, grains, and vegetables. These foods provide energy, as well as fiber, minerals,
and vitamins.
•Hard candies, sugar, honey, and jelly. If needed, you can even eat high-calorie desserts such
as pies, cakes, or cookies, as long as you limit desserts made with dairy, chocolate, nuts, or
bananas.
What foods can I include?
Contd….

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FATS
•Fats can be a good source of calories.
• Make sure to use monounsaturated and polyunsaturated fats to protect
your heart health.
•Include healthy fats, such as unsaturated fats
o1 teaspoon margarine or mayonnaise
o1 teaspoon oil (safflower, sunflower, corn, soybean, olive, peanut, canola)
o1 tablespoon oil-based salad dressing (such as Italian) or 2 tablespoons
mayonnaise-based salad dressing (such as ranch).
Contd….

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CALCIUM AND PHOSPHOROUS
The minerals calcium and phosphorous will be checked often. Even in the early stages
of CKD, phosphorous levels in the blood can get too high.
This can cause:
•Low calcium. This causes the body to pull calcium from your bones, which can make
your bones weaker and more likely to break.
•Itching.
•Some dairy foods are lower in phosphorous, including:
oTub margarine
oButter
oCream, ricotta, brie cheese
oHeavy cream
oSherbet
oNondairy whipped toppings
Contd….

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POTASSIUM
Normal blood levels of potassium help keep your heart beating steadily. However, too much potassium can
build up when the kidneys no longer function well. Dangerous heart rhythms may result, which can lead to
death.
Fruits and vegetables contain large amounts of potassium, and for that reason should be avoided to maintain
a healthy heart.
Choosing the right item from each food group can help control your potassium levels.
When eating fruits:
•Choose peaches, grapes, pears, apples, berries, pineapple, plums, tangerines, and watermelon
•Limit or avoid oranges and orange juice, nectarines, kiwis, raisins or other dried fruit, bananas, cantaloupe,
honeydew, prunes, and nectarines
When eating vegetables:
•Choose broccoli, cabbage, carrots, cauliflower, celery, cucumber, eggplant, green and wax beans, lettuce,
onion, peppers, watercress, zucchini, and yellow squash
•Limit or avoid asparagus, avocado, potatoes, tomatoes or tomato sauce, winter squash, pumpkin, avocado,
and cooked spinach
Contd….

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FLUIDS
In the early stages of kidney failure, you do not need to limit the fluid you drink. But, as your condition gets
worse, or when you are on dialysis, you will need to watch the amount of liquid you take in.
In between dialysis sessions, fluid can build up in the body. Too much fluid will lead to shortness of breath,
an emergency that needs immediate medical attention.
Your provider and dialysis nurse will let you know how much you should drink every day. Keep a count of
foods that contain a lot of water, such as soups, fruit-flavored gelatin, fruit-flavored ice pops, ice cream,
grapes, melons, lettuce, tomatoes, and celery.
Use smaller cups or glasses and turn over your cup after you have finished it.
Tips to keep from becoming thirsty include:
•Avoid salty foods
•Freeze some juice in an ice cube tray and eat it like a fruit-flavored ice pop (you must count these ice cubes
in your daily amount of fluids)
•Stay cool on hot days
Contd….

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SALT OR SODIUM
Reducing sodium in your diet helps you control high blood pressure. It also keeps you
from being thirsty, and prevents your body from holding onto extra fluid.
Look for these words on food labels:
•Low-sodium
•No salt added
•Sodium-free
•Sodium-reduced
•Unsalted
Contd….

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59. End Of Life Care (EOL)
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60. Treatment of common EOL symptoms in CKD patients
SYMPTOM TREATMENT OPTIONS
Pruritus Antihistamines, skin lotion with
menthol, dexamethasone
Dyspnea Relaxation exercises, diuretics,
oxygen, morphine
Pain Opioids ±adjuvants
Dry mouth Artificial saliva, swabs, good local
care
Nausea, Vomiting Haloperidol at 50% normal dose,
compazine
Constipation Senokot, stool softners, lactulose,
enemas – avoid phosphosoda,
magnesium
Respiratory tract secretions Hyoscyamine 0.125 mg po or SL,
scopolamine patch
Source : data from Davidson and douglas
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Do’s for CKD

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Do's for Dialysis patients

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Don'ts for Dialysis patients

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Thank you