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Chronic Kidney Disease
Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function lasting over 3 months. CKD is evaluated based on glomerular filtration rate (GFR) and markers of kidney damage. Progression is defined as a sustained decline in GFR or a 25% drop from baseline. Management focuses on preventing progression through blood pressure control, ACE inhibitors/ARBs, glycemic control, salt restriction, and lifestyle changes like exercise and smoking cessation. Complications include anemia, bone disease, vitamin D deficiency, acidosis, cardiovascular disease, and increased risk of infection. Dialysis is initiated when symptoms develop or control of volume, pressure, or nutrition cannot be maintained.
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Chronic Kidney Disease
- 1. Chronic Kidney Disease Dr. KevinT John Medicine PG (PIMS)
- 3. DEFINITION OF CKD •CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health.
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- 18. EVALUATION OF CKD •In people with GFR <60 ml/min/1.73m2 (GFRcategories G3a-G5) • markers of kidney damage • review past history • previous measurements to determine duration of kidney disease • duration is >3 months • CKD IS CONFIRMED
- 19. EVALUATION OF CKD •urinalysis to detect hematuria or pyuria , urine microscopy to detect RBC casts or WBC casts. • Ultrasound to assess kidney structure for kidney shape,size, symmetry and evidence of obstruction • Serum and urine electrolytes to assess renal tubular disorders
- 22. DEFINITION AND IDENTIFICATION OFCKD PROGRESSION • Define CKD progression based on one of more of the following • drop in GFR category accompanied by a 25% or greater drop in eGFR from baseline • Rapid progression is defined as a sustained decline in eGFR of more than 5 ml/min/1.73 m2/year • confidence in assessing progression is increased with increasing number of serum creatinine measurements and duration of follow-up.
- 23. FOLLOWUP • Assess GFRand albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression • The AER is one of the best indicators of diabetic nephropathy risk in both type 1 and type 2 diabetes
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- 26. PREVENTION OF CKDPROGRESSION • BLOOD PRESSURE • diabetic and non diabetic adults with CKD and urine albumin excretion < 30mg/24 hours treated with BP- lowering drugs to maintain a BP that is consistently<140mm and diastolic <90. • CKD and with urine albumin excretion of >30mg/24 hours maintain a BP <130/80mmhg
- 27. • Use ofARB or ACE-I in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours • If diabetic, albuminuria 30-300mg /24 hrs is indicated for ACE/ARBI • electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and drug side effects has be given close attention in CKD to prevent adverse effects of antihypertensive therapy.
- 28. CKD and riskof AKI • All CKD patients are at risk for AKI • All reversible precipitating factors has to be avoided
- 29. Protein intake inCKD • protein intake restriction to 0.8 g/kg/day in adults with diabetes or without diabetes and GFR <30 ml/min/ 1.73 m2. • avoid high protein intake (1.3 g/kg/day) in adults with CKD at risk of progression
- 30. Diabetic control • Glycemiccontrol improves outcomes in people with diabetes with or without CKD • In people with CKD and diabetes, glycemic control should be part of a multifactorial intervention • Blood pressure control and cardiovascular risk, ACE-I,ARBS,Statins and antiplatelet therapy to be used where clinically indicated • Recommended target (HbA1c)at 7.0% and not less to prevent hypoglycaemia and to delay progression of the microvascular complications of diabetes, including diabetic kidney disease
- 31. Salt intake • Saltlowering intake to <2 g per day of sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated.
- 32. • Individuals withCKD should receive expert dietary advice and information as a education program, based on severity of CKD and the need to intervene on salt,phosphate, potassium, and protein intake where indicated.
- 33. • Patients withCKD be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30minutes 5 times per week), • BMI - 20 to 25, and • Stop smoking
- 34. COMPLICATIONS ASSOCIATED WITHLOSS OF KIDNEY FUNCTION • CKD are prone to develop a variety of complications which reflect loss of endocrine or exocrine function of the kidney.
- 35. Anaemia Diagnose anemiain adults and children >15 years when the Hb concentration is • <13.0 g/dl in males • <12.0 g/dl in females. Blood Hb monitoring in CKD • when clinically indicated in people with GFR >60 ml/min/1.73 m2 • at least annually in people with GFR 30-59 ml/min/1.73 m2 • at least twice per year in people with GFR<30 ml/min/1.73 m2
- 36. Anaemia (Cont) • Work-upfor anemia in CKD • Iron replacement therapy if indicated • ESA therapy is not recommended in those with active malignancy • ESAs should not be used to increase the Hb concentration above 11.5g/dl
- 37. CKD METABOLIC BONEDISEASE • Changes in bone mineral metabolism and alterations in calcium and phosphate homeostasis occur early in the course of CKD and progress as kidney function decline • serum levels of calcium,phosphate, PTH, and alkaline phosphatase activity at least once in adults with GFR o45 ml/min/1.73 m2. • Aluminium hydroxide, Calcium citrate, Magnesium carbonate,calcium acetate phosphrus binders are used
- 38. Vit D hypovitaminosois •As CKD progresses, levels of 1,25(OH)2D progressively fall • Deficiency of 25(OH)D increases fracture risk and is associated with increased mortality • In vitamin D-deficient subjects supplementation with vitamin D increases BMD and muscle strength, reduces risk for fractures reduces, and reduces PTH.
- 39. Acidosis • Severity ofmetabolic acidosis in people with CKD progressively rises as GFR falls. • Chronic metabolic acidosis is associated with increased protein catabolism, uremic bone disease, muscle wasting, chronic inflammation, impaired glucose homeostasis, impaired cardiac function, progression of CKD, and increased mortality • In CKD with serum bicarbonate concentrations <22 mmol/l ,oral bicarbonate supplementation be given to maintain serum bicarbonate within the normal range
- 40. Cardiovascular disease • HeartOutcomes Prevention • Evaluation (HOPE) study demonstrated that any degree of albuminuria is a risk factor for cardiovascular events in individuals with or without diabetes
- 41. • 1. Smokingcessation • 2. Exercise • 3. Weight reduction to optimal targets • 4. Lipid modification recognizing that the risk reduction associated with statin therapy in adults with CKD • 5. Optimal diabetes control HbA1C o7% (53 mmol/mol) • 6. Optimal BP control to o140/90 mm Hg or o130/80 • mm Hg in those with CKD and depending on the degree • of proteinuria (see Recommendations 3.1.4 and 3.1.5) • 7. Aspirin is indicated for secondary prevention but not • primary prevention • 8. Correction of anemia to individualized targets
- 42. Peripheral arterial disease •CKD patients are at high risk of developing PAD • Regularly examined for signs of peripheral arterial disease • Patients with CKD and diabetes are offered regular podiatric assessment
- 43. MEDICATION MANAGEMENT ANDPATIENT SAFETY IN CKD
- 44. • All adultswith CKD should be annually vaccinated with influenza vaccine,unless contraindicated. • They should receive vaccination with polyvalent pneumococcal vaccine and hepatitis B.
- 45. TIMING THE INITIATION OFRRT Dialysis be initiated when one or more of the following are present: • serositis, pericarditis • acidbase or electrolyte abnormalities • Pruritus • Inability to control volume status or blood pressure • a progressive deterioration in nutritional status refractory to dietary intervention • cognitive impairment
- 46. TIMING THE INITIATION OFRRT • Living donor preemptive renal transplantation in adults • GFR is <20 ml/min/1.73 m2, • evidence of progressive and irreversible CKD over the preceding 6-12 months
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Editor's Notes
- #3 This figure represents the current conceptual model of CKD and the continuum of development, progression, and complications of CKD and strategies to improve outcomes. Horizontal arrows between circles represent development, progression, and remission of CKD. Left-pointing horizontal arrowheads signify that remission is less frequent than progression. Diagonal arrows represent occurrence of complications of CKD, including drug toxicity, endocrine and metabolic complications, cardiovascular disease, and others such as infection, cognitive impairment, and frailty. Complications might also arise from adverse effects of interventions to prevent or treat the disease.
- #17 For most clinical circumstances, estimating GFR from serum creatinine (SCr) is appropriate for diagnosis, staging, and tracking the progression of CKD. However, like all diagnostic tests, interpretation is influenced by varying test characteristics in selected clinical circumstances and the prior probability of disease. In particular, an isolated decreased eGFR in otherwise healthy individuals is more likely to be a false positive than in individuals with risk factors for kidney disease or markers of kidney damage. Confirmation of decreased eGFR by measurement of an alternative endogenous filtration marker (cystatin C) or a clearance measurement is warranted in specific circumstances when GFR estimates based on SCr are thought to be inaccurate and when decisions depend on more accurate knowledge of GFR, such as confirming a diagnosis of CKD, determining eligibility for kidney donation, or adjusting dosage of toxic drugs that are excreted by the kidneys. Pediatric considerations: The use of SCr and recently derived pediatric specific GFR estimating equations, which incorporate a height term, are preferred over the use of SCr alone in the initial assessment of pediatric renal function (see KDIGO 2012 CKD Guideline, Reference Keys on p. ix)
- #18 For adults: Use the following measurements for initial testing of proteinuria (in descending order of preference, in all cases an early morning urine sample is preferred): urine albumin-to-creatinine ratio (ACR); urine protein-to-creatinine ratio (PCR); reagent strip urinalysis for total protein with automated reading; reagent strip urinalysis for total protein with manual reading. Urine albumin measurement provides a more specific and sensitive measure of changes in glomerular permeability than urinary total protein. There is substantial evidence linking increased albuminuria to outcomes of CKD and there is also evidence that urinary albumin is a more sensitive test to enable detection of glomerular pathology associated with some other systemic diseases including diabetes, hypertension and systemic sclerosis. For children: Use the following measurements for initial testing of proteinuria in children (in descending order of preference): urine PCR, early morning urine sample preferred; urine ACR, early morning urine sample preferred; reagent strip urinalysis for total protein with automated reading; reagent strip urinalysis for total protein with manual reading. Currently urinary PCR should be favored over urine ACR in children. Unlike in adults where powerful evidence exists in support of the use of measures of albumin rather than total protein to predict adverse outcomes, this level of evidence is currently lacking in children.
- #21 For all CKD complications, prognosis will vary depending on: 1) cause; 2) GFR; 3) degree of albuminuria; and 4) other comorbid conditions. Risk for kidney disease endpoints, such as kidney failure and AKI, is predominately driven by an individual patient’s clinical diagnosis, GFR, and the degree of albuminuria or other markers of kidney damage and injury. For cardiovascular disease, risk will be determined by history of cardiovascular disease and traditional and non-traditional cardiovascular disease risk factors. For other conditions, the risk will be determined by risk factors specific for those conditions. For all conditions, the cause of CKD, GFR category and albuminuria category will still have important influence as “risk multipliers,” but will have smaller overall influence on disease prediction than risk factors specific for the condition. All these conditions have an impact on life expectancy and quality of life and contribute substantially to predicting the prognosis of CKD. Pediatric considerations: The rationale and principles behind this statement would apply to pediatrics though the data are not available.
- #22 For all CKD complications, prognosis will vary depending on: Cause of CKD; GFR category; Albuminuria category; Other risk factors and comorbid conditions. The risk associations of GFR and albuminuria categories appear to be largely independent of one another. Therefore, neither the category of GFR nor the category of albuminuria alone can fully capture the prognosis for a patient with CKD. All of the parameters above have an impact on life expectancy and quality of life and contribute substantially to predicting the prognosis of CKD. Key to color grid: Colors indicate groups of patients at higher risk of major outcomes: Green represents low risk. If the patient does not have other markers of kidney disease, then CKD is not diagnosed or confirmed. Compared with the Green box (eGFR>60 ml/min/1.73 m2 and ACR<30 mg/g [<3 mg/mmol]): Yellow = is one step away from normal down or across. It represents moderately increased risk. Orange = is two steps away from normal: down two, across two, or down one/across one. It represents high risk. Red = is three steps away from normal. It represents very high risk.
- #25 General parameters to monitoring people with CKD: Assess GFR and albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression, and/or where measurement will impact therapeutic decisions. More frequent measures of eGFR and albuminuria should be considered in patients with a lower GFR and greater albuminuria as these people are more likely to progress. Frequency of measurement should also be individualized based on the patient history and underlying cause of kidney disease. Recognize that: Regular monitoring of stable patients may include more frequent monitoring than annually, but will be dictated by underlying cause, history, and estimates of GFR and ACR values obtained previously. Small fluctuations in GFR are common and are not necessarily indicative of progression. CKD progression is defined based on one of more of the following: Decline in GFR category (≥90, 60–89, 45–59, 30–44, 15–29, <15 ml/min/1.73 m2). A certain drop in eGFR is defined as a drop in GFR category accompanied by a 25% or greater drop in eGFR from baseline. Rapid progression is defined as a sustained decline in eGFR of more than 5 ml/min/1.73 m2/yr. The confidence in assessing progression is increased with increasing number of serum creatinine measurements and duration of follow-up. Note: These are general parameters only based on expert opinion and must take into account underlying comorbid conditions and disease state, as well as the likelihood of impacting a change in management for any individual patient. Not all individuals with CKD require close surveillance and monitoring; clinical context remains an important modifier for all recommendations.