The document discusses chronic kidney disease, providing an introduction that defines CKD and its causes. It then covers the classification of CKD stages based on kidney damage and function. Risk factors for CKD like diabetes and hypertension are examined. Treatment options including lifestyle changes, medications and dialysis are also outlined.

1. Chronic kidney disease
Vipul sharma
M.pharm (pharmacy practice)
Manipal college of pharmaceutical sciences (MAHE), MANIPAL

2. INTRODUCTION
• Under normal conditions each of the 2 million nephrons of the kidneys work in an
organized fashion to filter, reabsorb, and excrete various solutes and water.
• The kidney is the primary regulator of sodium and water balance, as well as of acid-base
homeostasis.
• Chronic kidney disease, also called chronic kidney failure, describes the gradual loss of
kidney function.
• kidneys filter wastes and excess fluids from our blood, which are then excreted in our
urine, When chronic kidney disease reaches an advanced stage, dangerous levels of fluid,
electrolytes and wastes can build up in our body.
• Reduction of kidney mass, development of glomerular hypertension, and intratubular
proteinuria are key mechanisms responsible for the progression of CKD
• Hypertension is a frequent complication of chronic renal failure.

4. CKD CLASSIFICATION
• CKD is classified into five stages
based on the presence of kidney
structural damage (e.g.,
proteinuria) and/or kidney
function (glomerular filtration
rate).
• The use of GFR versus serum
creatinine concentration
(henceforth, serum creatinine)
to define the stages of CKD.

5. AGE GROUP RELATED CKD

6. EPIDEMIOLOGY OF CKD INDIA
• US has seen a 30% increase in prevalence of chronic kidney disease (CKD)
in the last decade.
• Unfortunately, from India there is no longitudinal study and limited data on
the prevalence of CKD.
• In India too, diabetes and hypertension today account for 40–60% cases of
CKD.
• In a recently published Screening and Early Evaluation of Kidney Disease
study the mean age of the population was 45.22 ± 15.2 years, and any
adult could participate in the study. They performed dipstick proteinuria,
and GFR calculation was with CKD-EPI equation. They found the prevalence
of CKD as 17.2% with stage 1, 2, 3, 4, 5. 43.1% of their cohort had
hypertension.

9. TREATMENT ALGORITHM

11. DIALYSIS
• Dialysis has been used since the 1940s to treat people with kidney
problems
• Dialysis performs the function of the kidneys if they’ve failed.
According to the National Kidney Foundation, end-stage kidney failure
occurs when the kidneys are performing at only 10 to 15 percent of
their normal function.
• TYPES of Dialysis: 1. Haemodialysis
2. Peritoneal dialysis
3. Continuous renal replacement therapy (CRRT)

12. 3. HEMODIALYSIS
• Hemodialysis is the most common
type of dialysis. This process uses
an artificial kidney (hemodialyzer)
to remove waste and extra fluid
from the blood. The blood is
removed from the body and filtered
through the artificial kidney. The
filtered blood is then returned to
the body with the help of a dialysis
machine.

13. 2. PERITONEAL DIALYSIS
• Peritoneal dialysis involves surgery
to implant a peritoneal dialysis
(PD) catheter into abdomen. The
catheter helps filter blood through
the peritoneum, a membrane in
abdomen. During treatment, a
special fluid called dialysate flows
into the peritoneum. The dialysate
absorbs waste. Once the dialysate
draws waste out of the
bloodstream, it’s drained from
abdomen.

14. 3. Continuous renal replacement
therapy (CRRT)
• This therapy is used primarily in
the intensive care unit for people
with acute kidney failure. It’s also
known as hemofiltration. A
machine passes the blood through
tubing. A filter then removes waste
products and water. The blood is
returned to the body, along with
replacement fluid. This procedure
is performed 12 to 24 hours a day,
generally every day.

15. SOAP (for example how to
write soap)

16. SUBJECTIVE EVIDENCE
• Admitted for elective AV fistula creation
• Left AVF-h/o bleeding with ulcer- closure done outside
OBJECTIVE EVIDENCE
• MEDICAL HISTORY: K/C/O CKD-5D on MHD- 3/7 (MON, WED, FRI).
K/C/O HTN × 20yrs on Medication.
• MEDICATION HISTORY: T. Amlong 5mg 1-0-1.
• 29/1/2020: FISTULOPLASTY- Right brachio axillary fistula with PTFE graft 6mm under LA
was done.
• Hemodialysis was done on 29/1/2020

17. ASSESSMENT

18. ASSESSMENT
• FINAL DIAGNOSIS:
CKD-5D, Bilateral small kidneys, HTN, CAD- DVD
• RISK FACTORS:
- Diabetes
- Hypertension
- Cardiovascular Disease
- Family History of Kidney Disease
- Smoking.

19. Whether the therapy is indicated or not?
Yes, the therapy was indicated
1) Fistuloplasty was done as the patient is admitted for AV fistula creation.
2) Haemodialysis was done as the patient is a K/C/O CKD- 5D.

20. ASSESSMENT OF CURRENT THERAPY
1) T. AMLODIPINE 5MG 1-0-1 (D1-D4)
Brand name: T. Amlong
Class: CCB
Indication: HTN
MOA: Amlodipine is a dihydropyridine CCB that exerts its effect by blocking
the transmembrane influx of calcium ions into cardiac and vascular smooth
muscles.
ADRs: Edema, Abdominal pain, Nausea, Fatigue

21. JUSTIFICATION:
The objective of this study was to perform a systematic literature review
to examine the effectiveness of amlodipine in lowering SBP in a variety of patient
subgroups and clinical settings. In this review of the published literature,
amlodipine monotherapy was effective in reducing SBP. Antihypertensive agents
such as amlodipine warrant consideration for the management of patients with
inadequately controlled SBP. The median daily dose was 5 mg (range, 1.25-15 mg)
in both the fixed-dose and dose-titration groups.
REFERENCE:
Levine CB, Fahrbach KR. Effect of amlodipine on systolic blood pressure. Clinical
Therapeutics; 2003 Jan;25(1):35-57.

22. 2) Aspirin(75mg)+ Atorvastatin(10mg) 0-0-1 (D1-D4)
Brand name: Ecosprin AV 75mg
Class: Aspirin(antiplatelet agent), Atorvastatin(statins)
Indication: Coronary Artery Disease(CAD).
MOA: Aspirin is a more potent inhibitor of both prostaglandin synthesis and
platelet aggregation. This prevents the conversion of arachidonic acid to
thromboxane A(2).
Atorvastatin calcium selectively and competitively inhibits HMG-CoA
reductase, a rate-limiting enzyme that converts 3-hydroxy-3-methylglutaryl-
coenzyme A to mevalonate.
ADRs: Abdominal pain, heart burn, constipation, joint pain, drowsiness
Justification: patient has CAD-DVD

23. 3) C. CALCITRIOL 0.25µg 1-0-0 (D3-D4)
Brand name: C. Elcitrol
Class: synthetic version of Vit D3
Indication: Calcium deficiency in CKD patients
MOA: Calcitriol increases blood levels of calcium by increasing the absorption
of calcium in the kidneys, increasing the absorption of calcium and phosphorus
from the intestine, and increasing the release of calcium and phosphorus from
bones.
ADRs: hypercalcemia, hypercalciuria, hyperphosphatemia.

24. JUSTIFICATION:
For more than sixty years, vitamin D, nutritional vitamin D (ergocalciferol,
cholecalciferol or calcifediol) and nonselective vitamin D receptor (VDR) activators
(calcitriol, alfacalcidol) have been used in the prevention and treatment of SGPT. The
K/DOQI and KDIGO guidelines recommended testing for vitamin D insufficiency and
deficiency in patients with CKD. In chronic kidney disease (CKD) alteration of vitamin
D metabolism is one of the most important factors in the pathogenesis of secondary
hyperparathyroidism and features of chronic kidney disease-mineral bone disease
(CKD-MBD). In addition, many observational studies have shown an association with
vitamin D disturbance, i.e. low levels of vitamin D in CKD and cardiovascular disease
(left ventricular hypertrophy and vascular calcification, hypertension and faster
progression of kidney disease). Thus, in recent years there has been renewed
interest in vitamin D metabolism and action.
• REF: Katičić D, Josipović J, Pavlović D. Vitamin D i srčanožilne bolesti. Cardiol
Croat. 2014;9:263–272.

25. 4) C. RABEPRAZOLE+ DOMPERIDONE 20/30mg 1-0-0 (D1-D4)
Brand name: C. Veloz D
Class: Rabeprazole( PPI)+ Domperidone( anti-emetic)
Indication: Gastritis
MOA: Rabeprazole suppress gastric acid secretion by inhibiting the gastric H+, K+
ATPase at the secretory surface of the gastric parietal cells.
ADRs: constipation, feeling weak, osteoporosis, low blood magnesium.

26. 5) INJ. EPOITIN ALFA 10000U ONCE WEEKLY (D2)
Brand name: Inj. EPO
Class: colony-stimulating factors
Indication: Anaemia in CKD patients
MOA: Erythropoietin (EPO) is a glycoprotein that regulates the production of red
blood cells by stimulating the division and differentiation of committed erythroid
progenitor cells in the bone marrow.
ADRs: Diarrhoea, joint pain, bone pain, muscle pain or spasms, dizziness.

27. JUSTIFICATION:
A randomized controlled study was conducted 375 subjects with CKD were
randomized equally to the three groups and treated for 44 wk; to explore the
impact of changing from TIW to QW administration on hemoglobin (Hb) control
and adverse events, subjects on TIW switched to QW after 22 wk. The Hb was
measured weekly, and the dose of epoetin alfa was adjusted to achieve and
maintain an Hb level of 11.0 to 11.9 g/dl. Results showed that administration of
epoetin alfa at QW and Q2W intervals are potential alternatives to TIW dosing for
the treatment of anemia in CKD subjects.
• REF: Pergola PE, Gartenberg G, Fu M. A randomized controlled study of weekly
and biweekly dosing of epoetin alfa in CKD Patients with anemia. Clinical Journal
of the American Society of Nephrology. 2009 Nov;4(11):1731-40.

28. 6)INJ.CEFOPERAZONE(1gm)+ SULBACTAM(500mg) IV Q12H (D2-D4)
Brand name: Inj. Sulbacef
Class: 3rd generation Cephalosporin
Indication: As Prophylaxis of AVF
MOA: Cefoporazone exerts its bactericidal effect by inhibiting the bacterial cell wall
synthesis,
Sulbactum act as a beta lactamase inhibitor, to increase the antibacterial
activity of cefoperazone against beta lactamase producing organisms.
ADRs: Hypoprothrombinemia, hypersensitivity reaction, nausea, vomiting,
diarrhea.

29. 7) INJ. ENOXAPARIN 0.2 ml @ 4pm (D3-D4)
Brand name: INJ. Clexane
Class: Low molecular weight heparin
Indication: To prevent increased bleeding risk (prophylaxis)
MOA: Enoxaparin binds to and potentiates antithrombin which irreversibly
inactivates clotting factor Xa.
ADRs: Fever, swelling in hand or feet, diarrhea.
JUSTIFICATION: A total of 72 separate acute coronary syndrome patient
admissions were retrospectively reviewed. All patients had anti-Xa levels
taken and creatinine clearance values <30 mL/min during enoxaparin therapy
anti-Xa levels can assist with dosing of enoxaparin in renally impaired
patients are effective in adjusting dosing to reach target anti-Xa levels.

30. • Ref : Jessica M Ma, Cynthia A Jackevicius. Anti-Xa Monitoring of
Enoxaparin for Acute Coronary Syndromes in Patients with Renal
Disease. Volume: 38 issue: 10, page(s): 1576-1581 Issue
published: October 1, 2004

31. 8) T. ACENOCOUMAROL 1mg 0-0-1 @ 6pm ( D3-D4)
Brand name: T. Acitrom
Class: Anti- coagulant
Indication: To prevent bleeding
MOA: Acenocoumarol inhibits the reduction of vit k by vit k reductase.
This prevents the carboxylation of certain glutamic acid residues near
the N terminal of clotting factors II, VII, IX and X.
ADRs: Nose bleed, bleeding gums, headache , dizziness .

32. • JUSTIFICATION: Evidence from randomized controlled trials supports
the efficient and safe use of warfarin and direct oral anticoagulants
(DOACs) in mild and moderate CKD Warfarin remains the first‐line
treatment in end‐stage renal disease.
• Ref : Aursulesei V, Costache II. Anticoagulation in chronic kidney
disease: from guidelines to clinical practice. Clin Cardiol.
2019;42(8):774–782. doi:10.1002/clc.23196.

33. PLANNING

34. DISCHARGE MEDICATIONS:
S.NO. Brand name Generic name Strength Frequency day
1. T. Amlong AMLODIPINE 5mg 1-0-1 continue
2. T. Ecosprin AV ASPIRIN+ ATORVASTATIN 75mg 0-0-1 continue
3. C. Elcitrol CALCITRIOL 0.25µg 1-0-0 continue
4. C. NU 36 MULTIVITAMIN SUPPLEMENT - 0-0-1 continue
5. T. Veloz D RABEPRAZOLE + DOMPERIDONE 20/30mg 1-0-1 continue
6. Inj. EPO EPOITIN ALFA 10000U S/C once weekly
7. T. Acitrom ACENOCOUMAROL 1mg 0-0-1 6PM
8. T. Poweroxime CEFUROXIME 500mg 1-0-1 5 days

35. GOALS OF THERAPY
• To control the underlying conditions such as HTN, diabetes.
• To decrease the incidence and prevalence of ESRD.
• To improve the patient quality of life.
• To delay the progression of CKD.
• To reduce the morbidity and mortality of disease.

36. MONITORING PARAMETERS
THERAPUETIC MONITORING
 Blood pressure
 Haemoglobin
 Cardiovascular disease
 Thyroid test
TOXICITY MONITORING
 Hypercalcemia, hypercalciuria,
hyperphosphatemia - CALCITROIL.
 Osteoporosis, low blood magnesium
- RABEPRAZOLE D.
 Increased risk of several deadly
diseases, such as stroke and cerebral
or pulmonary embolism - OVER USE
OF INJ. EPO.

37. POINTS TO PHYSICIAN
 Some of the studies state that rabeprazole should not be given in CKD patients as
it can lead to risk of ESRD.
A case-control study was conducted in a nation-wide data setting from the Taiwan National Health
Insurance Research Database (NHIRD) form 2006 to 2011. Results showed that PPIs use is
associated with the risk of ESRD in patients with renal diseases.
REF: Antoniou T, Macdonald EM, Hollands S, et al. Proton pump inhibitors and the risk of acute
kidney injury in older patients: a population-based cohort study. CMAJ Open 2015; 3:E166–E171.

38. POINTS TO PATIENT
•
• Drug Related: Do not stop the medication abruptly without
consulting the physician and dose shouldn’t be missed and if so take
as soon as you remember do not double the dose in case you forget
to take mediation earlier
• Diet Related: Avoid tender coconut juice and fruit juices, Low
potassium diet, Salt – 3gm/ day.
• Life Style Related: Do exercise 15 min/day and jogging

39. REFERENCES
• Jeffrey B. Halter, William R.Prediction, Progression and Outcomes of
Chronic Kidney Disease in Older Adults. JASN. June 2009:20(6):1199-
1209.
• Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al.
Prevalence of chronic kidney disease in the United States. JAMA
2007;298:2038-47.
• Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK,
Almeida AF, et al. What do we know about chronic kidney disease in
India: First report of the Indian CKD registry. BMC Nephrol
2012;13:10.

40. • Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SR, Acharya
VN, et al. Epidemiology and risk factors of chronic kidney disease in
India - results from the SEEK (Screening and Early Evaluation of Kidney
Disease) study. BMC Nephrol 2013;14:114.