learning slides

1. CHRONIC KIDNEY
DISEASE
29TH JULY 2022
BY: DR. LUCY MURUGARA

2. SCOPE
Epidemiology
Definition
Classification
Causes
Risk factors
Complications
Prevention
diagnosis
Management of CKD Progression & Complications

3. EPIDEMILOGY
Chronic kidney disease (CKD) has been recognized as a leading public health problem worldwide.
 The global estimated prevalence of CKD is 13.4% (11.7-15.1%), and patients with end-stage kidney disease
(ESKD) needing renal replacement therapy is estimated between 4.902 and 7.083 million.
Through its effect on cardiovascular risk and ESKD, CKD directly affects the global burden of morbidity and
mortality worldwide.
The global increase in this disease is mainly driven by the increase in the prevalence of diabetes mellitus,
hypertension, obesity, and aging.
But in some regions, other causes such as infection, herbal and environmental toxins are still common.
In US, More than 1 in 7, that is 15% of US adults or 37 million people, are estimated to have CKD.
 As many as 9 in 10 adults with CKD do not know they have CKD. About 2 in 5 adults with severe CKD do not
know they have CKD.
The large number of deaths is due to poor access to renal replacement therapy in developing countries

4. Definition
Chronic kidney disease is defined as the presence of kidney damage (usually detected as
urinary albumin excretion of ≥30 mg/day or equivalent) or decreased kidney function (defined
as estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) for three or more months,
irrespective of the cause.

6. staging
The stages of CKD are classified as follows :
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m 2)
Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m 2)
Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m 2)
Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m 2)
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m 2)
Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m 2 or dialysis)

7. Albuminuria categories

8. •GFR and albuminuria levels are also used when evaluating risks for overall mortality,
cardiovascular disease, end-stage kidney failure, acute kidney injury, and the progression of CKD.
• Patients with CKD should be referred to a nephrologist when the estimated glomerular filtration
rate (eGFR) is <30 mL/min/1.73 m2 in order to discuss and potentially plan for kidney
replacement therapy

9. 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. (Not Graded
Define CKD progression based on one or more of the following: Decline in GFR category (≥90
[G1], 60-89 [G2], 45-59 [G3a], 30-44 [G3b], 15-29 [G4], <15 [G5] ml/min/1.73m2).
 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/1.73m2/year.
The confidence in assessing progression is increased with increasing number of serum
creatinine measurements and duration of follow-up.

10. causes
Diseases and conditions that cause chronic kidney disease include:
Type 1 or type 2 diabetes
High blood pressure
Glomerulonephritis , an inflammation of the kidney's filtering units (glomeruli)
Interstitial nephritis, an inflammation of the kidney's tubules and surrounding structures
Polycystic kidney disease or other inherited kidney diseases
Prolonged obstruction of the urinary tract e.g. in enlarged prostate, kidney stones and some
cancers
Vesicoureteral reflux, a condition that causes urine to back up into your kidneys
 pyelonephritis

11. Risk factors
Factors that can increase your risk of chronic
kidney disease include:
Diabetes
High blood pressure
Heart (cardiovascular) disease
Smoking
Obesity
Being Black, Native American or Asian
American
Family history of kidney disease
Abnormal kidney structure
Older age
Frequent use of medications that can damage
the kidneys

12. complications
Fluid retention (Anarsaca, high blood pressure, pulmonary edema)
hyperkalemia
Anemia
Heart disease
Weak bones and an increased risk of bone fractures
Low libido, erectile dysfunction or reduced fertility
CNS - difficulty concentrating, personality changes or seizures
Decreased immune response, which makes you more vulnerable to infection, malignancy
Pericarditis
Pregnancy complications
end-stage kidney disease
Death

13. prevention
To reduce the risk of developing kidney disease:
Follow instructions on over-the-counter medications or a prescribed by doctor
Maintain a healthy weight.
Don't smoke.
Manage your medical conditions with your doctor's help, If you have diseases or conditions
that increase your risk of kidney disease,

14. Signs and symptoms
Patients with CKD stages 1-3 are generally asymptomatic, if symptomatic, they are often non-specific
Nausea
Vomiting
Loss of appetite
Fatigue and weakness
Sleep problems
Urinating more or less
Decreased mental sharpness
Muscle cramps
Swelling of feet and ankles
Dry, itchy skin
High blood pressure (hypertension) that's
difficult to control
Shortness of breath, if fluid builds up in the
lungs
Chest pain, if fluid builds up around the lining
of the heart

15. Signs and symptoms
Signs of metabolic acidosis in stage 5 CKD include the following:
Protein-energy malnutrition
Loss of lean body mass
Muscle weakness
Signs of alterations in the way the kidneys are handling salt and water in stage 5 include the
following:
Peripheral edema
Pulmonary edema
Hypertension

16. Anemia in CKD is associated with the following:
Fatigue
Reduced exercise capacity
Impaired cognitive and immune function
Reduced quality of life
Development of cardiovascular disease
New onset of heart failure or the development of more severe heart failure
Increased cardiovascular mortality

17. Other manifestations of uremia in ESRD:
Pericarditis
Encephalopathy:
Peripheral neuropathy, usually asymptomatic
Restless leg syndrome
Gastrointestinal symptoms: Anorexia, nausea, vomiting, diarrhea
Skin manifestations: Dry skin, pruritus, ecchymosis
Fatigue, increased somnolence, failure to thrive
Malnutrition
Erectile dysfunction, decreased libido, amenorrhea
Platelet dysfunction with tendency to bleeding

18. Diagnosis
History and physical examination
Complete blood count (CBC)
Basic metabolic panel – U/E/Cs, eGFR
Urinalysis
Serum albumin levels
Lipid profile
Serum calcium and phosphate
25-hydroxyvitamin D
Alkaline phosphatase
Intact parathyroid hormone (PTH) levels

19. Others
Serum and urine protein electrophoresis and free light chains: Screen for a monoclonal protein
possibly representing multiple myeloma
Antinuclear antibodies (ANA), double-stranded DNA antibody levels: Screen for systemic lupus
erythematosus
Serum complement levels: Results may be depressed with some glomerulonephritides
Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody (C-ANCA and P-ANCA)
levels: Positive findings are helpful in the diagnosis of granulomatosis with polyangiitis (Wegener
granulomatosis); P-ANCA is also helpful in the diagnosis of microscopic polyangiitis
Anti–glomerular basement membrane (anti-GBM) antibodies: Presence is highly suggestive of
underlying Goodpasture syndrome
Hepatitis B and C, human immunodeficiency virus (HIV), Venereal Disease Research Laboratory
(VDRL) serology: Conditions associated with some glomerulonephritides

20. Imaging studies
Renal U/S: Useful to screen for hydronephrosis, which may not be observed in early obstruction
or dehydrated patients; or for involvement of the retroperitoneum with fibrosis, tumor, or
diffuse adenopathy; small, echogenic kidneys are observed in advanced kidney failure
pyelography: useful in cases with high suspicion for obstruction despite negative renal
ultrasonograms, for diagnosing renal stones
CT scan: Useful to better define renal masses and cysts usually noted on ultrasonograms; also
the most sensitive test for identifying kidney stones
MRI: Useful in patients who require a CT scan but who cannot receive intravenous contrast;
reliable in the diagnosis of renal vein thrombosis
Renal radionuclide scanning: Useful to screen for renal artery stenosis when performed with
captopril administration; also quantitates the renal contribution to the GFR

21. Biopsy indications
kidney impairment and/or proteinuria approaching the nephrotic range
diagnosis is unclear after appropriate workup

22. management
General management of the patient with CKD involves the following issues
• Treatment of reversible causes of kidney failure
• Preventing or slowing the progression of kidney disease
• Treatment of the complications of kidney failure
• Adjusting drug doses when appropriate for the level of estimated glomerular filtration rate (eGFR)
• Identification and adequate preparation of the patient in whom kidney replacement therapy will be
required
Management of CKD requires a multidisciplinary approach.

23. Management of CKD complications
Anemia: When the hemoglobin level is below 10 g/dl, treat with erythropoiesis-stimulating
agents (ESAs), which include epoetin alfa and darbepoetin alfa after iron saturation and ferritin
levels are at acceptable levels
Hyperphosphatemia: Treat with dietary phosphate binders and dietary phosphate restriction
Hypocalcemia: Treat with calcium supplements with or without calcitriol
Hyperparathyroidism: Treat with calcitriol or vitamin D analogues or calcimimetics
Hypertension is present in approximately 80 to 85% of patients with CKD. ACEIs & ARBs are
recommended

24. Hyperlipidemia - Use statins
Fluid overload: Treat with loop diuretics or ultrafiltration
Metabolic acidosis: Treat with oral alkali supplementation e.g. sodium bicarbonate
Uremic manifestations: Treat with long-term renal replacement therapy (hemodialysis,
peritoneal dialysis, or renal transplantation

25. Infection and vaccination — Patients with CKD are at increased risk for infection that increases
with the decline in kidney function(Pul’ &GUT). Vaccination is important
2012 KDIGO guidelines
• Adults with all stages of CKD should be offered annual vaccination with influenza virus unless
contraindicated.
• Adults with stage 4 and 5 CKD who are at high risk of progression of CKD should be immunized
against hepatitis B and the response confirmed by immunologic testing.
• Adults with CKD stages 4 and 5 should be vaccinated with polyvalent pneumococcal vaccine unless
contraindicated. Patients who have received pneumococcal vaccination should be offered
revaccination within five years.
REFERRAL TO A NEPHROLOGISTS
◦ Patients with CKD should be referred to a nephrologist when the estimated glomerular filtration rate
(eGFR) is <30 mL/min/1.73 m2 in order to discuss and potentially plan for kidney replacement therapy

26. Indications for renal replacement therapy include the following:
Severe metabolic acidosis
Hyperkalemia
Pericarditis/ Pleuritis (URGENT)
Encephalopathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in
severe, cases, seizures(URGENT)
Intractable volume overload
Hypertension poorly responsive to antihypertensive medications

27. Failure to thrive and malnutrition
Persistent nausea and vomiting
Peripheral neuropathy
A clinically significant bleeding diathesis attributable to uremia (urgent indication).
In asymptomatic patients, a GFR of 5-9 mL/min/1.73 m², irrespective of the cause of the CKD
or the presence or absence of other comorbidities
Relative indications for the initiation of dialysis include decreased attentiveness and cognitive
tasking, depression, persistent pruritus, or the restless leg syndrome

28. Dialysis should be initiated in the patient with symptoms and/or signs due to uremia.
To help avoid the onset of possible life-threatening complications of uremia, dialysis should be
initiated in the asymptomatic patient with an extremely low eGFR, such as an eGFR of
approximately 8 to 10 mL/min/1.73 m2

29. Replacement therapy
The 2015, KDOQI guidelines recommend that patients with an estimated glomerular filtration
rate (eGFR) <30 mL/min/1.73 m2 should be educated on replacement therapy
Replacement therapy: hemodialysis, peritoneal dialysis and renal transplant
Kidney transplantation is the treatment of choice for ESKD.
Patient declining replacement therapy should be offered conservative management ( KDIGO,
2012).
Conservative care includes the management of symptoms, advance-care planning, and
provision of appropriate palliative care
There are three major types of vascular access for maintenance hemodialysis: primary
arteriovenous (AV) fistulas, AV grafts, and tunneled hemodialysis catheters

30. Arteriovenous fistulas
AVFs are the preferred form of vascular access given their significantly higher long-
term patency rates and lower rate of complications (infections).
A well-constructed radial cephalic fistula that functions for the first six months can
be expected to function for up to 20 years. routinely
The patient should be instructed on the care of the fistula e.g.
• checking for a thrill and notifying the nephrologist if this is not present.
• The arm that has the fistula should not be used for blood drawing or for blood pressure
checks.
• Patients should avoid sleeping on the access arm, avoid tight clothing on the access, and
not carry anything that weighs more than 5 pounds with that arm.
 The fistula should be regularly examined by a clinician

31. Arteriovenous grafts
AV grafts are constructed by interposing a graft between an artery and vein, most commonly
polytetrafluoroethylene (PTFE).
provide excellent vascular access in patients who have inadequate vascular anatomy to support
an AV fistula.
AV grafts have a higher long-term complication rate (eg, infection, thrombosis) compared with
primary fistulas.
patient should be instructed in the care of the AV graft
The graft should be regularly examined by a clinician.

32. Tunneled hemodialysis catheters
This can be used immediately after placement (in the right internal jugular vein).
Are primarily used as intermediate-duration vascular access during maturation of AV fistulas.
They can also provide acceptable long-term access in patients with contraindications to AV
access or those who have exhausted all available sites.
Are inferior to AV access, they provide lower flows and have higher rates of infection and other
complications.

33. Peritoneal dialysis
Catheters are placed into the abdominal cavity
can be used immediately after placement .
 However, to minimize the risk of fluid leak, it is preferable to wait at least 10 to 14 days before
beginning dialysis.
 If dialysis is required less than 10 days following catheter placement, small volume exchanges
performed in the recumbent position can be performed with little risk of leak

34. Dietary recommendations in CKD
CARBOHYDRATES
If your provider has recommended a low-protein diet, you may replace the calories from
protein by eating carbohydrates
PROTEINS - a low-protein is recommended
FATS -Fats can be a good source of calories. Use monounsaturated and polyunsaturated fats
(olive oil, canola oil, sunflower oil)

35. CALCIUM AND PHOSPHOROUS
Hyperphosphatemia in CKD leads to hypocalcemia
Patient is advised to limit phosphorus intake by limiting dairy foods e.g. yogurt, and cheese.
calcium supplements may be require to prevent bone disease, and
vitamin D to control the balance of calcium and phosphorous in your body.
"phosphorous binders" may be recommended if diet changes alone do not work to control the
balance of this mineral in your body.

36. FLUIDS
No fluid limitation is required in the early stages of CKD.
In advanced stages and when on dialysis, patient needs to watch the amount of liquid he/she takes in.
Take fluids as recommended
Patient should 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

37. SALT OR SODIUM
Sodium intake reduction helps control high blood pressure.
It also keeps you from being thirsty, and prevents your body from holding onto extra fluid.
 When buying foods look for these words on food labels: Low-sodium, No salt added, Sodium-
free, Sodium-reduced, Unsalted
Check all labels to see how much salt or sodium foods contain per serving.
 Also, avoid foods that list salt near the beginning of the ingredients.
Look for products with less than 100 milligrams (mg) of salt per serving.
DO NOT use salt when cooking and take the salt shaker away from the table. Most other herbs
are safe, and you can use them to flavor your food instead of salt.
DO NOT use salt substitutes because they contain potassium. People with CKD also need to
limit their potassium.

38. POTASSIUM
 Hyperkalemia is associated with arrhythmias – death.
Fruits and vegetables contain large amounts of potassium, and for that reason should be avoided or
chosen carefully to maintain a healthy heart.
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
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,
and cooked spinach

39. IRON
 anemia in KF requires extra iron.
Sources of iron - liver, beef, pork, chicken, lima and kidney beans, iron-fortified cereals.

40. DIETARYRECOMMENDATIONSFOR ADULTPATIENTSWITHCHRONICRENAL FAILURE WHO
ARE NOT ON DIALYSIS
Nutrient Recommendation
Protein 0.6–0.8 g/kg/day
Calories 35 kcal/kg/day
Phosphorus 0.8–1.2 g/day
Calcium 1.2–1.6 g/day
Sodium 1–3 g/day
Potassium <60 mEq/day (restricted if serum potassium level is
elevated or urinary output is <1 L/day)

41. DIETARYRECOMMENDATIONSFOR ADULTSWITHEND-STAGE RENALDISEASE ON DIALYSIS
Nutrient Recommendation for Hemodialysis Recommendation for
Peritoneal Dialysis
Protein 1.1–1.4 g/kg/day 1.2–1.5 g/kg/day
Calories 30–35 kcal/kg/day 25–35 kcal/kg/day
Phosphorus <17 mg/kg/day <17 mg/kg/day
Calcium 1.0–1.8 g/day 1.0–1.8 g/day
Fluid Daily urinary output + 500–750 mL/day 2–3 L/day based on
weight and blood pressure
Sodium 2–3 g/day 3–4 g/day based on weight
Potassium 40 mg/kg Unrestricted unless elevated

43. REFERENCES
Uptodate, overview of chronic kidney disease https://www.uptodate.com/contents/overview-
of-chronic-kidney-disease-
https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-
20354521
KDIGO CKD GUIDELINES, 2014.
American Dietetic Association. Manual of Clinical Dietetics. 6th ed. Chicago, IL: Academy of
Nutrition and Dietetics; 2000.