Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function lasting over 3 months. The document summarizes guidelines for staging CKD based on cause and glomerular filtration rate, evaluating CKD, managing progression through controlling blood pressure and protein intake, and addressing complications like anemia and cardiovascular disease. The timing of renal replacement therapy like dialysis depends on symptoms and declining kidney function.

1. CHRONIC KIDNEY DISEASE
Dr.Manoj Aryal MBBS ,MD
DM Resident Nephrology
Bir Hospital

2. OBJECTIVES
• Definition
• Staging of CKD
• Evaluation of CKD
• Predicting prognosis in CKD
• Management of CKD progresssion
• Complication

3. DEFINITION OF CKD
• CKD is defined as abnormalities of kidney structure or function,
present for >3 months, with implications for health.

4. STAGING OF CKD
• KDIGO guidelines recommend classification of CKD based on cause,
category of glomerular filtration rate (GFR), and albuminuria.
• Assign GFR categories as follows

5. STAGING OF CKD
• Assign cause of CKD:

6. CLINICAL PRESENTATION
• Usually asymptomatic until late stage G4 or stage G5.
• Screening of the general population for CKD is not recommended
• UK NICE: testing to people with an increased prevalence of CKD:
 Diabetes,
 Hypertension,
 previous AKI,
 CVD,
 structural renal tract disease, renal calculi, prostatic hypertrophy,
 multisystem diseases with potential kidney involvement (e.g., SLE)
 a family history of category G5 CKD, or hereditary kidney disease
 and after opportunistic detection of hematuria or proteinuria

7. CLINICAL PRESENTATION

8. EVALUATION OF CKD
Evaluation of chronicity:
• In people with GFR <60 ml/min/1.73 m2 or markers of kidney
damage, review past history and previous measurements to determine
duration of kidney disease.
 If duration is >3 months, CKD is confirmed.
 If duration is not >3 months or unclear, CKD is not confirmed. Patients
may have CKD or acute kidney diseases (including AKI) or both and
tests should be repeated accordingly.

9. EVALUATION OF CKD
Evaluation of cause
• Evaluate the clinical context, including personal and family history,
social and environmental factors, medications, physical examination,
laboratory measures, imaging, and pathologic diagnosis to determine
the causes of kidney disease.

10. EVALUATION OF CKD
Evaluation of GFR
• Recommend using serum creatinine and a GFR estimating equation
for initial assessment.

11. EVALUATION OF CKD
Evaluation of albuminuria
• Suggest using the following measurements for initial testing of
proteinuria (in descending order of preference, in all cases an early
morning urine sample is preferred) :
1) urine albumin-to-creatinine ratio (ACR);
2) urine protein-to-creatinine ratio (PCR);
3) reagent strip urinalysis for total protein with manual reading.

12. EVALUATION OF CKD
Kidney Imaging
• Imaging of the kidneys with ultrasound is useful.
 Small kidneys with reduced cortical thickness, showing increased
echogenicity, scarring, or multiple cysts, suggest a chronic process.
 Structural abnormalities such as ADPKD, hydronephrosis caused by
obstruction, or coarse renal scarring may be detected.
 NICE guidelines propose that kidney ultrasound scanning is important only in
certain circumstances and suggests counseling patients if ADPKD is suspected
before imaging.
 In some situations, imaging with computed tomography, magnetic resonance, or
angiography may be useful, taking into account the risks of administering contrast
media.

13. MANAGEMENT OF PROGRESSION
BP and RAAS interruption
• Individualize BP targets and agents according to age, coexistent CVD
and other comorbidities, risk of progression of CKD, presence or
absence of retinopathy, and tolerance of treatment.
• Inquire about postural dizziness and check for postural hypotension
regularly.
• Tailor BP treatment regimens in elderly patients and gradual
escalation of treatment and close attention to adverse events related to
BP treatment.

14. MANAGEMENT OF PROGRESSION
• Recommend that in both diabetic and non-diabetic adults with CKD
and AER <30 mg/ 24 hours whose office BP is consistently >140/90
mm Hg be treated with BP-lowering drugs to maintain a BP ≤140/90.
• Suggest that in both diabetic and non-diabetic adults with CKD and
AER >30 mg/ 24 hours whose office BP is consistently >130/80 mm
Hg be treated with BP-lowering drugs to maintain a BP ≤130/80.

15. MANAGEMENT OF PROGRESSION
• Suggest that an ARB or ACE-I be used in diabetic adults with CKD
and AER 30–300 mg/ 24 hours.
• Recommend that an ARB or ACE-I be used in both diabetic and non-
diabetic adults with CKD and AER>300 mg/24 hours.
• Insufficient evidence to recommend combining an ACE-I with ARBs
to prevent progression of CKD.

16. MANAGEMENT OF PROGRESSION
Protein intake
• Suggest lowering protein intake to 0.8 g/kg/day in adults with
diabetes or without diabetes and GFR <30 ml/min/ 1.73 m2 , with
appropriate education.
• Suggest avoiding high protein intake (>1.3 g/kg/day) in adults with
CKD at risk of progression.

17. MANAGEMENT OF PROGRESSION
Glycemic control
• Recommend a target HbA1c ~7.0% to prevent or delay progression of
the microvascular complications of diabetes, including diabetic kidney
disease.
• Recommend not treating to an HbA1c target of <7.0% in patients at
risk of hypoglycemia.
• Suggest that target HbA1c be extended above 7.0% in individuals
with comorbidities or limited life expectancy and risk of
hypoglycemia.

18. MANAGEMENT OF PROGRESSION
Salt intake
• Recommend lowering salt intake <90 mmol (<2 g) per day of sodium
(~5 g NaCl) in adults, unless contraindicated.
Hyperuricemia
• Insufficient evidence to support use of agents to lower serum uric
acid concentrations in people with CKD and either symptomatic or
asymptomatic hyperuricemia in order to delay progression of
CKD.

19. MANAGEMENT OF PROGRESSION
Lifestyle
• Recommend that people with CKD be encouraged to undertake
physical activity compatible with CV health and tolerance (aiming
for at least 30 min 5 times/week), achieve a healthy weight (BMI
20 to 25), and stop smoking.
Additional dietary advice
• Recommend that individuals with CKD receive expert dietary
advice and information in the context of an education program,
tailored to severity of CKD and the need to intervene on salt,
phosphate, potassium, and protein intake where indicated.

20. COMPLICATIONS ASSOCIATED WITH LOSS
OF KIDNEY FUNCTION
Definition and identification of anemia in CKD
• Diagnose anemia in adults and children >15 years with CKD when the
Hb concentration is <13.0 g/dl in males and <12.0 g/dl in females.
• Diagnose anemia in children with CKD if Hb concentration is <11.0
g/dl in children 0.5–5 years, <11.5 g/dl in children 5–12 years, and
<12.0 g/dl in children 12-15 years.

21. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
CKD METABOLIC BONE DISEASE
• Recommend measuring serum levels of calcium, phosphate, PTH, and
ALP activity at least once in adults with GFR <45 ml/min/1.73 m2.
• If GFR <45 ml/min/1.73 m2, suggest maintaining serum phosphate
concentrations in the normal range.
• If GFR <45 ml/min/1.73 m2 the optimal PTH level is not known.
Suggested that people with levels of intact PTH above the upper
normal limit of the assay are first evaluated for hyperphosphatemia,
hypocalcemia, and vitamin D deficiency.

22. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION

23. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
Vitamin D supplementation and bisphosphonates in CKD
• Suggest not to routinely prescribe vitamin D supplements or vitamin
D analogs, in the absence of suspected or documented deficiency, to
suppress elevated PTH concentrations in people with CKD not on
dialysis.
• Suggest not to prescribe bisphosphonate treatment in people with
GFR <30 ml/min/1.73 m2 without a strong clinical rationale.

24. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION

25. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
METABOLIC ACIDOSIS
• Suggest that in people with CKD and serum bicarbonate
concentrations <22 mmol/l, treatment with oral bicarbonate
supplementation be given to maintain serum bicarbonate within the
normal range, unless contraindicated.

26. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
CKD AND CVD
• Recommend that all people with CKD be considered at increased risk
for CVD.
• Suggest that adults with CKD at risk for atherosclerotic events be
offered treatment with antiplatelet agents unless there is an increased
bleeding risk that needs to be balanced against the possible CV
benefits.

27. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
• Suggest that the level of care for heart failure offered to people with
CKD should be the same as is offered to those without CKD.
• In people with CKD and heart failure, any escalation in therapy and/or
clinical deterioration should prompt monitoring of eGFR and serum
potassium concentration.

28. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
Non-invasive testing
• Recommend that people with CKD presenting with chest pain should
be investigated for underlying cardiac disease and other disorders
according to the same local practice for people without CKD.
• Suggest that clinicians are familiar with the limitations of non-
invasive cardiac tests (e.g., exercise ECG, nuclear imaging,
echocardiography, etc.) in adults with CKD and interpret the results
accordingly.

29. COMPLICATIONS ASSOCIATED WITH
LOSS OF KIDNEY FUNCTION
CKD AND PERIPHERAL ARTERIAL DISEASE
• Recommend that adults with CKD be regularly examined for signs of
peripheral arterial disease and be considered for usual approaches to
therapy.
• Suggest that adults with CKD and diabetes are offered regular
podiatric assessment.

30. TIMING THE INITIATION OF RRT
• Despite all attempts to optimize the management of CKD, many patients will
progress to needing RRT.
• All patients with eGFR <20 ml/ min/1.73 m2 and/or who are likely to progress to
ESRD within 12 months should receive education and counseling.
• If HD is the preferred option, AVF should be constructed, remembering that it may
take 8 to 12 weeks for veins to become adequately arterialized before needling can
be attempted.
• Similar plans need to be made for preemptive insertion of a peritoneal dialysis
catheter to allow time for healing and training before any acute need for
commencement of dialysis.

31. TIMING THE INITIATION OF RRT
• Early kidney transplantation may be associated with improved
longterm outcome, so patients should be assessed for their suitability
and, when feasible, activated on the waiting list before dialysis is
commenced.
• maximizes the chances of the potential recipient remaining in
reasonable health. The availability of a living donor should be
explored to increase the chances of preemptive transplantation before
the patient begins dialysis.
• KDIGO: living donor preemptive kidney transplantation in adults be
considered when the GFR <20 ml/min/1.73 m2 and evidence of
progressive and irreversible CKD over the preceding 6 to 12 months.

32. TIMING THE INITIATION OF RRT
• Planned early initiation of dialysis is not associated with improvement
in outcomes compared with commencement when indicated by signs
and symptoms of uremia.
• KDIGO suggests that dialysis be initiated when one or more of the
following are present:
 symptoms or signs attributable to kidney failure (serositis, acid-base or
electrolyte abnormalities, pruritus);
 inability to control volume status or BP;
 a progressive deterioration in nutritional status refractory to dietary intervention;
 or cognitive impairment.

33. REFERENCES
• Comprehensive Clinical Nephrology. 6th Edition.
• KDIGO 2012 Clinical Practice Guideline for the Evaluation and
Management of Chronic Kidney Disease

34. •THANK YOU

35. SUMMARY

36. SUMMARY

37. STAGING OF CKD

38. MANAGEMENT OF PROGRESSION
CKD and risk of AKI
• Recommend that all people with CKD are considered to be at
increased risk of AKI.
• In people with CKD, the recommendations detailed in the KDIGO
AKI Guideline should be followed for management of those at risk of
AKI during intercurrent illness, or when undergoing investigation and
procedures that are likely to increase the risk of AKI.