Chronic Kidney Disease

Chronic Kidney Disease

► A 54 year old woman is evaluated for a Cr of 1.3; 18
months ago it was 0.9. She has a 5 year history of DM 2,
dyslipidemia and HTN well controlled with lisinopril, HCTZ,
and atenelol. She is also on glipizide and simvastatin.
Hemoglobin is normal. What is the most appropriate for
this patient?
 24 hour collection for proteinuria
 Kidney USG
 Measurement of Urine micro albumin
 SPEP
 Measurement of HbA1C
► In the United States, there is a rising incidence and
prevalence of Kidney Disease.
► Nearly 350,000 of these are on dialysis.
► Also, there is an increasing prevalence of earlier stages of
chronic kidney disease which unfortunately is “under-
diagnosed” and “under-treated” in the United States.
► In 2000, the National Kidney Foundation (NKF) Kidney
Disease Outcomes Quality Initiative (K/DOQI) Advisory
Board approved development of clinical practice guidelines
to define chronic kidney disease and to classify stages in
the progression of chronic kidney disease.
Stages of Chronic Kidney Disease
Stage 1 Kidney damage with GFR ≥ 90 ml/min/1.73
normal or ↑ GFR m2
Stage 2 Kidney damage with GFR 60-89

mild ↓ GFR
Stage 3 Moderate ↓ GFR GFR 30-59
Stage 4 Severe ↓ GFR GFR 15-29
Stage 5 Kidney failure GFR <15 (or dialysis)

Causes of End Stage Renal Disease
100%
90% Other
80%
70% Interstit N
60% Cystic KD
% 50% GN
40% BP
30%
Diabetes
20%
10%
0%
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Al hi ac
k is a ian
W Bl A Ind
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Am
USRDS Annual Data Report
► Many terms are used to describe states of

reduced glomerular filtration (GFR) not requiring
renal replacement therapy;
 Chronic Renal Insufficiency
 Chronic Renal Failure
 Renal Insufficiency
 Pre dialysis renal disease
 Pre uremia
 Renal dysfunction
► They are imprecise & poorly defined.
► Measurement of GFR
 Gold standard is Inulin Iothalamate.
 Creatinine Clearance calculated by timed (24h) urine
collection along with serum collection for Creatinine.
 Overestimate GFR when CKD is severe due to an
increase in tubular secretion of creatinine.
 This factor can be corrected by cimetidine.
► Estimation of GFR
 More than 10 formulae for estimation of GFR.
 MDRD most widely accepted now.
CKD – Risk Factors
► Diabetes Mellitus ► Family history of CKD
► Hypertension ► Kidney Stones
► Cardiovascular Disease ► Infections like Hep C
► Obesity and HIV
► Metabolic Syndrome ► Autoimmune diseases
► Age and Race ► Nephrotoxics like
► Acute Kidney Injury

NSAIDS
► Malignancy
CKD - Causes
► Diabetic
► Non Diabetic
 Glomerular
►Nephritic:PIGN, IgA, MPGN
►Nephrotic: FSGS, Membranous, Amyloidosis
 Tubulointerstitial: Analgesic, Reflux, Ch. Obs

 Vascular: Vasculitis, HTN, RAS
 Cystic: ADPKD
 CKD in transplantation
CKD - Causes
CKD - Manifestations
► Abnormal Sodium-Water metabolism
 Edema, Hypertension
► Abnormal Acid-base abnormalities
 Metabolic Acidosis due to uremia or RTA
► Abnormal hematopoesis
 Anemia of CKD
► Cardiovascular Abnormalities
 LVH, CAD, Diastolic Dysfunction
► Abnormal Calcium-Phosphorus metabolism
 Hyperphosphatemia, pruritus, arthralgia
 Hyperparathyroidism
 Renal Osteodystrophy
CKD - Management
CKD - Management
► Diagnostic work up to decide underlying etiology

► Treatment of Hypertension and Dyslipidemia
► Treatment of Anemia
► Treatment of Hyperphosphatemia
► Avoidance of Dehydration & Nephrotoxic agents
► Proper Dosing of Drugs
► Preparation for Renal Replacement Therapy
CKD - Evaluation
CKD - Evaluation
► Serum electrolytes
► Urine spot protein analysis (24 hour no longer
recommended).
► ANA, C3, C4
► SPEP, UPEP
► Kidney Ultrasound
► Urine sediment analysis
► Biopsy
 Evidence of glomerular disease without diabetes
 Sudden onset of nephrotic syndrome or glomerular
hematuria
CKD - Management

CKD - Hypertension
► Anti-Hypertensive Agents
 Single most important measure could be adequate BP
control
 Target BP <130/80 with minimal proteinuria and
BP<125/75 with significant proteinuria (>1g).
 ACEIs and ARBs have been demonstrated to slow both
diabetic and non-diabetic renal disease in both
experimental and human studies.
 Decrease the sodium intake to 2.5 g /day
 Usually requires more than 2 medications.
 Diuretics enhance the antihypertensive and
antiproteinuric effects of other agents..
CKD - Dyslipidemia
► Dyslipidemia and Cardiovascular morbidity
 Several studies like the 4D study showed no
benefit of statins in dialysis patients.
 However, post hoc analysis of this data does
suggest that the management of dyslipidemia
in CKD 2 – 4 improves cardiac mortality and
morbidity.
 Dyslipidemia is frequently seen in glomerular
disease with proteinuria (nephrotic syndrome)
and its control reduces atherosclerosis related
morbidity and mortality.
CKD - Management

CKD - Anemia
► Decreased quality of
life with anemia.
► Diagnosis of exclusion.
► Mostly apparent in the
stage 4 and 5 of CKD.
► Due to decrease in
EPO production in the
kidney.
CKD - Anemia
► Erythropoietin
 Epoetin alfa :Procrit ® , Epogen®
 Darbepoietin Alpha: ARANESP ®
► Target Hg levels between 11g and 12g but
not exceeding 13g.
► Greater than 13g showed increased
mortality as per the CHOIR study.
► Sufficient Iron should be administered to
correct iron stores.
CKD - Management

CKD - Hyperphosphatemia
► Control of Hyperphosphatemia
 Due to decreased excretion in urine.
 Control of hyperphosphatemia by dietary measures slow
progression in experimental models of CKD.
 Hyperphosphatemia leads to pruritus, calcification in
synovial membranes, blood vessels and even cardiac
valves.
 Therapy includes Phosphorus restriction to 800mg/day
and use of phosphrous binders with food.
► Calcium Carbonate (TUMS), Ca-acetate (PHOSLO)
► Lanthanum
► Renagel
CKD – Bone and Mineral disease
► Hyperparathyroidism:
 High phosphorus and low Vitamin D causing low
calcium.
 Monitor Intact PTH levels and keep between
100 and 500.
 Maintain Phosphorus and Calcium within normal
ranges.
 Vitamin D analog paricalcitol.
 Calcimimetic agents like cinacalcet.
CKD - Management

CKD - Nephrotoxics
► Avoidance of Dehydration/Nephrotoxic Agents
 Drugs such as Aminoglycosides, NSAIDs
 Avoiding exposure to Radio contrast agents.
 In presence of dehydration, even in absence of
renovascular disease, ACEIs or ARBs can aggravate
renal dysfunction
 Dehydration is frequent in tubulo-interstitial disorders
where urinary concentration is impaired.
 Proper Dosing of Drugs eg. Allopurinol
CKD - Management

CKD – Medication Dosing
 Uremia affects GI absorption; eg Iron.
 Impaired plasma protein binding of drugs; eg Dilantin.
 Increased volume of distribution;
 Excretion of many drugs depends upon the kidney;
► Some drugs used in normal dose will lead to nephrotoxic effects
eg. Allopurinol
► Other drugs when used in normal dose will lead to other toxic
effects eg. Vancomycin.
► Dose Reduction or Interval Extension
CKD - Management

CKD - RRT
 Education for Options of Dialysis & Renal
Transplantation for Renal Replacement
 Hemodialysis Vs Peritoneal Dialysis
 Avoidance of Veni-puncture & insertion of
catheters in peripheral veins once GFR < 60mls.
 Timely placement of vascular access or PD
catheter.
CKD - RRT
► Indications (Absolute):
 Uncontrolled hyperkalemia and acidosis
 Uncontrollable hypervolemia (pulmonary edema)
 Pericarditis
 AMS and somnolence (advanced encephalopathy)
 Bleeding diathesis
► Indications (Relative):
 Nausea, vomiting and poor nutrition
 Metabolic acidosis
 Lethargy and Malaise
 Worsening kidney function <10 ml or <15 ml in diabetics
CKD - RRT
► Transplantation:
 Preemptive transplant
carries both patient and
graft survival
advantage.
 Graft survival better
with living donor
kidneys.
 Immunosuppresion is
almost always a must.
CKD - RRT
► Transplantation:
 Diseases like FSGS may reccur early in the
transplanted kidney.
 Increased risk for infection, bone loss,
cardiovascular disease.
 Contraindications:
►Malignancy (recent or metastatic)
►Current infection
►Severe extra renal disease
►Active use of illicit drugs
CKD - Summary
► In creasing prevalence of CKD in the
population.
► Early detection and prevention of
progression.
► Early involvement of nephrologists in the
care (when GFR<30).
► Treatment of Manifestations and
complications.
► Renal Replacement Therapy
 Timely referral for Access
 Timely Transplant Work up.
► A 70 yr old woman comes for F/U of recently diagnosed
CKD and HTN. She is asymptomatic. Her only medications
is Lisinopril which has been titrated to its maximum dose in
the last 3 months. She is compliant and uses salt
restriction. BP is 160/90. exam is normal except for trace
pedal edema. Cr is 1.3, K is 5 and Urine Prot is 2.1 gm.
Which of the following is the most appropriate treatment
for this patient?
 Chlorthalidone
 Losartan
 Metoprolol
 Minoxidil
 Amlodipine

Chronic Kidney Disease

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Chronic Kidney Disease

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Chronic Kidney Disease

Chronic Kidney Disease

Stage 2 Kidney damage with GFR 60-89

Stage 3 Moderate ↓ GFR GFR 30-59

Stage 4 Severe ↓ GFR GFR 15-29

Stage 5 Kidney failure GFR <15 (or dialysis)

► Many terms are used to describe states of

► Age and Race ► Nephrotoxics like

► Acute Kidney Injury

 Tubulointerstitial: Analgesic, Reflux, Ch. Obs

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

► Diagnostic work up to decide underlying etiology

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