Chronic Kidney Disease

Halley Willson, PharmD

Definition: 1) Presence of kidney damage or 2) eGFR < 60 mL for a Notes:

duration > 3 months -Progressive loss of kidney
Staging CKD: function, ultimately will need
dialysis or transplant
Category  GFR  Terms  -Kidney damage = pathologic
G1  > 90  Normal or high  abnormalities (image or
G2  60-89  Mildly decreased  biopsy), abnormalities in
G3a  45-59  Mildly to moderately decreased  urine sediment, or increased
G3b  30-44  Moderately to severely decreased  urinary albumin excretion.
G4  15-29  Severely decreased  -Common causes: T2DM,
G5  < 15  Kidney failure  T1DM, HTN,
glomerulonephritis, chronic
Albuminuria: tubulointerstitial nephritis,
hereditary or cystic diseases,
Category  ACR Terms 
sickle cell nephropathy
A1  < 30  Normal to mildly increased
-Prerenal = CHF or cirrhosis
A2  30 – 300  Microalbuminuria, moderately increased
(can lead to ↑ AKI)
A3  > 300  Macroalbuminuria, severely increased
-[(140-age) x wt]/(72*Cr)
Non-Pharmacological Management: Management of Comorbidities:
 Protein: Avoid intake > 1.3 g/kg/day or lower  T2DM: Target A1C < 7.0% || ACEi/ARB,
intake to 0.8g/kg/day (DM or GFR < 30) SGLT2i, or finerenone for albuminuria
 Salt: Lower intake to < 2 g/day  HTN: Target BP of <140/<90 or <130/<80 if
 Exercise: 30 min 5x per week albuminuria || ACEi/ARB for albuminuria

**Always keep renal dosing of medications in mind for CKD patients**

Complications of CKD:

Hyperphosphatemia (GFR <45), use binders when phos persistently > 5.5 (want < 4.5), 900 mg/day
Notes: Treatment: [Take with meals or will not work]
-Impaired Phos excretion -Aluminum-based: Risk of aluminum accumulation (Aluminum hydroxide)
-Mortality risk ↑ with ↑ Phos -Calcium-based: First line (Calcium acetate or carbonate) | SE: ↑ Ca
-In diet in protein-rich foods -Al + Ca-free: Expensive | (Lanthanum carbonate) SE: N/V, diarrhea
-Take with meals, TID -Sevelamer: No Al or Ca, not systemically absorbed | SE: N/V, diarrhea
Secondary Hyperparathyroidism (Routine replacement of Vit D not recommended)
Notes: Treatment:
-Kidneys can’t activate Vit D -Vit D Analogs: Calcitriol, Doxercalciferol, Paricalcitol, Calcifediol; SE: ↑ Ca
-+ ↑ Phos = lower Ca -Calcimimetic: Cinacalcet, Etelcalcetide; SE: ↓ Ca

Anemia
Notes: Treatment:
-Iron deficiency + anemia of -IV or PO iron: IV iron if TSAT < 30% and ferritin is < 500
chronic disease -ESA: If Hgb < 10, d/c if Hgb > 11; Monitor Hgb monthly on initiation
-Reduced production of
erythropoietin

Nephrotoxic Medications:

Source: KDIGO Guidelines (CKD Evaluation and Management, Anemia in CKD, Diabetes in CKD, Blood Pressure in CKD)
NSAIDs, acetaminophen, aminoglycosides, amphotericin B, vancomycin, chemotherapy (carmustine,
cisplatin), contrast dye, diuretics, ACEi/ARBs, PPI, allopurinol, phenytoin, lithium, etc.

Agents for Hypertension and/or Diabetes:

ACEi/ARB SGLT2i Finerenone

-Moderate evidence from RCT that -Empagliflozin, canagliflozin, -Proven to slow CKD progression
ACEi decrease all-cause mortality dapagliflozin RCT (EMPA-REG, in adults with T2DM (FIDELIO-
and reduces albuminuria/Cr CANVAS, DECLARE-TIMI) show DKD)
progression slowed CKD progression SE: ↑ K, hypotension
SE: Cough, angioedema, -SE: UTI, yeast infection
hypotension

Patient Case:

KL is a 68-year-old male admitted to the hospital for treatment of community-acquired pneumonia. His PMH
includes CKD, T2DM, HTN, HLD, GERD, and HF. The med rec has been completed, and the hospitalist has
resumed his home medications of metformin 1000 mg BID, metoprolol succinate 100 mg daily, furosemide 20
mg daily, famotidine 20 mg BID, atorvastatin 20 mg daily, fluoxetine 20 mg daily, ferrous sulfate 325 mg daily,
and sevelamer 800 mg TID. Home lisinopril 40 mg daily and spironolactone 25 mg daily were held due to soft
BP and elevated Cr from baseline of 1.6. Other home meds not resumed include Trulicity 3 mg weekly.

The patient was started on azithromycin 500 mg daily and ceftriaxone 1 g daily for CAP.

Vitals: Wt 68 kg Ht 172.7 cm

BP 106/58 HR 62 Temp 99.4 F

O2 96% on 2L nasal cannula

Labs: Cr 1.8 Phos 4.6 K 4.3

BUN 32 WBC 15.4 Hgb 10.2

TSAT 33 Ferritin 432 ACR 47

What is KL’s current creatinine clearance? What stage of CKD is KL in? 38 mL/min, stage G3b [43 Cl normal]

Do any of KL’s medications need to be adjusted for his renal function? Metformin (500 mg BID max),
famotidine (20 mg daily)

What is KL currently on to treat CKD related complications? Sevelamer, ferrous sulfate

Is KL an appropriate candidate for ESA therapy? No, TSAT is not < 30 and Hgb is > 10

What medication(s) would you recommend adding to KL’s therapy? SGLT2i, potentially swap spironolactone
for finerenone in the future

Conclusion:

1. CKD is a progressive disease, and it is imperative to manage lifestyle and comorbidities appropriately to
prevent deterioration to ESRD and need for dialysis.
2. Complications of CKD can include hyperphosphatemia, vitamin D deficiency, secondary
hyperparathyroidism, anemia, and more.

Source: KDIGO Guidelines (CKD Evaluation and Management, Anemia in CKD, Diabetes in CKD, Blood Pressure in CKD)
3. Nephrotoxic agents should be avoided when possible, and medications must be renally dosed as
appropriate.

Source: KDIGO Guidelines (CKD Evaluation and Management, Anemia in CKD, Diabetes in CKD, Blood Pressure in CKD)