Chronic Kidney Disease

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 Risk factors for CKD
• Diabetes
• Hypertension
• Obesity
• Advanced age (> 60 years of age)
• Substance use (smoking, alcohol, recreational drugs)
• Acute kidney injury
• Family history of CKD
• African American
Clinical features
Manifestations • Hypertension and heart failure
of Na+/H2O • Pulmonary; and peripheral edema
retention

Manifestations
of uremia
CLINICAL FEATURES
Constitutional symptoms
Fatigue
Gastrointestinal symptoms
Nausea and vomiting
Weakness Loss of appetite
Serositis Neurological symptoms
Uremic pericarditis chest pain Asterixis
worsened by inhalation Signs of uremic encephalopathy
• Physical examination findings
Friction rub on auscultation
Seizures
Somnolence
ECG changes normally seen Coma
in nonuremic pericarditis (e.g., paresthesias
diffuse ST-segment elevation) are Hematologic symptoms
not usually seen Anemia
Pleuritis Leukocyte dysfunction → ↑ risk of
Dermatological manifestations infection
Pruritus ↑ Bleeding tendency caused by
Uremic frost abnormal platelet adhesion and
aggregation
INVESTIGATION
1.General Investigations
2.Parameters of renal function
• Serum markers: ↑ creatinine and BUN
(alternatively, ↑ cystatin C)
• Glomerular filtration rate: ↓ eGFR
• Serum creatine-based eGFR (preferred)
• Serum cystatin C-based eGFR
3.Urine studies
• ↑ Spot Urine albumin to Creatinine Ratio: used to
determine the albuminuria category for CKD staging.
• ↑ Spot urine protein-to-creatinine ratio (UPCR): Nephrotic-
range proteinuria may be seen.
• Urine dipstick: may show hematuria or proteinuria
• Urine microscopy: may show abnormal urine sediment, e.g.,
the presence of waxy casts
4.Ultrasound of the kidneys and urinary tract
• First-line imaging technique for the assessment of kidney structure
• Consider obtaining for all patients to further support the diagnosis and
help determine the etiology.
• Findings that suggest chronic kidney damage include:
• ↓ Kidney length (< 10 cm)
• ↓ Parenchymal and/or cortical thickness
• ↑ Cortical echogenicity
• Cysts
• Calcifications
Findings that suggest specific etiologies
• Ureteral or renal pelvic dilation suggests obstructive nephropathy.
• Bilaterally enlarged kidneys with multiple cysts suggest polycystic kidney
disease
5.Investigation for specific underlying cause
MANAGEMENT
 1.Nutritional management
Fluid intake: Ensure appropriate fluid intake and avoid dehydration.
• Protein and energy consumption
• Mediterranean diet, ↑ fruit and vegetable intake
Protein restriction (e.g., 0.55–0.60 g/kg/day) in patients with CKD
category G3–G5
Electrolytes
• Sodium restriction (< 2.3 g/day)
• Potassium intake adjustment
• Phosphorus intake adjustment
Micronutrients: Consider multivitamin supplementation for patients
with inadequate dietary vitamin (e.g., vitamin D) intake
 2.Medication management
Renally cleared medications: Adjust dosing based on the
patient's eGFR.
• Potentially nephrotoxic substances
Avoid use (except when the benefits outweigh the risks).
• Contrast imaging
• The risk of contrast-induced nephropathy is
highest in patients with eGFR < 30 mL/min/1.73 m2.
 3. Renal replacement therapy
Nonoperative (hemodialysis or peritoneal dialysis)
Indications include:
• Hemodynamic or metabolic complications that are refractory to medical
therapy, e.g.:
1. Volume overload or hypertension
2. Metabolic acidosis
3. Hyperkalemia
4. Serositis: e.g., uremic pericarditis
5. Other symptoms of uremia: e.g., signs of encephalopathy
6. Refractory deterioration in nutritional status

Operative: kidney transplantation

 MANAGEMENT OF RISK
FACTORS AND COMPLICATIONS
1.ASCVD
2.Anemia
3.CKD bone and mineral disorder
 1.ASCVD risk assessment

• Perform for all patients (CKD is an ASCVD risk-

enhancing factor).
Includes:
• Diabetes mellitus screening
• Blood pressure monitoring
• Screening for lipid disorders
Blood pressure control Systolic blood pressure (SBP) target
SBP < 120 mm Hg
Pharmacological therapy
• First-line therapy: RAAS inhibitors (i.e.,
ACEI or ARB)Nephroprotection and
reduced proteinuria
• may cause hyperkalemia
Lipid Control Statins
Diabetes • Dietary changes
• Medication
 2.Anemia
Management
• Consider erythropoietin-stimulating agents (ESAs): for
patients with Hb < 10.0 g/dL
• Treatment target: usually Hb concentration between 11
and 12 g/dL
• adjunctive iron replacement therapy

Adverse effects include increased risk of thrombosis, an

increase in blood pressure, and headache.
 3.CKD bone and mineral disorder
Treatment (under specialist guidance): The goal is to normalize
phosphate, calcium, and PTH levels.
1.Treatment of hyperphosphatemia
• Dietary phosphate restriction
• Phosphate binders (e.g., sevelamer)
2.Treatment of hyperparathyroidism
• Cholecalciferol or ergocalciferol supplementation for vitamin D
deficiency or insufficiency
• Calcitriol (not routinely recommended)
• Calcimimetics (e.g., cinacalcet)
• Parathyroidectomy (last-line therapy)
Defect in the activation of vitamin D in the kidneys
due to chronic kidney disease (CKD) leads to
hypocalcemia and hyperphosphatemia, resulting in
a compensatory increase in parathyroid gland
cellularity and parathyroid hormone production
and causing secondary hyperparathyroidism