CHRONIC

DISEASE

KIDNEY

CKD - DEFINITION
Evidence of structural or functional
kidney abnormalities that persists
for at least 3 months, with or
without a decreased GFR.
GFR <60 mL/min/1.73m for 3
months, with or without kidney damage
Prevalence 4.7% or 8.3 million
NKF. Am J Kidney Dis. 2002;39(supp1):S1

PREVALENCE OF CKD

NKF. Am J Kidney Dis. 2002;39(supp 1):S1

MULTIPLE RISK FACTORS FOR CKD

Diabetes
Hypertension
Autoimmune disease
Systemic infections
Exposure to drugs
associated with acute
decline in kidney function
Recovery from acute
kidney failure

Older age
Family history of
kidney disease
Reduced kidney
mass
Racial/ethnic
background
Smoking
NKF. Am J Kidney Dis. 2002;39:S46
Pinto-Sietsma. Ann Intern Med. 2000;133:585

Identify reversible causes

Think about volume contraction, urinary
obstruction, or toxic effects of medications
Rx

ACEs/ARBs
NSAIDs
Aminoglycosides and amphotericin B
IV radiocontrast agents

Other etiologies

Renovascular disease
Glomerulonephritis
Nephrotic syndrome
Hypercalcemia
Multiple myeloma
Chronic UTI

STAGES OF CHRONIC KIDNEY

DISEASE
Stage

Description

GFR (mL/min/1.73m)

Kidney Damage with

normal or increased
GFR

>90

II

Kidney Damage with

mildly decrease GFR

60-89

III

Moderately decreased 30-59

GFR

IV

Severely decreased
GFR

15-29

Kidney Failure

<15

Signs & Symptoms

General
Fatigue & malaise
Edema

Ophthalmologic
AV nicking

Cardiac

HTN
Heart failure
Pericarditis
CAD

GI
Anorexia
Nausea/vomiting
Dysgeusia

Skin
Pruritis
Pallor

Neurological
MS changes
Seizures

EVALUATING PATIENTS AT RISK

FOR CKD

Evaluating risk factors and identifying GFR

declines are essential to the prompt and
appropriate management of CKD
GFR or age/weight-sensitive eGFR
Blood pressure
Glucose
Urinalysis
Microalbuminuria/proteinuria

MANAGEMENT OF PATIENTS WITH

CKD

Blood pressure control

Diabetes control
Cardiovascular disease management
Anemia management
Iron management
Vitamin D and vital bone protection
Eating well and exercise
Access planning

Management
Identify and treat factors
associated with progression of CKD
HTN
Proteinuria
Glucose control
Metabolic changes

Hypertension
Target BP
<130/80 mm Hg
<125/75 mm Hg
pts with proteinuria (> 1 g/d)

Consider several anti-HTN medications with different

mechanisms of activity

ACEs/ARBs
Diuretics
CCBs
HCTZ (less effective when GFR < 20)

PREVALENCE OF HYPERTENSION IN
CKD
1795 patients with
kidney diseases were
screened
GFR range 13-55
mL/min/1.73m
BP in 83% of
patients (n=1494)

Buckalew. Am J Kidney Dis 1996;28:811.

BLOOD PRESSURE IS POORLY

CONTROLLED IN CKD

Coresh. Arch Intern Med. 2001;161:1207

BLOOD PRESSURE CONTROL IN

CKD: GOALS
Target population

SBP

DBP

CKD stages 1-4 with

proteinuria(>1g/day)or
diabetic kidney disease

<125

<75

CKD stages 1-4 without

proteinuria

<135

<85

CKD stage 5

<140

<90

NKF. Am J Kidney Dis. 2002;3a(suppl 1):S1

BP CONTROL: INTERVENTIONS

ACE inhibitors
Angiotensin-receptor blockers (ARBs)
Calcium channel blockers (CCBs)
Diuretics
Low-sodium diet
Combination therapy

Proteinuria
Single best predictor of disease progression
Normal albumin excretion
<30 mg/24 hours

Microalbuminuria
20-200 g/min or 30-300 mg/24 hours

Macroalbuminuria
>300 mg/24 hours

Nephrotic range proteinuria

>3 g/24 hours

Am J Kidney Dis 2002; 39(S2): S1-246

Metabolic changes with CKD

Hemoglobin/hematocrit
Bicarbonate
Calcium
Phosphate
PTH
Triglycerides

Metabolic changes
Monitor and treat biochemical
abnormalities
Anemia
Metabolic acidosis
Mineral metabolism
Dyslipidemia
Nutrition

Anemia
Common in CKD
HD pts have increased rates of:
Hospital admission
CAD/LVH
Reduced quality of life

Can improve energy levels, sleep,

cognitive function, and quality of life in HD
pts

Metabolic acidosis
Muscle catabolism
Metabolic bone disease
Sodium bicarbonate
Maintain serum bicarbonate > 22 meq/L
0.5-1.0 meq/kg per day
Watch for sodium loading
Volume expansion
HTN

Mineral metabolism
Calcium and phosphate metabolism
abnormalities associated with:
Renal osteodystrophy
Calciphylaxis and vascular calcification

14 of 16 ESRD/HD pts (20-30 yrs) had

calcification on CT scan
3 of 60 in the control group

NEJM 2000; 342(20): 1478-83

Dyslipidemia
Abnormalities in the lipid profile
Triglycerides
Total cholesterol

NCEP recommends reducing lipid

levels in high-risk populations
Targets for lipid-lowering therapy
considered the same as those for the
secondary prevention of CV disease
JAMA 1993; 269(23): 3015-23

Nutrition
Think about uremia
Catabolic state
Anorexia
Decreased protein intake

Consider renal dietician

Properly monitored by experienced dietitian
and nephrologist may improve long-term
survival of patients
Protein malnutrition is common in CKD

Evaluation for CKD

Blood
CBC with diff
SMA-7 with Ca2+
and phosphorous
PTH
HBA1c
LFTs and FLP
Uric acid and Fe2+
studies

Urine
Urinalysis with
microscopy
Spot urine for
microalbumin
24-urine collection
for protein and
creatinine

Ultrasound

Key points
The serum creatinine level is not enough!
Target BP for CKD
<130/80 mm Hg
<125/75 mm Hg in proteinuria

HTN and proteinuria are the two most

important modifiable risk factors for
progressive CKD

MANAGEMENT INCLUDES
Exercise
Hemodialysis
Follow-ups

Bailey. Therapy in Nephrology and Hypertension. 1998:474

EXERCISE
Physical functioning
Blood pressure control
Muscle, bone strength
Level of cholesterol and
triglycerides
Better sleep
Control of body weight
NKF. Staying fit with Kidney Disease

VASCULAR ACCESS FOR

HEMODIALYSIS
Establish communication between
nephrologist and PCP
Preserve an arm: no intravenous
injections or blood draws
Refer to surgeon for fistula when SCr
>4mg/dL, CrCl <25 mL/min, or dialysis
anticipated within 1 year
Fistula may take 3 to 4 months to
mature
NKF. Am J Kidney Dis. 2001;37(suppl 1):S147

TEAM APPROACH: ROLE OF

PRIMARY PHYSICIAN AND
NEPHROLOGIST IN CKD
Primary Physician
Screen and identify
risk factors of CKD
Provide ongoing
management of
patients with CKD
Provide role-specific
patient education

Nephrologists
Assist in development
of care strategy
Aid recommendation
and implementation of
patient care
Provide role-specific
patient education

BENEFITS OF EARLY INTERVENTION

IN THE MANAGEMENT OF CKD
Delayed progression of CKD
Improved teamwork between physicians
Decreased risk of cardiovascular
complications
Improved dialysis outcomes
Better educated and prepared patients

Pereira. Kidney Int. 2000;57:351.