Chronic kidney disease

Criteria of CKD:
• Presence of either kidney damage or decreased kidney function for
>3months
• Either one of the following must be present for 3 months
1. markers of kidney damage
• Albuminuria (ACR >30mg/g)
• Urine sediment abnormalities (haematuria, WBC cast)
• Electrolyte and other abnormalities due to tubular disorders
• Abnormalities detected by histology
• Structural abnormalities detected by imaging
• History of kidney transplantation

2. GFR <60mL/min/1.73m2
Joachim Jankowski. Circulation. Cardiovascular Disease in Chronic Kidney Disease, Volume: 143, Issue: 11, Pages: 1157-1172, DOI: (10.1161/CIRCULATIONAHA.120.050686)
Worsening CKD associated with increased
risk for:
• CVD
• ESRD
• Malignancies
• infections
• mortality
Worsening CKD associated with increased
risk for:
• CVD
• ESRD
• Malignancies
• infections
• mortality
Cause
• Diabetes (T2>T1DM)
• HTN
General management
• Goal: Preventing/slowing the progression of kidney disease
• BP control
• Glycemic control
• Proteinuria reduction
• Smoking cessation
• Metabolic acidosis treatment
• Treatment of complication
• Renal replacement therapy
BP • Multifactorial
• Sodium retention, inc RAAS and SNS activity

• <140/90 (most patients)

• <130/90 (CKD + proteinuria)

• Protenuria + CKD
• 1st line: ACEi/ARBi
• Consider adding diuretic and NDCCB
• 4th line: minerocorticoid receptor antagonist

• Nocturnal dipping
• At least one antiHTN taken before bedtime
Proteinuria reduction
• Higher proteinuria = more rapid decline in GFR
• Initial evaluation 24hr urine protein excretion
• Protein excretion >500 to 1000mg/d
• Target lower BP <130/80
• Anti HNT: ACEi/ARB, non dihydropyridine Ca channel blockers,
mineralocorticoid antagonist
• Proteinuria, non diabetic CKD goal <1000mg/day or reduction of 50-
60% from baseline + protein excretion <3.5g/day
Glycemic control
• Target ~7%
• Higher target if patient have shorter life expectancy, higher risk of
hypoglycemia, hypoglycemic unawareness
• HbA1c inaccurate in some CKD (acidosis, anemia )
• Treatment with SLGT2i : slow CKD progression and dec risk of CVD
General management
• Goal: Preventing/slowing the progression of kidney disease
• BP control
• Glycemic control
• Proteinuria reduction
• Smoking cessation
• Metabolic acidosis treatment
• Treatment of complication
• Renal replacement therapy
Fluid overload

Fluid overload
hyperkalemia

Metabolic
- Dietary sodium
acidosis restriction
- <2g/day unless CI
Mineral bone - Daily diuretics
disease
(typically loop
diuretics)
Anaemia

Dyslipidemia
Fluid overload

Chronic hyperkalemia
hyperkalemia

The major: metabolic acidosis, kidney transplantation and

Metabolic dietary modification
acidosis

Mineral bone
- Limit dietary intake
disease - Stop NSAID, COX2i, K sparing diuretics
- Consider reducing BB/ACEi/ARB
Anaemia
- Consider adding loop/thiazide

Dyslipidemia
Fluid overload

Metabolic acidosis
hyperkalemia

Metabolic
• Serum bicarb <22
acidosis • Cx: progression of CKD, osteoporosis -> fracture, muscle
wasting, high BSL, high mortality
Mineral bone
disease
• Rx: dietary intake, alkali therapy (Na bicarb, Na citrate)
• 0.5 – 1mEq/kg/day
Anaemia

Dyslipidemia
Fluid overload

CKD-MBD
hyperkalemia
Characterized:
• Abnormalities of Ca, P, PTH, or Vit D metabolism and/or
Metabolic • Abnormalities in bone turnover, mineralization, growth, strength ->
acidosis
fracture, bone pain, deformities, OP
• Extraskeletal calcification -> CAD, vascular calcification
Mineral bone • Elevated PTH?
disease
• Elevated P? phos-binders (avoid aluminium binders unless severe)
• hypoCa? Ca supplements
Anaemia • Vit D def? vit D3
• Consider calcitriol/vit D analogue and/or calcimimentics in worsening
PTH
Dyslipidemia • Parathyroidectomy if severe hyperPTH or not responding to medical
therapy
Calciphylaxis

No cure
Mineral bone disease
• Reduce phosphorus excretion,
increase serum p level
• In the bone, this increase the
enzyme FGF23
• FGF23 reduce the P absorption in
the kidney, reduction of the
conversion of activated vitamin D
• Reduced activated D -> PTH ->
PTH secretion
• Affects the Gut, reduce ca and P
absorption
Fluid overload

Anaemia
hyperkalemia
>75% in CKD 5
• Increased morbidity and
Metabolic
acidosis mortality
• Promote progression for CKD
Mineral bone • dec EPO production,
disease
functional iron de and
inflammation with increased
Anaemia hepcidin levels.
• Iron def (Ferritin <500, iron
sat <30%), trial oral iron for
Dyslipidemia 1-3 months.
Fluid overload

Anaemia
hyperkalemia
Recombinant human EPO
• Hb <10 g/dL, providing the TSAT >20 and
Metabolic ferritin >200
acidosis
• Aim Hb 10.0 and 11.5
• >13g/dL associated with increased risk of adverse
Mineral bone outcome
disease
• CI: active or recent hx of malignancy, stroke,
uncontrolled HTN
Anaemia • Reduce need for blood transfusion, improve
survival impact QOL
• Blood transfusion; reduce allosensitisation in
Dyslipidemia pt with good transplant candidate. Leuko
reduce RBC
Fluid overload

Dyslipidemia
hyperkalemia
KDIGO recommendation:
• Stage 1-2: start statin if >50y.o
Metabolic
acidosis • Stage 3-5
• Age 18-49: statin if known CAD, MI, DM, stroke
Mineral bone • >50: statin
disease

• Lifestyle modification
Anaemia

Dyslipidemia
Renal replacement therapy
• Refractory electrolyte abnormality
• Fluid overload, recurrent admission for CHF exacerbation
• Uremic pericarditis/pleuritis
• Uremic encephalopathy
• Bleeding diathesis
• HTN poorly responsive to antiHTN medications
• Persistent N+V
• malnutrition