CHRONIC

KIDNEY
DISEASE
Sayyid Moh Faiz, S.Ked
18 22 777 14 506
DEFINITION

Chronic kidney disease (CKD) is long-standing, progressive

deterioration of renal function. Symptoms develop slowly and in
advanced stages include anorexia, nausea, vomiting, stomatitis,
dysgeusia, nocturia, lassitude, fatigue, pruritus, decreased mental
acuity, muscle twitches and cramps, water retention, undernutrition,
peripheral neuropathies, and seizures. Diagnosis is based on
laboratory testing of renal function, sometimes followed by renal
biopsy. Treatment is primarily directed at the underlying condition
but includes fluid and electrolyte management, blood pressure
control, treatment of anemia, various types of dialysis, and kidney
transplantation.
 Etiology of CKD

•Diabetic nephropathy Hypertensive nephrosclerosis

.

•Various primary and secondary glomerulopathies

Metabolic syndrome, in which hypertension and any cause of renal dysfunction of
sufficient magnitude.
type 2 diabetes are present, is a large and growing
cause of renal damage.
.
 Pathophysiology of CKD
35%
chronic kidney disease (CKD) is initially described as
diminished renal reserve or renal insufficiency, which may
progress to renal failure (end-stage renal disease). Initially,
as renal tissue loses function, there are few noticeable
abnormalities because the remaining tissue increases its
performance (renal functional adaptation).
Creatinine and urea
Plasma concentrations of creatinine and urea (which
are highly dependent on glomerular filtration) begin a
hyperbolic rise as GFR diminishes. .
Sodium and water
Despite a diminishing GFR, sodium and water balance
is well-maintained by increased fractional excretion of
sodium in urine and a normal response to thirst. .
Potassium
For substances whose secretion is controlled mainly
through distal nephron secretion (eg, potassium), renal
adaptation usually maintains plasma levels at normal
until renal failure is advanced or dietary potassium
intake is excessive. .
28%
Decreased renal function interferes with the kidneys’ ability to
maintain fluid and electrolyte homeostasis. The ability to concentrate
urine declines early and is followed by decreases in ability to excrete
excess phosphate, acid, and potassium. When renal failure is
advanced (glomerular filtration rate [GFR] ≤ 15 mL/min/1.73 m 2), the
ability to effectively dilute or concentrate urine is lost; thus, urine
osmolality is usually fixed at about 300 to 320 mOsm/kg, close to that
of plasma (275 to 295 mOsm/kg), and urinary volume does not
respond readily to variations in water intake.
Calcium and phosphate
abnormalities of calcium, phosphate, parathyroid
hormone (PTH), and vitamin D metabolism can occur,
as can renal osteodystrophy. .
pH and bicarbonate
Moderate metabolic acidosis (plasma bicarbonate
content 15 to 20 mmol/L) is characteristic. .
Anemia
anemia is characteristic of moderate to advanced CKD
(≥ stage 3). The anemia of CKD is normochromic-
normocytic, with a hematocrit of 20 to 30% (35 to 40%
in patients with polycystic kidney disease). .
Symptoms and Signs of CKD

With more severe renal disease (eg, estimated glomerular filtration

rate [eGFR] < 15 mL/min/1.73 m2), neuromuscular symptoms may
be present, including coarse muscular twitches,
peripheral sensory and motor neuropathies, muscle cramps,
hyperreflexia, restless legs syndrome, and seizures (usually the
result of hypertensive or metabolic encephalopathy).

Anorexia, nausea, vomiting, in advanced CKD, pericarditis

weight loss, stomatitis, and an and gastrointestinal ulceration
unpleasant taste in the mouth and bleeding may occur.
are almost uniformly present. Hypertension is present in > 80%
The skin may be yellow-brown of patients with advanced CKD
and/or dry. and is usually related to
Occasionally, urea from sweat hypervolemia. Heart failure
crystallizes on the skin (uremic caused by hypertension or
frost). Pruritus may be especially coronary artery disease and
uncomfortable. Undernutrition renal retention of sodium and
leading to generalized tissue water may lead to dependent
wasting is a prominent feature of edema and/or dyspnea.
chronic uremia.
 Diagnosis of CKD

•Electrolytes, blood urea nitrogen •Quantitative urine protein (24-hour

(BUN), creatinine, phosphate, calcium, urine protein collection or spot urine
complete blood count (CBC) protein to creatinine ratio)

Add Title
•Urinalysis (including urinary sediment •Ultrasonography
examination) •Sometimes renal biopsy
 Stages of chronic kidney disease
GFR (in mL/min/1.73 m2) in CKD can be estimated by the Chronic Kidney
Disease Epidemiology Collaboration (CKD-EPI 2021) creatinine equation:

STAGE 1
Normal GFR (≥ 90 mL/min/1.73 m2) plus either
persistent albuminuria or known structural or
hereditary renal disease
.
STAGE 2
GFR 60 to 89 mL/min/1.73 m2.

STAGE 3
3A : 45 to 59 mL/min/1.73 m2
3B : 30 to 44 mL/min/1.73 m2

STAGE 4
GFR 15 to 29 mL/min/1.73 m2.
STAGE 5
GFR < 15 mL/min/1.73 m2
Prognosis for CKD
Progression of chronic kidney disease (CKD) is predicted in
most cases by the degree of proteinuria. Patients with
nephrotic-range proteinuria (> 3 g/24 h or urine
protein/creatinine ratio > 3) usually have a poorer prognosis
and progress to renal failure more rapidly. Progression may
occur even if the underlying disorder is not active. In patients
with urine protein < 1.5 g/24 h, progression usually occurs
more slowly if at all. Hypertension, acidosis, and
hyperparathyroidism are associated with more rapid
progression as well.
 Treatment of CKD
•Treatment of contributing comorbidities
•Control of underlying (eg, heart failure, diabetes mellitus,
disorders nephrolithiasis, prostatic hypertrophy)

•Possible restriction of •Doses of all drugs adjusted

dietary protein, phosphate, as needed
and potassium

•Dialysis for severely decreased

•Vitamin D supplements glomerular filtration rate (GFR) if
symptoms and signs not adequately
managed by medical interventions

•Treatment of anemia
•Maintaining sodium bicarbonate level in the
normal range (23–29 mmol/L)
 Nutrition
severe protein restriction in renal disease is
controversial. However, moderate protein
restriction (0.8 g/kg/day) among patients with
estimated GFR (eGFR) < 60 mL/min/1.73
m2 without nephrotic syndrome is safe and
easy for most patients to tolerate.
Anemia and coagulation disorders
Anemia is a common complication of moderate to
advanced CKD (≥ stage 3) and, when < 10g/dL, is
treated with erythropoiesis-stimulating agents (ESA),
such as recombinant human erythropoietin
(eg, epoetin alfa). Due to risk of cardiovascular
complications, including stroke, thrombosis, and
death, the lowest dose of these agents needed to
keep the Hb between 10 and 11 g/dL is used.
Mineral and bone disorders
Based on updated KDIGO 2017 clinical practice
guidelines (3), it is recommended that serum
levels of calcium, phosphate, PTH, vitamin
D 25-OH, and alkaline phosphatase activity be
monitored beginning in CKD stage 3a
Heart failure
Symptomatic heart failure is treated with
•Sodium restriction
•Diuretics
•Sometimes, dialysis
Fluid and electrolytes Dialysis
1. Restricted water intake Dialysis is usually initiated at the
2. Sodium restriction onset of either of the following:
3. Potassium restriction •Uremic symptoms (eg, anorexia,
nausea, vomiting, weight loss,
pericarditis, pleuritis)
•Difficulty controlling fluid overload,
hyperkalemia, or acidosis with drugs
and lifestyle interventions
Drugs
Renal excretion of drugs is often impaired in
patients with renal failure. Common drugs
that require revised dosing include
penicillins, cephalosporins, aminoglycosides,
fluoroquinolones, vancomycin, and digoxin.
Transplantation
If a living kidney donor is available,
better long-term outcomes occur
when a patient receives the
transplanted kidney early, even before
beginning dialysis. Patients who are
transplant candidates but have no
living donor should be placed on the
waiting list of their regional transplant
center early because wait times may
exceed several years in many regions
of the US.
Thank you