Chronic Kidney Disease

Dr. Atma Gunawan SpPD.KGH

Division of Nephrology and Hypertension - Department of Internal Medicine
Medical Faculty of Brawijaya University – Dr Saiful Anwar Hospital
 Learning Objectives

Overview of Chronic Kidney Disease (CKD)

Definition and staging of CKD; Risk factors
Burden & etiology of CKD
Measurements and classification of CKD
 Serum Creatinine and eGFR
 Proteinuria, MAU
 Other tests of CKD
Intervention of CKD/ Stage wise and new Rx.
Nephrotoxic Drugs – Dosage adjustments
Diet in Chronic Kidney Disease
 CKD – A Silent Killer

CKD – Increased Death CKD at a glance

• CKD – A Global Pandemic
• CKD 1-2 are asymptomatic
• Third after CVD, Cancer
• 10 million people of CKD
• Term ‘CRF’ no longer used
• Dialysis ↑ death rate 100 x
• Small ↑ in Creat - ↑ ↑ in CV
 CKD Predicts CVD
Cadio-vascular events
per 1000 person
years

Estimated GFR (ml/min/1.73 m2)

Causes of CKD
 Screening for CKD?

Why screen for CKD?

• Therapeutic interventions are available
• CKD is easily detectable, preventable
What tests are to be ordered ?
• Blood – eGFR, Serum Creatinine
• Urine – Albuminuria (dipstick), Microalbuminuria,
sedimen urine : erythrocyte, leucocyte, cast
• Imaging studies only in selected cases (USG & BNO
for renal stones)
 Who are at Risk for CKD

• Diabetes
• Hypertension
• Heart disease
• Age >65
• Obese
• Family H/o Kidney Disease
• Recurrent UTI
• Urinary Stone Disease
• Loss of Renal mass (etc nephrectomy)
• Neoplasia of any part
• Nephrotoxic Drugs (NSAIDs,aminogycoside )
CKD DEFINITION - STAGES
 Definition of CKD

1. Either GFR < 60 ml/min/1.73m2 for  3 month or

2. Kidney damage for  3 mon as manifested by
a. Persistent microalbuminuria / macroproteinuria
b. Biochemical abnormalities in RFT
c. Persistent non-urological hematuria
d. Structural renal abnormalities by USG
e. Biopsy proven Glomerulonephritis (rarely needed)
(Any one of the above evidences)
Why eGFR ?
Blind creatinine, the role of cystacin-C
 CKD Clinical Stages

Stage Description GFR

(ml/min/1.73 m2)

1 Kidney damage with normal or ↑ GFR  90

2 Kidney damage with mild  GFR 60-89

3 Kidney damage with moderate  GFR 30-59

4 Severe  GFR 15-29

5 Kidney Failure (ESRD) < 15 (or dialysis)

 Clinical Features – CKD 3-5

• Unintentional weight loss

• Nausea, vomiting General ill feeling
• Fatigue; Headache; Frequent hiccups
• Generalized itching (pruritus)
• Increased or decreased urine output
• Need to urinate at night, polyuria
• Easy bruising or bleeding
 Clinical Features – CKD 3-5

• Blood in the vomit or in stools

• Decreased alertness; Muscle cramps
• Seizures; Agitation; Hypertension
• Peripheral sensory neuropathy
• Breath fetor; Loss of appetite;
• Uremic frost on the skin
• Uremic pericarditis, CHF
MANAGEMENT OF CKD
Early treatment makes
a difference in CKD

Brenner, et al., 2001

 Principles of Management of CKD Patients
• Early recognition of CKD
– Estimate the severity of CKD
– What is the cause of CKD?
• Detection and correction of any reversible cause.
(obstruction, nephrotoxic drug, volume depletion).
• Institution of interventions to delay progression
• Treatment of complications
• Planning for renal replacement therapy
Intervention to delay progression
of CKD (K/DOQI Guidelines 2002)
Have been proven to be effective :
• Strict glucose control in diabetes
• Strict blood pressure control
• RAA system blockade

Have been studied, inconclusive result :

• Dietary protein restriction
• Lipid-lowering therapy
• Partial correction of anemia

21
 B.P. Treatment in CKD

1. Maintain B.P. less than 125/75 mmHg

2. Use ACE Inhibitor or ARB early enough

3. More than one drug is usually required

4. Diuretic should be part of the regimen

5. Achieve best possible glycemic control in Diabetics

 The Renal Injury (CKD) Triad
(the importance of ACE –I)

Angiotensin II

Hypertension Proteinuria
Effect ACE-I to proteinuria
and sclerosis No treatment

Enalapril

X 3 anti HT

Proteinuria

J Clin Invest 1986; 77 (6) : 1993-2000

 Intervention Renal Diet

• Protein Restriction
• High calories
• Low potassium
• Low salt
• Low phosphate
 Nutrient requirement in patient with
CKD and dialysis
Parameter Normal CKD st III-V Hemodialisis Peritoneal
dialisis

Kalori 30-37 35 (< 60 th) 35 (< 60) 35 (> 60)

(cal/kg/day) 30-35 (≥ 60 th) (30-35 > 60th) 30-35(> 60)
Protein 0,8 0,6-0,75 1,2 1,2-1,3
(gr/kg/day)
Fat (% total kcal) 30%–35% Patients considered at highest risk for cardiovascular disease;
emphasis on PUFAc, MUFAd, 250–300 mg cholesterol/day
Sodium (mg/day) unrestricted 2000 2000 2000
Kalium unrestricted correlated to lab. 2000-3000 3000-4000
(mg/day ) value
Kalsium(mg/day) unrestricted 1.200 1200-2000 1200-
2000
Phosphate(mg/day) unrestricted correlated to lab 800-1000 800-1000
Fluid unrestricted unrestricted with 500-1000 + monitored;
normal urine output urine output 1500-2000
 Nutritional Intervention
• Rationale :
– AA loads induce glomerular hyperfiltration
– Protein restriction in small studies  retards
CKD progression
– Obesity (BMI >38 kg/m2) — associated with
glomerular hyperfiltration

 Protein Intake Associated with  Kidney Function

S Klahr, et al. N Engl J Med 1994;330:877–884.

28
EL Knight, et al. Ann Intern Med 2003;138:460–467.
 Anemia is an Important
CV Risk Factor in CKD

Chronic Kidney Anemia

Disease

Cardiovascular disease
 Anemia in CKD

• Decreased production • Reticulocyte count

– Low EPO (RF) • Red Blood Cell indices:
– Nutritional MCV, RDW
• (Iron, B12, Folate) • Iron Parameters
– inflammation – TIBC
– Serum Ferritin
– Infection, Ca
• Vitamins:
• Blood Loss
– Folate\B12 levels
• Serum Erythropoietin
• Stools for occult blood
levels not indicated
 Principles of renal anemia
• Correction the causes of anemia
• Targets
– Hb 11 to 12 g/dl
– PCV 33% to 36%
 Nephrotoxic Drugs

• Which drug is (not) nephrotoxic?

– Antibiotics
• Aminiglycosides, Indinavir, Amphotericin
• Penicillin / -lactums, Tetracyclines
• Fluoroquinolones, Sulphas, Ketoconozole gr.
– NSAIDS/ COX2 inhibitors, Indometh. Nimesulide
– Cancer: MTX, Cisplatin, Acyclovir, Pentamidine
– Heavy metals: Hg, Pb, Ar, Bi, Lithium
– IV Contrast dyes
– ACEi / ARBs if Serum creatinine > 3.5
Preparation for Renal Replacement
Therapy (RRT)
• Choice of Renal Replacement Therapy
(hemodialysis, peritoneal dialysis, kidney
transplant)
• When GFR < 25ml/min
– Renal transplant is the first choice
– Workup living donors
– If no donors available
– List patient on cadaver transplant list
– Placement A-V fistula if HD preferred
– Placement PD cateheter for CAPD
AV-fistulae
R.R.T – THE RENAL
REPLACEMENT THERAPY
PERITONEAL DIALYSIS
 JENIS PERITONEAL DIALISIS (PD)

Continuos ambulatory peritoneal

Automated peritoneal dialysis (APD) dialysis (CAPD)
Hemodialysis
 Access fo HD
(central vein catheter)
Kidney transplant
Indications for Renal Replacement Therapy
• GFR < 15 for Diabet
• GFR < 10 for CKD non diabet
• GFR < 15 for CKD non diabet
with uremia
• Refractory CHF
• Uremic pericarditis
• Uremic encephalopathy
• Uremic Bleeding
• Tujuan RRT :
- Removal uremic toxins
- Fluid removal
- Normalize acidosis and
electrolyte imbalance
- To help blood pressure
control
- Increase quality of life
Normal ESRD
Wassalam

47