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Chronic Kidney Disease (CKD) (The uremic syndrome (symptoms of CKD)…
Chronic Kidney Disease (CKD)
The presence of markers of kidney damage for ≥ 3 months, as defined by structural or functional abnormalities of the kidney with or without decreased glomerular filtration rate (GFR), that can lead to decreased GFR, manifest by either pathological abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests. OR
The presence of GFR < 60 ml/min/1.73m2 for ≥ 3 months, with or without other signs of kidney damage as described above.
either decreased kidney function (GFR <60 mL/min) or kidney damage (structural or functional abnormalities) for at least 3 months, regardless of cause
irreversible
in early stages is characterised by kidney damage and level of kidney function.
in later stages is defined as an estimated glomerular filtration rate (eGFR) for at least 3 months of – eGFR < 60 mL/min/1.73m2
Stages of CKD are ranked by classifying severity of disease with declining eGFR and kidney damage.
Stages
Albuminuria in CKD
Risk Factors
most common causes of ESRD are:
Diabetes
, Vascular nephropathies including
hypertensive
nephropathy,
Glomerulopathies
, Polycystic kidney disease
prevalent in diabetology and cardiology practices
Diagnosis
silent and under-diagnosed in earlier stages.
GFR can be measured using filtration markers such as inulin, iohexol or iothalamate but such methods are costly and cumbersome
sCr is an alternative that is easily measured but affected by factors such as age, gender, race & body size
eGFR is used to assess kidney function
Serum Creatinine
is Not a Good Measure of eGFR
Depends on: Age, Gender, Body weight, Muscle mass, Race
eGFR
can be more accurately predicted from variables such as age, gender, race and body sizes with sCr
Commonly used prediction equations:
Cockcroft-Gault uses sCr, age, weight and sex
MDRD (Modification of Diet in Renal Disease) in its simplest form uses sCr, age, sex and race
eGFR is a better indicator of renal function than sCr alone
eGFR= 186 x [creatinine/88.4 ]-1,154 x age -0,203 x 0,742
x 1,210*
.
*- women
**- Afro-American
Cockcroft – Gault formula
eGFR={(140-age) x weight/ (creatinine x 72) x 0,85 for women}
Management
Modifying Progression Factors to Slow CKD
Strict BP control, ACE inhibitors, ARBs.
Timely treatment of CKD anaemia, Cholesterol and lipids
Diabetes, Low protein diet, low phosphate diet
Avoid nephrotoxic agents, Use of statins
Lifestyle adjustment (smoking cessation)
Hypertension
Treatment goal is to lower BP and slow CKD progression but also to reduce risk of CVD
Strict BP control should modify targets to renal ranges <130/80 mmHg
BP target when protein excretion >1 g/d should be <125/75 mmHg
ACE inhibitors/ARBs
Target a 50% reduction in proteinuria within the first 6 months of treatment
Use maximum tolerated doses of ACE inhibitors as higher doses have greater anti- proteinuric effect
ARBs - first line therapy for ACE inhibitor resistance
Diabetes
Optimal glycaemic control (Hb A1c <7%)
– Preprandial glucose 80-120 mg/dL
– Bedtime glucose 100-140 mg/dL
Additional
Dietary counselling including low protein diets and cholesterol control
Use of statins to control dyslipidaemia
Phosphate and parathyroid hormone control
Smoking cessation
CKD Anaemia
A Common Complication in CKD
Hb decreases progressively with degree of renal impairment
CKD anaemia occurs earlier in patients with Type 1 diabetes
CKD patients should be treated with epoetin to reach and maintain Hb >11 g/dL
This gives the potential to provide
– Survival benefit
– Slow renal deterioration
– Improve LV abnormalities
– Increase quality of life
CKD progression can be slowed
Transplantation
Progression Factors
Persistent activity of underlying disease
Elevated blood pressure (BP)
Persistent proteinuria
High protein/phosphate diet
Hyperlipidaemia, Hyperphosphataemia, Anaemia,
Cardiovascular disease (CVD), Smoking
The uremic syndrome (symptoms of CKD)
General and miscellaneous symptoms:
polyuria, polydipsia, thirst, diminished libido, impotence
uremic foetor, hypothermia
Nervous system:
Fatigue, stupor, coma, Dementia, Malaise
Insomnia, Headache, Restless legs, Flapping tremor Polyneuritis, Convulsions, Motor weakness, Concentration disturbances Drowsiness, Irritability, Cramps
Gastrointestinal system:
stomatitis, gastritis, anorexia, nausea, vomiting, pancreatitis gastrointestinal ulcers
Hemalotogical system:
anaemia, bleeding diathesis
Cardiovascular system:
pericarditis, hypertension, accelerated atheromatosis, edema, cardiomyopathy, chronic heart failure
Pulmonary system:
pulmonary edema, pleuritis, uremic lung
Skin:
dry skin, pruritus, retarded wound healing, melanosis, nail atrophy
Bone disease:
Vit. D metabolism defect, secondary hyperparathyroidism
osteodystrophy, soft tissue calcifications, b2M amyloidosis
Azotemia (elevated BUN and Cr)
