Chronic Kidney Disease

Manju Sood GPST3

What is CKD?

•Chronic renal failure is the progressive loss of nephrons resulting in permanent compromise of renal function.

•defined by evidence of kidney damage

and level of renal function

as measured by glomerular filtration rate (GFR).

STAGES OF CHRONIC KIDNEY DISEASE

Stage 1: Normal GFR; GFR >90 mL/min/1.73 m2 with other evidence of chronic kidney damage

Stage 2: Mild impairment; GFR 60-89 mL/min/1.73 m2 with other evidence of chronic kidney damage

Stage 3: Moderate impairment; GFR 30-59 mL/min/1.73 m2

Stage 3 CKD should be split into two subcategories defined by (2):

GFR 45-59 ml/min/1.73 m2 (stage 3A)

GFR 30-44 ml/min/1.73 m2 (stage 3B)

Stage 4: Severe impairment: GFR 15-29 mL/min/1.73 m2

Stage 5: Established renal failure (ERF): GFR < 15mL/min/1.73 m2 or on dialysis

Offer people testing for CKD if they have any of the following risk factors:

– diabetes– hypertension– cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vasculardisease and cerebral vascular disease)– structural renal tract disease, renal calculi or prostatic hypertrophy– multisystem diseases with potential kidney involvement – eg. SLE– family history of stage 5 CKD or hereditary kidney disease

– opportunistic detection of haematuria or proteinuria.

Stage eGFR [(ml/min/1.73m2] Testing frequency

1 ≥ 90 Normal or increased GFR, with 12 monthly other evidence of kidney damage2 60–89 Slight decrease in GFR, with other evidence of kidney damage3A 45–59 Moderate decrease in GFR, 6 monthly3B 30–44 with or without other evidence of kidney damage

4 15–29 Severe decrease in GFR, with 3 monthly or without other evidence of kidney damage5 < 15 Established renal failure 6 weeks

Test eGFRc: Annually in all at risk groups. During intercurrent illness and perioperatively in all patients with CKD.

Investigations•Testing kidney function- eGFR and

S creatinine, correct for ethinicity, avoid eating meat 12 hours before test.

•Testing for proteinuria – ACR or PCR, do not use strips. ACR recommended in Diabetes. If ACR>30 but <70, confirm on early morning sample. Repeat not required if >70.

•Testing for haematuria- use dipstick rather than microscopy. Evaluate further if +1 or more. Confirm invisible haematuria by 2 out of 3 positive reagent strips.

Offer Renal ultrasound to those who-have progressive CKD-have visible or persistent invisible haematuria-have symptoms of urinary tract obstruction-have a family history of polycystic kidney disease and are aged over 20-have stage 4 or 5 CKD-are considered by a nephrologist to require a renal biopsy.

Refer to a specialist-stage 4 and 5 CKD (with or without diabetes)

-higher levels of proteinuria (ACR≥ 70 mg/mmol) unless known to be due to diabetes and already appropriately treated

-proteinuria (ACR ≥ 30 mg/mmol) together with haematuria

-rapidly declining eGFR (> 5 ml/min/1.73 m2 in 1 year, or > 10 ml/min/1.73 m2 within 5 years)

-CKD and hypertension that remains poorly controlled

-people with, or suspected of having, rare or genetic causes of CKD

--suspected renal artery stenosis.

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People with CKD without DiabetesIdentify risk factors

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People with CKD with Diabetes

Management•Information and education •Lifestyle advice – dietary advice like protein restriction [not until end stage], phosphate, salt, potassium

-- exercise, healthy weight , smoking•Control blood pressure•Reduce proteinuria•Assess for 10 yr cardiovascular risk and manage. •Test for Anaemia in CKD 3b-5 and treat if Hb < 11.•Manage bone conditions –measure S calcium, phosphate and PTH esp. in CKD 4-5.When vitamin D supplementation is indicated in people with CKD offer:

− cholecalciferol or ergocalciferol to people with stage 1, 2, 3A or 3B CKD

− 1-alpha-hydroxycholecalciferol (alfacalcidol) or 1,25-dihydroxycholecalciferol (calcitriol) to people

with stage 4 or 5 CKD.

Management of BP

• For slow deterioration of CKD and to reduce proteinuria•Aim to keep SBP below 140 mmHg and DBP below 90 mmHg.•In people with diabetes and CKD or when the ACR is ≥ 70 mg/mmol aim to keep SBP below 130 mmHg and DBP below 80 mmHg.

•In Diabetics, ACR > 2.5 mg/mmol (men) or > 3.5 mg/mmol

(women) with or without hypertension – offer ACE # / ARBs

•In non- diabetics, - ACR >70 with or without hypertension-

Offer ACE#/ ARBs

- ACR >30 with hypertension -

offer ACE#/ARBs

Progressive CKD-Define progression as a decline in eGFR of > 5 ml/min/1.73 m2 within 1 year, or > 10 ml/min/1.73 m2 within 5 years.

– Take at least 3 eGFRs over at least 90 days.

– For a new finding of reduced eGFR, repeat test within 2 weeks to exclude acute kidney injury (acute renal failure).

- Risk factors

cardiovascular disease smoking

Proteinuria black or Asian ethnicity

hypertension chronic use of NSAIDs

diabetes urinary outflow tract obstruction

Thanks…..