Chronic Kidney Disease CKD

Definition of Chronic Kidney DiseaseDefinition of Chronic Kidney Disease

Kidney Damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney with or without decreased GFR: blood, urine, imaging, or pathological abnormalities.

Definition of Chronic Kidney DiseaseDefinition of Chronic Kidney Disease

GFR ≤ 60 ml/min/ 1.73 m² for ≥ 3 months, with or without damage.

Stages of Chronic Kidney DiseaseStages of Chronic Kidney Disease

Stage 1 CKD GFR is > 90 mL/ min Stage 2 CKD GFR is 60-89 mL/min Stage 3 CKD GFR is 30-59 mL/min Stage 4 CKD GFR is 15-29 mL/min Stage 5 CKD GFR is < 15 mL/min

Etiology of Chronic Kidney DiseaseEtiology of Chronic Kidney Disease

• Diabetes 46%• HTN 28%• Glomerular disorders 8%• Underlying renal disease all other causes 18%• Automimmune disease• Polycystic kidney disease

• Other• Infections• Obstructive uropathy• Interstitial disorders

Risk Factors for Chronic Kidney DiseaseRisk Factors for Chronic Kidney Disease

• Diabetes• HTN• Age• Family history of kidney disease or diabetes• Male gender

Risk Factors for Chronic Kidney Disease cont..Risk Factors for Chronic Kidney Disease cont..

• Racial ethnic background• African American• Native American• Asian American• Pacific Islander• Latin American

• Tobacco use

Risk Factors for Chronic Kidney Disease cont..Risk Factors for Chronic Kidney Disease cont..

• Coexisting kidney disease• Anemia• High protein diet (controversial)• Hyperlipidemia

Risk Factors for Chronic Kidney Disease cont..Risk Factors for Chronic Kidney Disease cont..

• Atherosclerosis• Obesity• Exposure to nephrotoxic drugs• NSAIDS• Contrast Dye• Hydrocarbons

Recommended Screening Tests for Recommended Screening Tests for Chronic Kidney Disease Chronic Kidney Disease

• Serum Creatinine• Blood Pressure• Glucose• Urinalysis• Microalbuminuria/Proteinuria

Evaluation of Chronic Kidney Disease Evaluation of Chronic Kidney Disease

• Laboratory testing• Serum creatinine should NOT be used alone to assess kidney function• Level of GFR is most accurate predictor• Utilize prediction equations, such as MDRD and Cockroft-Gault to calculate GFR

Urinalysis Urinalysis

• Abnormalities of urine sediment• RBC and RBC casts• WBC and WBC casts• Tubular cells• Cellular casts• Granular casts• Fats

Microalbuminuria/Proteinuria Microalbuminuria/Proteinuria

• Albumin excretion above the normal range (> 30 mg/24 hrs)• Increased excretion of albumin is a more sensitive marker for Chronic Kidney Disease secondary to diabetes, glomerular disease and hypertension than proteinuria

Protein/Creatinine Ratio Protein/Creatinine Ratio

• Collection of timed urine sample is inaccurate and inconvenient• Spot urine protein to creatinine ratio provides an accurate estimate of urinary protein excretion rate and is unaffected by hydration state • Normal < 200 mg/dl

Proteinuria Proteinuria

• Detection allows identification of CKD in asymptomatic individuals • Key finding in the differential diagnosis of type of CKD • Key prognostic indicator (increasing level) is associated with greater loss of kidney function

Proteinuria Proteinuria

• Beneficial therapy to reduce proteinuria• ACE inhibitors and ARBs lower glomerular capillary pressure and decrease protein filtration, conferring a “reno-protective” effect on the kidney• First choice in individuals with diabetes and may be used in non-diabetics with or without proteinuria

Radiographic Studios Radiographic Studios

• Ultrasound• General appearance, increased echogenicity , size disparities and scarring, doppler interrogation

Radiographic Studios cont.. Radiographic Studios cont..

• Intravenous pyelography (IVP) • Risk from use of iodinated dyes, used infrequently

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• CT• Obstruction, tumors, cysts, ureteral calculi• CT with contrast may show renal artery stenosis

• MRI• Renal vein thrombosis, mass lesions• MR angiography with gadolinium to preserve renal function

Nuclear Scan Nuclear Scan

• Symmetry of kidney size or function, RAS, acute pyelonephritis, or scarring

Renal Biopsy Renal Biopsy

• Invasive procedure to determine the nature and extent of kidney disease• Provides information on the diagnosis

Renal Biopsy cont.. Renal Biopsy cont..

• May guide the treatment of kidney disease• Provide prognosis information

Management of CKD Stages 1 and 2 Management of CKD Stages 1 and 2

• B/P control• Goal 130/80 or 125/75 with proteinuria

• Diabetes control• A1C hemoglobin goal < 7.0

Management of CKD Stages 1 and 2 cont.. Management of CKD Stages 1 and 2 cont..

• Use of ACE I or ARB• Reduce proteinuria• Avoid nephrotoxins

Blood Pressure Control Blood Pressure Control

• B/P Goal <130/80 or < 125/75 with proteinuria• Therapeutic Lifestyle Changes, such as:• Weight loss• Smoking cessation• Dietary counseling• Exercise

Blood Pressure Control cont.. Blood Pressure Control cont..

• Indications for use of ACEI or ARB• Diabetic kidney disease• Non-diabetic kidney disease with spot urine protein/creatinine ratio > 500-1000mg/g• ACEI & ARB’s can be used as alternatives to each other or in conbination to lower B/P and reduce proteinuria

Monitoring Therapy Monitoring Therapy

• Monitor for:• Hypotension• Decreased GFR•Hyperkalemia

• May continue if serum potassium is < 5.5 or decline of GFR < 30% in 4 months

Glycemic ControlGlycemic Control

• Intensive glycemic control has been shown to slow progression of CKD• ADA recommendation• Hgb A1C < 7.0% FPG < 120 mg/dl

Glycemic Control cont..Glycemic Control cont..

• Routine annual testing for microalbuminuria and serum creatinine to determine GFR• Early intervention with ACE or ARB with microalbuminuria• Pt at risk to develop hypoglycemia due to prolonged half life of insulin in circulation

Lipid ControlLipid Control

• CKD is a CHD risk equivalent• LDL goal < 100

Timely Referral to NephrologyTimely Referral to Nephrology

• Referral indications• Uncontrolled HTN on numerous agents• Proteinuria > 1Gm/24 hr• Estimated GFR < 60 ml/min

Early InterventionEarly Intervention

• When creatinine level reaches 1.5 to 2.0 mg/dl most patients have lost more than one half of their GFR

Stage 3 Stage 3

• GFR 59 - 30 ml/min 1. Evaluate and treat complications2. Slow Progression

Anemia Management Anemia Management

• Iron replacement if ferritin less than 300 or percent of transferrin saturation less than 20%• Oral iron• IV iron• Administer Erythropoiten

Bone Disease and Disorders of Calcium and Bone Disease and Disorders of Calcium and Phosphorous Metabolism Phosphorous Metabolism

• Osteitis fibrosa cystica: most common in CKD, associated with high PTH levels• Adynamic bone disease: associated with low or normal PTH levels

Bone Disease Bone Disease

• High serum phosphorus: Low phosphorus diet• Phosphate binders: Calcium carbonate or Sevalamer

Metabolic Acidosis Metabolic Acidosis

• Acid base disorder characterized by a fall in serum bicarbonate concentration

Metabolic Acidosis Metabolic Acidosis

• Failure to treat may:• Decrease bone mineralization• Increase protein catabolism

• Management• Sodium bicarbonate treatment

Volume Overload Volume Overload

• Edema• Shortness of breath, DOE, PND, Orthopnea• CHF• HTN

Volume Overload Volume Overload

• Management:• Fluid restriction• Diuretics• DC medications that may contribute to sodium and water retention

Hyperkalemia Hyperkalemia

• Increases in serum potassium level and generally more prevalent in later stages of CKD• Assessment:• Elevated serum potassium level• EKG changes• Muscle weakness

Hyperkalemia Management Hyperkalemia Management

• Low K + Diet• Careful use of medications (ACEI & ARBS and aldosterone inhibitors) that may contribute to hyperkalemia• Sodium polystyrene• Dialysis if indicated

Stage 4 Stage 4

• GFR 29 - 15 ml/min 1. Treat complications2. Prepare for renal replacement therapy

Management of CKD Management of CKD

• Taking care of the BEANS B = Blood pressure E = EPO A = Access for long term dialysis N = Nutritional care S = Specialist referral

B = Blood Pressure Control B = Blood Pressure Control

• ACEI or ARB• < 130/80• HTN exacerbates the vascular complications of diabetes• DM plus HTN have 5-6 fold higher risk of developing CKD 6 than HTN alone

E = Erythropoietin E = Erythropoietin

• Higher HCT improves LVH and CHF• When Hgb < 10 or HCT < 30• Check Fe, TIBC, Ferritin• Check stools for occult blood• Improved Hgb leads to improved energy levels and ability to work

A = Access A = Access

• Ideally-early creation of simple AV fistula with 3-6 months to mature• Avoid subclavian catheters secondary to subclavian stenosis

A = Access cont.. A = Access cont..

• Create AV fistula when serum creatinine is greater than 4 or GFR < 20 ml/min• Synthetic AV grafts inserted can be uses 2-4 weeks after placement• CAPD catheters inserted 3-4 weeks before use

N = Nutrition N = Nutrition

• Malnutrition in CKD 5 extremely common • Albumin is marker of nutrition• 2 year mortality > 3.0 g/dl = 20-30%• 2 year mortality < 3.0 g/dl = 30-40%

N = Nutrition cont.. N = Nutrition cont..

• Uremic anorexia often causes spontaneous protein restriction• Folate•Avoid vitamins A,C, titrate D3 carefully

N = Nutrition cont.. N = Nutrition cont..

• Phosphorus should be kept at level between 3.5 and 5.0• Use calcium acetate or calcium carbonate• Renagel, Lanthanum• Sensipar• Ideally dietary PO4 less than or equal to 1 Gm/day

S = Specialist Referral S = Specialist Referral

• Acute GN, nephrosis-see Nephrologist ASAP• See Nephrology GFR < 30 Serum creatinine 3.0 or more

S = Specialist Referral cont..S = Specialist Referral cont..

• Gateway to• Early dialysis access• Renal Dietician• Renal Social Worker• RN Educators

• Continuation and nurture of primary care-patient relationship after dialysis begins