CHRONIC KIDNEY DISEASE

RS BHAKTI MULIA

Dr. Bhanu BMedSc, SpPD

 STAGES IN PROGRESSION OF CHRONIC KIDNEY
DISEASE AND THERAPEUTIC STRATEGIES

Complications
Complications

Increased
Increased Kidney
Kidney CKD
CKD
Normal
Normal Damage
Damage  GFR
GFR
risk
risk failure
failure death
death

Screening CKD risk Diagnosis Estimate Replacement

for CKD reduction; & treatment; progression; by dialysis
risk factors Screening for Treat Treat & transplant
CKD comorbid complications;
conditions; Prepare for
Slow replacement
progression
Acute Kidney Disease
Limitations of RIFLE Criteria

• Need for baseline SCr

• Complex determination of UOP
• Often not used in clinical situations
Signs of Kidney diseases
CHRONIC KIDNEY DISEASE
DEFINITION

CHRONIC KIDNEY DISEASE IS DEFINED AS A SLOW LOSE OF RENAL FUNCTION

OVER TIME. THIS LEADS TO A DECREASED ABILITY TO REMOVE WASTE
PRODUCTS FROM THE BODY AND PERFORM HOMEOSTATIC FUNCTIONS.
DURATION OF ILLNESS : 3 MONTHS
CLINICAL DEFINITION

• GFR OF LESS THAN 60 ML/MINUTE PER 1.73M2 PER BODY

SURFACE AREA (NORMAL IS 125ML/MIN) .
• GFR CALCULATOR:
HTTP://WWW.KIDNEY.ORG/PROFESSIONALS/KDOQI/GFR_CALC
ULATOR.CFM
• PRESENCE OF KIDNEY DAMAGE, REGARDLESS OF THE
CAUSE, FOR THREE OR MORE MONTHS
IMPORTANCE OF PROTEINURIA IN CKD
Interpretation Explanation

Marker of kidney Spot urine albumin-to-creatinine ratio >30 mg/g or

damage spot urine total protein-to-creatinine ratio >200 mg/g
for >3 months defines CKD
Clue to the type Spot urine total protein-to-creatinine ratio >500-
(diagnosis) of CKD 1000 mg/g suggests diabetic kidney disease,
glomerular diseases, or transplant glomerulopathy.

Risk factor for adverse Higher proteinuria predicts faster progression of

outcomes kidney disease and increased risk of CVD.
Effect modifier for Strict blood pressure control and ACE inhibitors are
interventions more effective in slowing kidney disease
progression in patients with higher baseline
proteinuria.

Hypothesized If validated, then lowering proteinuria would be a

surrogate outcomes goal of therapy.
and target for
interventions
PATHOPHYSIOLOGY

• REPEATED INJURY TO KIDNEY

SYMPTOMS

• HEMATURIA
• FLANK PAIN
• EDEMA
• HYPERTENSION
• SIGNS OF UREMIA
• LETHARGY AND FATIGUE
• LOSS OF APPETITE
• IF ASYMPTOMATIC MAY HAVE ELEVATED SERUM CREATININE
CONCENTRATION OR AN ABNORMAL URINALYSIS
 RISK FACTORS

• AGE OF MORE THAN 60 YEARS

• HYPERTENSION AND DIABETES
• RESPONSIBLE FOR 2/3 OF CASES
• CARDIOVASCULAR DISEASE
• FAMILY HISTORY OF THE DISEASE.
• RACE AND ETHNICITY
• HIGHEST INCIDENCE IS FOR AFRICAN AMERICANS
• HISPANICS HAVE HIGHER INCIDENCE RATES OF ESRD THAN NON-
HISPANICS.
CONVERGENCE OF GENETIC FACTORS
• GENES FOR HEART AND VASCULAR DISEASE
• GENES THAT MAINTAIN IONIC BALANCE
• GENES FOR GLOMERULONEPHRITIS
• GENES FOR DIABETES
• GENES THAT MAY BE INVOLVED IN INHERITED RENAL
DISEASES
 IMPORTANCE OF PROTEINURIA IN CKD
Interpretation Explanation

Marker of kidney Spot urine albumin-to-creatinine ratio >30 mg/g or

damage spot urine total protein-to-creatinine ratio >200 mg/g
for >3 months defines CKD
Clue to the type Spot urine total protein-to-creatinine ratio >500-
(diagnosis) of CKD 1000 mg/g suggests diabetic kidney disease,
glomerular diseases, or transplant glomerulopathy.
Risk factor for adverse Higher proteinuria predicts faster progression of
outcomes kidney disease and increased risk of CVD.
Effect modifier for Strict blood pressure control and ACE inhibitors are
interventions more effective in slowing kidney disease
progression in patients with higher baseline
proteinuria.

Hypothesized If validated, then lowering proteinuria would be a

surrogate outcomes goal of therapy.
and target for
interventions
WE CAN HAVE AN IMPACT ON PROGRESSION OF
CKD

• INTENSIVE GLYCEMIC CONTROL LESSENS PROGRESSION FROM MICROALBUMINURIA

IN TYPE 1 DIABETES–GOAL IN TYPE 2 IS LESS CLEAR
- DCCT, 1993

- ACCORD, 2008

• ANTIHYPERTENSIVE THERAPY WITH ACE INHIBITORS OR ARBS LESSENS PROTEINURIA

AND PROGRESSION
- GIATRAS, ET AL., 1997
- PSAIT, ET AL., 2000
- JAFAR, ET AL., 2001

• BLOOD PRESSURE BELOW 130/80 IS BENEFICIAL

- SARNAK, ET AL., 2005
 GENETICS OF CKD
• MARKERS OF KIDNEY FUNCTION FOUND TO BE 27-33%
HERITABLE.
• SERUM CREATININE, GFR, ALBUMIN, PROTEINURIA, BUN

• MANY GENES ASSOCIATED WITH CHRONIC KIDNEY DISEASE:

• APOL1 IN AFRICAN AMERICANS
• UMOD
• SHROOM3
• GATM-SPATA5L1
• MMP20
• MPPED2, DDX1, CDK12, CASP9, AND INO80
• LASS2, GCKR, ALMS1, TFDP2, DAB2, SLC34A1, VEGFA, PRKAG2, PIP5K1B, ATXN2,
DACH1, UBE2Q2, AND SLC7A9N
 WHAT SHOULD PATIENTS AND DOCTORS KNOW
PREVENTION
• KEEP DIABETES AND BLOOD PRESSURE CONTROLLED
• IF AT RISK PERFORM SCREENING TESTS
• REDUCE EXPOSURE TO NEPHROTOXIC DRUGS
• EAT RIGHT AND EXERCISE
• MONITORING EVERY 3 MONTHS FOR MEDIUM RISK PATIENTS /
• ONCE A MONTH FOR HIGH RISK PATIENTS
• KNOW YOUR FAMILY HISTORY
• IF YOU HAVE A POSITIVE FAMILY HISTORY ASK DOCTOR TO PERFORM COMMON
SCREENING TESTS FOR KIDNEY FUNCTION.
 WHAT CAN PRIMARY CARE PROVIDERS DO?
(CONTINUED)

• Monitor eGFR and UACR

• Treat cardiovascular risk, especially with smokers and
hypercholesterolemia
• Screen for anemia (Hgb), malnutrition (albumin), metabolic bone
disease (Ca, Phos, PTH)
• Refer to dietitian for nutritional guidance
• Consult or team with a nephrologist
• Encourage labs to report estimated eGFR and urine
albumin/creatinine ratios
 INDICATIONS OF URGENT DIALYSIS (CITO)

A : ACIDOSIS – METABOLIC
E : ELECTROLYTE IMBALANCE
I : INTOXICATION
O : OVERLOAD
U : UREMIC SYNDROME (ENCEPHALOPATHY,
GASTROPATHY)
INDICATIONS OF DIALYSIS (INITIATION)
EGFR < 15 ML/MIN/1.73M2
WITH SYMPTOMS

OR

EGFR < 7 ML/MIN/1.73M2

WITH OR WITHOUT SYMPTOMS

MAKE SURE TO EXCLUDE ACUTE KIDNEY INJURY FIRST