Chronic Kidney Disease

Lavadia, MD
Liwanag, MD
Internal Medicine
Objectives
1. Be able to define Chronic Kidney Disease, able to be familiar with staging
and prognosis of CKD
2. To identify and acknowledge clinical manifestation of CKD
3. To know the management of CKD:
a. Prevention of progression
b. Control of symptoms
4. Be able to identify complications of CKD and its management.
5. To know the role of Renal Replacement Therapy in CKD patients.
REPORT OUTLINE
1. Definition and classification of Chronic Kidney Disease
a. Definition of CKD
b. Staging of CKD
c. Predicting prognosis of CKD
2. Management of progression and complications of Chronic Kidney Disease
a. Prevention of CKD progression
i. BP and RAAS interruption
ii. Protein intake
iii. Glycemic control
iv. Salt intake
v. Hyperuricemia
vi. Other recommended therapy
REPORT OUTLINE
b. Complications of CKD
i. Anemia
ii. Metabolic bone disease
iii. Acidosis
iv. Cardiovascular risk
v. Risk of infections
c. Role of renal replacement therapy
i. When to initiate renal replacement
ii. Types of renal replacement therapy
d. Conservative management in CKD
Case
● N.J.
● 27/M

● CC: fever and chills during HD

This Photo by
Unknown Author
is licensed under
CC BY-NC
History of Present Illness
● Recently admitted last Feb 1-23, 2021 as a case of
○ Uremic Encephalopathy
Anemia and Hyperkalemia prob secondary to AKI sec to 1) Herbal Medicine 2) Drug (ARB) on top of probable CKD
stage V sec to 1) CGN 2) Hypertensive Nephrosclerosis
Hypertension stage II, controlled
○ Regular Hemodialysis at Osmak every Tues and Sat.
● Patient was discharged well.
○ Morning PTC, during dialysis, patient had fever of 38C. Denies cough, dob, palpitations, diaphoresis. He was given
Paracetamol and was referred to ER for management.
 Review of Systems

HEENT: No headache, no injury, (-) Neck Pain,

Constitutional, no fever, loss of appetite, fatigue
dizziness

C/L: No Cough, No Hemoptysis, No SOB

CVS: No Chest pain, no tightness, no palpitations, no
exertional dyspnea

Abdomen: No heartburn, no early satiety, no vomiting

No BM changes

Urinary: decreased frequency of voiding, no urgency,

no dysuria, no hematuria, no incontinence
Skin: No dryness, no blisters

Vascular: No leg pain, no easy bruising,

Musculoskeletal: Muscle, Joint Pain, Redness of joints,

no trauma
Past Medical History
● Recently diagnosed with Hypertension – January 2021, LHC
○ Losartan 50mg/tab OD
○ Self Medicates with Aspirin – dizziness
● Not known diabetic
● No prior surgeries
● Unremarkable dermatologic history
● No allergies
Personal and Social History
● Consumes about 1-2 sticks/day in ~ 1 year
● Denies use of illicit Drugs
● (+) use of Herbal Tea (Serpentina) for 3 months ~ 1 year
Family History
● unremarkable
 Temporal Profile

Day of Consult
Few months PTA On regular dialysis  ER due to fever and
chills
Easy fatigability, dizziness 3/9 NA 139 K 4.6 CL 105.6 ICA 1.11 MG
No fever, LBM, dysuria, 1.03 P 1.07
vomiting, no tea colored urine, 3/7 BUN 17.30 CREA 1234 NA 139 K 4.5
no jaundice, no changes in CL 104.20 ICA 1.01 MG 1.04 P 1.36 ALB 26
U.O.
Hgb: 9.0
Hospitalized Feb 1-22, seen with findings of Anemia (Hgb 5.2), Electrolytes:
BUN 63.6 CREA 2914 NA 130 K 4 ICA 0.59 MG 1.12 KUB UTZ 02/10: BILATERALLY SMALL
Phos4.75 KIDNEYS WITH PARENCHYMAL
DISEASE; CYSTITIS;
Underwent hemodialysis with discharge labs:
UNDERDISTENDED URINARY
2/21 HGB 9.6 HCT 0.30 WBC 13.3 RBC 3.4 LT 188 SEG 86 LYM 6 MONO 8 BLADDER WITH INDWELLING FOLEY
2/21 BUN 29.80 CREA 1168 NA 141 K 3.4 ICA 0.95 MG 1.07 PH 1.92 CATHETER; MINIMAL BILATERAL
PERINEPHRIC AND PELVIC ASCITES
02/02 PH 7.16 PCO2 20 PO2 170 HCO3 7.1 O2 SAT 99 AT 1LPM

2 months PTA
Physical Examination
VS : 140/90, 78, 18, 37.9 98%

General Survery Conscious coherent not in cardiorespiratory

distress
SHEENT Skin is dry, Pink palpebral conjunctivae, anicteric
sclera, (-) Cervical lymphadenopathy, (-) neck vein
engorgement (-) tonsillopharyngeal congestion
Chest and Lungs Chest: Symmetrical chest expansion, no
retractions, crackles on the Right Lung Base.

Cardiovascular Adynamic precordium, normal rate, regular rhythm,

(-) murmurs
Physical Examination

Cardiovascular Adynamic precordium, normal rate, regular

rhythm, (-) murmurs
Abdomen Abdomen: Flat/flabby, soft, non tender,
normoactive bowel sounds, (-)palpable mass,
Extremities Extremities: full and equal pulses (-) cyanosis (-)
edema
Salient Features

● 27/M, known case of CKD on regular HD

● Easy Fatigability, dizziness, fever on HD, with
● PE: crackles on right lung base
● Dx:
○ BUN 63.6 CREA 2914 NA 130 K 4 ICA 0.59 MG 1.12
○ Anemia (Hgb 5.2)
○ Phos4.75
○ KUB UTZ 02/10: BILATERALLY SMALL KIDNEYS WITH PARENCHYMAL DISEASE
○ 02/02 PH 7.16 PCO2 20 PO2 170 HCO3 7.1 O2 SAT 99 AT 1LPM
Present Working Impression
Catheter Related Bloodstream Infection
Hospital Acquired Pneumonia
COVID suspect, moderate pneumonia
CKD Vd secondary to: CGN vs HPN NSS
Hypertension Stage II, controlled
s/p femoral catheter insertion (2/15/21, OsMak)
DEFINITION AND
CLASSIFICATION OF
CHRONIC KIDNEY
DISEASE
Definition of Chronic Kidney Disease

“CKD is defined as abnormalities of kidney structure or

function, present for >3 months with implications for
health”
-KDIGO 2013
Definition of Chronic Kidney Disease
Definition of Chronic Kidney Disease
Staging of Chronic Kidney Disease

“Classified based on cause, GFR category, and

albuminuria category”
- KDIGO 2013
Classification based on Estimated Glomerular Filtration Rate

“We recommend using serum creatinine and a GFR

estimating equation for initial assessment.”
- KDIGO 2013
Classification based on Estimated Glomerular Filtration Rate
Classification based on Estimated Glomerular Filtration Rate
Classification based on Estimated Glomerular Filtration Rate

“Report eGFR in adults using the 2009 CKD-EPI

creatinine equation”
-KDIGO 2013
2009 CKD-EPI Creatinine equation
Classification based on Estimated Glomerular Filtration Rate

“We suggest using additional tests (such as cystatin C or a

clearance measurement) for confirmatory testing in
specific circumstances when eGFR based on serum
creatinine is less accurate”
KDIGO 2013
2012 CKD-EPI creatinine–cystatin C equation:
Staging of Chronic Kidney Disease

“Assign albuminuria *note that where albuminuria measurement

is not available, urine reagent strip results can be substituted”
- KDIGO 2013
Classification based on Albuminuria

COMPREHENSIVE NEPHROLOGY 6TH EDITION

COMPREHENSIVE NEPHROLOGY 6TH EDITION
Staging of
Chronic Kidney
Disease
RATIONALE
● greater than 3 times
the normal value
● reagent strip can
detect albumin as
trace
● increased risks of
complications of CKD
Staging of Chronic Kidney Disease
Staging of Chronic Kidney Disease

“Assign cause of CKD based on presence or absence of

systemic disease and the location within the kidney of
observed or presumed pathologic-anatomic findings”
- KDIGO 2013
Classification based on Chronic Kidney Disease cause
Classification based on Chronic Kidney Disease cause
Prognosis of Chronic Kidney Disease

“Identify factors associated with CKD progression to inform

prognosis. This include cause of CKD, level of GFR, level of
albuminuria, age, sex, race/ethnicity, elevated BP, hyperglycemia,
dyslipidemia, smoking, obesity, history of CVD, ongoing
exposure to nephrotoxic agents”
- KDIGO 2013
Prognosis of Chronic Kidney Disease
MANAGEMENT OF
PROGRESSION AND
COMPLICATIONS OF
CKD
PREVENTION OF CKD PROGRESSION
Blood pressure and RAAS interruption
Blood pressure and RAAS interruption

COMPREHENSIVE NEPHROLOGY 6TH EDITION

Blood pressure and RAAS interruption

COMPREHENSIVE NEPHROLOGY 6TH EDITION

COMPREHENSIVE NEPHROLOGY 6TH EDITION
COMPREHENSIVE NEPHROLOGY 6TH EDITION
Protein intake

“Lowering protein intake to 0.8g in adults with diabetes or without

diabetes and GFR <30ml/min/1.73m2”
“Avoid high protein intake (>1.3g/kg/day) in adults with CKD at risk
of progression”
- KDIGO 2013
Glycemic Control

“Target hemoglobin A1c of = 7.0% (53 mmol/mol) to

prevent or delay progression of the microvascular
complications of diabetes”
- KDIGO 2013
Salt intake

“We recommend lowering salt intake to <90 mmol (<2g)

per day of sodium (corresponding to 5g of sodium
chloride) in adults, unless contraindicated”
- KDIGO 2013
Hyperuricemia

“There is insufficient evidence to support or refute the use of

agents to lower serum uric acid concentrations in people with
CKD and either symptomatic or asymptomatic hyperuricemia
in order to delay progression of CKD”
- KDIGO 2013
Lifestyle and Dietary advice

“We recommend that people with CKD be encouraged to

undertake physical activity compatible with health and
tolerance (aiming for at least 30 mins 5 times per week),
achieve a healthy weight (BMI 20 to 25) and stop smoking”
- KDIGO 2013
COMPLICATIONS OF CKD
Anemia

“Diagnose anemia in adults and children >15 year old

with CKD when the HB concentration is <13.0 g/dl
(<130g/l) in males and <12.0 g/dl (120g/l) in females”
- KDIGO 2013
Anemia

“Initial evaluation of anemia includes; Complete blood count,

which include HB concentration, red cell indices, white blood cell
count and differential, and platelet count; absolute reticulocyte
count, serum ferritin level, serum transferrin saturation, serum
vitamin B12 and folate levels”
- KDIGO 2013
Anemia
Anemia
Anemia

“Avoid administering IV iron to patients with active

systemic infections.”
- KDIGO 2013
Anemia

“Address all correctable causes of anemia (including iron

deficiency and inflammatory states) prior to initiation of
ESA therapy”

- KDIGO 2013
Anemia
“For adult CKD ND patients with Hb concentration >10.0g.dl, we suggest
that ESA therapy not initiated”
“For adult CKD ND patients with HB concentration <10.0g/dl, decision
to initiate ESA therapy should be individualized”
“For adult CKD 5D patients, ESA therapy be used to avoid having HB
concentration fall below 9.0g/dl by starting ESA therapy when
hemoglobin is between 9.0-10.0g/dl”
- KDIGO 2013
Metabolic bone disease

“We recommend measuring serum levels of calcium,

phosphate, PTH, and alkaline phosphatase activity at
least once in adults with GFR <45ml/min/1.73m2”
- KDIGO 2013
Metabolic bone disease
Metabolic bone disease
Metabolic bone disease

“In people with GFR 45 ml/min/1.73m2 (GFR categories G3b-G5), we

suggest maintaining serum phosphate concentrations in the normal
range according to local laboratory reference values.”
“We suggest not to prescribe bisphosphonates in people with GFR
<30ml/min/1.73m2, without a strong clinical rationale”
- KDIGO 2013
Acidosis

“We suggest that in people with CKD and serum

bicarbonate concentrations <22 mmol/L treatment with
oral bicarbonate supplementation be given to maintain
serum bicarbonate within the normal range, unless
contraindicated.”
- KDIGO 2013
Cardiovascular disease
● Leading cause of morbidity and mortality in every stage of CKD
● Increased risk of hypertension, left ventricular hypertrophy, ischemic heart
disease, heart failure
● NICE (National Institute for Health and Care Excellence) suggest
antiplatelets offered → secondary prevention of CVD
● STATINS be offered → >50 years old and <50 years old but with additional
risk factors
● BP goal <130/80mmhg: in patients with DM and proteinuria >1g/24 hours
● ACE-I and ARBS slow the rate of decline of kidney function
Risk of infections
● Second most common cause of death
● Pathophysiology: T-cell response to de novo antigens are deficient,
neutrophil activation is defective, antibody responses to immunization is
poor
● Increased risk: Staph infection, TB reactivation, and HEP B and C
infection
● KDIGO recommends: Adults with CKD be offered influenza and
pneumococcal vaccination
RENAL REPLACEMENT THERAPY
● Can be in the ff modalities
○ Renal Transplant – offers the best potential for complete rehabilitation
○ Hemodialysis
○ Peritoneal Dialysis
● Dialysis relies on the principles of solute diffusion across a semipermeable
membrane, dependent on concentration gradient from the circulation into the
dialysis.
Absolute Indications Relative Indications

• Pericarditis/pleuritis (urgent indication) • Anorexia, and nausea

• Progressive uremic enceph: or • Impaired nutritional status
neuropathy, with signs of confusion, • Increased sleepiness
asterixis, myoclonus, wrist or foot drop, • Decreased energy level, attentiveness,
seizures (urgent indication) and cognitive tasking
• Clinically significant bleeding diathesis
attributable to uremia (urgent indication)
• Persistent metabolic distrubances that are
refractory to medical therapy:
hyperkalemia, hypercalcemia, metab. Acid,
hypocalcemia, hyperphosphatemia
• Fluid overload refractory to diuretics
• Hypertension poorly responsive to
antihypertensives
• Persistent nausea/vomiting
• Evidence of Malnutrition
 Reducing
Intraglomerular
Hypertension and
Proteinuria
Slowing the
progression of Diabetic
Nephropathy
Managing
Complications of CKD

CKD-MBD: Use of
phosphate binders, anti-
PTH: calcitriol
References
● Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons
Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
● Fatehi p., Hsu C., (2021), Chronic kidney disease (newly identified): Clinical presentation and
diagnostic approach in adults UpToDate. Retrieved March 14, 2021.
https://www.uptodate.com/contents/chronic-kidney-disease-newly-identified-clinical-
presentation-and-diagnostic-approach-in-adults.
● KDIGO Executive Committee. (2017). CKD, 101(8S), S1.
https://doi.org/10.1097/01.tp.0000522276.01738.f0.