1. Chronic Kidney Disease CKD

2. Definition 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.

3. Definition of Chronic Kidney Disease
GFR ≤ 60 ml/min/ 1.73 m² for ≥ 3 months, with or without damage.

4. Stages of Chronic Kidney Disease
Stage 1 CKD GFR is > 90 mL/ min
Stage 2 CKD GFR is mL/min
Stage 3 CKD GFR is mL/min
Stage 4 CKD GFR is mL/min
Stage 5 CKD GFR is < 15 mL/min

5. Etiology of Chronic Kidney Disease
Diabetes %
HTN %
Glomerular disorders %
Underlying renal disease all other causes 18%
Automimmune disease
Polycystic kidney disease
Other
Infections
Obstructive uropathy
Interstitial disorders

6. Risk Factors for Chronic Kidney Disease
Diabetes
HTN
Age
Family history of kidney disease or diabetes
Male gender

7. Risk Factors for Chronic Kidney Disease cont..
Racial ethnic background
African American
Native American
Asian American
Pacific Islander
Latin American
Tobacco use

8. Risk Factors for Chronic Kidney Disease cont..
Coexisting kidney disease
Anemia
High protein diet (controversial)
Hyperlipidemia

9. Risk Factors for Chronic Kidney Disease cont..
Atherosclerosis
Obesity
Exposure to nephrotoxic drugs
NSAIDS
Contrast Dye
Hydrocarbons

10. Recommended Screening Tests for Chronic Kidney Disease
Serum Creatinine
Blood Pressure
Glucose
Urinalysis
Microalbuminuria/Proteinuria

11. 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

12. Urinalysis Abnormalities of urine sediment RBC and RBC casts
WBC and WBC casts
Tubular cells
Cellular casts
Granular casts
Fats

13. 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

14. 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

15. 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

16. 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

17. Radiographic Studios Ultrasound
General appearance, increased echogenicity , size disparities and scarring, doppler interrogation

18. Radiographic Studios cont..
Intravenous pyelography (IVP)
Risk from use of iodinated dyes, used infrequently

19. Radiographic Studios cont..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

20. Nuclear Scan
Symmetry of kidney size or function, RAS, acute pyelonephritis, or scarring

21. Renal Biopsy
Invasive procedure to determine the nature and extent of kidney disease
Provides information on the diagnosis

22. Renal Biopsy cont.. May guide the treatment of kidney disease
Provide prognosis information

23. 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

24. Management of CKD Stages 1 and 2 cont..
Use of ACE I or ARB
Reduce proteinuria
Avoid nephrotoxins

25. 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

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

27. Monitoring Therapy Monitor for: Hypotension Decreased GFR Hyperkalemia
May continue if serum potassium is < 5.5 or decline of GFR < 30% in 4 months

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

29. 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

30. Lipid Control
CKD is a CHD risk equivalent
LDL goal < 100

31. Timely Referral to Nephrology
Referral indications
Uncontrolled HTN on numerous agents
Proteinuria > 1Gm/24 hr
Estimated GFR < 60 ml/min

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

33. Stage 3 GFR 59 - 30 ml/min Evaluate and treat complications
Slow Progression

34. Anemia Management
Iron replacement if ferritin less than 300 or percent of transferrin saturation less than 20%
Oral iron
IV iron
Administer Erythropoiten

35. Bone Disease and Disorders of Calcium and Phosphorous Metabolism
Osteitis fibrosa cystica: most common in CKD,
associated with high PTH levels
Adynamic bone disease: associated with low or normal PTH levels

36. Bone Disease High serum phosphorus: Low phosphorus diet
Phosphate binders: Calcium carbonate or Sevalamer

37. Metabolic Acidosis
Acid base disorder characterized by a fall in serum bicarbonate concentration

38. Metabolic Acidosis Failure to treat may: Decrease bone mineralization
Increase protein catabolism
Management
Sodium bicarbonate treatment

39. Volume Overload
Edema
Shortness of breath, DOE, PND, Orthopnea
CHF
HTN

40. Volume Overload Management: Fluid restriction Diuretics
DC medications that may contribute to sodium and water retention

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

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

43. Stage 4 GFR 29 - 15 ml/min Treat complications
Prepare for renal replacement therapy

44. 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

45. 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

46. 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

47. A = Access
Ideally-early creation of simple AV fistula with 3-6 months to mature
Avoid subclavian catheters secondary to subclavian stenosis

48. 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

49. 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%

50. N = Nutrition cont..
Uremic anorexia often causes spontaneous protein restriction
Folate
Avoid vitamins A,C, titrate D3 carefully

51. 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

52. S = Specialist Referral
Acute GN, nephrosis-see Nephrologist ASAP
See Nephrology
GFR < 30
Serum creatinine 3.0 or more

53. 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