1. Management of chronic kidney disease
Dr. Péter Studinger
Semmelweis University, First Department of Medicine
27/11/2015

2. Chronic kidney disease (CKD) - definition
Abnormalities of kidney structure or function
present for > 3 months
with implications for health
Glomerular filtration rate < 60ml/min/1.73 m2
Markers of kidney damage
albuminuria (AER > 30 mg/24 h / UACR > 3 mg/mmol)
urine sediment abnormalities
electrolyte and other abnormalities due to tubular disorders
abnormal histological finding
imaging abnormalities (small kidneys, polycystic kidneys)
history of kidney transplantation

3. Chronic kidney disease (CKD) - staging

4. Chronic kidney disease (CKD) –
who should be referred to a nephrologist ?
eGFR
• <15 ml/min/1.73m2 urgently (except pre mortem condition)
• ml/min/1.73m2 always, urgently if unstable
• ml/min/1.73m2 if age < 70 years
if eGFR falls rapidly (> 4 ml/min/1.73m2 / year)
if Hgb < 110 g/l or abnormal K, Ca, P, HCO3
• ml/min/1.73m2 if other condition necessitates referral

5. Chronic kidney disease (CKD) –
who should be referred to a nephrologist?
proteinuria / hematuria
• nephrotic syndrome: urgently
• UPCR > 350 mg/mmol: always, diabetes included
• UPCR >100 mg/mmol: always, except in diabetes
• UPCR > 45 mg/mmol: if associated with microhematuria
or suspicion if systemic immunologic disorder (SLE, vasculitis)
• microalbuminuria: only if other cause necessitates referral
• macrohematuria: urgently, if associated with proteinuria and
rising Screat
• micro/macrohematuria: without proteinuria, after exclusion of urologic causes

6. Progression of chronic kidney disease
Complications
Kidney
failure
normal
 risk
injury
 GFR
death
Prevention of progression
Treatment of complications
Preparation to dialysis
Screening for risk factors
Screening for kidney injury
Risk reduction
Diagnosis and treatment
Prevention of progression
Dialysis
Transplantation

7. Risk factors in chronic kidney disease
Impressionable
high blood pressure
impaired glycemic control
dyslipidemia
lifestyle
smoking
obesity
high protein diet
anemia
proteinuria
disorders of Ca-PO4 homeostasis
„acute-on-chronic” kidney injury
Unimpressionable
age
male gender
genetic abnormalities
race

8. Blood pressure goals in chronic kidney disease
Blood pressure goal : < 140/90 mmHg
„significant proteinuria”: < 130/90 mmHg
RAS-inhibitor (ACEI /ARB)
dual RAS-inhibition contraindicated
eGFR < 30 – spironolacton
contraindicated
ESH/ESC Recommendations,2013
Ravera M et al. JASN 2006

9. Blood pressure goals in chronic kidney disease
CKD 4 -5: tiazide/indapamide alone insufficient
furosemide should be added
CKD 5D : ???
home blood pressure vs. pre-dialysis/post-dialysis blood pressure * * * * * *
pre-dialyis
Zager P et al. Kidney Int. 1998

10. Management of diabetes in chronic kidney disease
Goals:
HbA1c ~ 7%
fasting glucose: < 6 mmol/l, postprandial glucose: < 7.5 mmol/l
CDA Clinical Practice Guidelines 2013

11. Management of dyslipidemia in chronic kidney disease
Large CV risk, independent of CKD stage and lipid levels
Chol < 4.5 mmol/l
LDL < 2.5 mmol/l
TG < 1.7 mmol/l
HDL > 1.0 (men) > 1.3 (women) mmol/l
statin: atorvastatin / fluvastatin / ezetimibe safe
rosuvastatin: CKD 3 – 20 mg, CKD 4-5 – 10 mg max.
fibrate: CKD 4-5 – only gemfibrozil
statin + fibrate: contraindicated in CKD 3-5D
CKD 5D – statin /ezetimibe treatment should not be initiated
– statin treatment should not be stopped if applied already

12. Lifestyle modification in chronic kidney disease
Cessation of smoking
Regular physical activity (min. 30 minutes, 5x/week)
Decrease salt intake (< 5g NaCl = 2g Na+ = 90 mmol Na+ /day)
Decrease protein intake : CKD 1-3: < 1.3 g/kg/day
CKD 4-5: < 0.8 g/kg/day ±
keto acid supplementation
Dietary recommendations
CKD 5D - obesity is favorable!
Kalantar-Zadeh et al., 2004

13. Anemia associated with chronic kidney disease
Anemia: Hb < 130 g/l (men), < 120 g/l (women)
Screening Follow-up
CKD 3: yearly CKD 3-5PD: every 3 months
CKD 4-5: every 6 months CKD 5HD: monthly
CKD 5D: every 3 months
Iron supplementation: CKD 3-5: per os /iv. CKD 5D: optimally iv.
if TSAT < 30% (20%), ferritin < 500 (200) ug/l
control at least every 3 months (TSAT, ferritin)
iv. iron (iron dextran) should be administered cautiously
active infection – do not supplement iron!

14. Anemia associated with chronic kidney disease
Erythropoietin (EPO) treatment:
Initial Hb: g/l (above 100 g/l individualized decision)
goal Hb: g/l, always < 130 g/l
avoidance of EPO considered /: previous stroke, tumor
EPO-resistance:
iron deficiency , Vitamin B12/folate deficiency, malnutrition, infection, uremia (underdialized condition) , hyperparathyroidism, hypothyroidism, bleeding, hemolysis,
malignancies, hematologic disorders

15. Proteinuria in chronic kidney disease
Dipstick
24 h protein
(mg)
TPCR (mg/mmol) –
< 150
< 15
ACR mg/mmol
Proteinuria
Micro-albuminuria
Healthy
< 30
– /trace +
> 450
> 45
> 300
24 h albumin (mg)
< 3
3 - 30
> 30
False positive results: fever, strenuous exercise, urinary infection,
menstruation, uncontrolled hypertension / diabetes
Screening: morning urine sample TPCR – proteinuria
morning urine sample ACR - microalbuminuria

16. Proteinuria in chronic kidney disease
Screening proteinuria / albuminuria
screening
morning urine sample
screening
confirmation
morning urine ACR
morning urine TPCR
follow-up
Significant PU
Nephrotic PU
referral to nephrologist
if other cause
if + hematuria
if + non-diab.
always
treatment
ACEI if diab.
ACEI if non-diab.
+ statin
+ anticoag.
Mátyus et al., 2012

17. Ca-PO4 homeostasis in chronic kidney disease

18. Ca-PO4 homeostasis in chronic kidney disease
Floege J. (ed): Comprehensive Clinical Nephrology , 2010
Diagnosis: bone biopsy (seldom performed)
ODM – CKD 3B-5D: no sense / therapeutic consequence
measurement of collagen synthesis /degradation markers: no sense

19. Ca-PO4 homeostasis in chronic kidney disease
PO4 control: - PO4 intake < mg/day application of phosphate binders
CKD 3-5: CaCO3, Ca-acetate
CKD 5D: above ± sevelamer, lanthanum
Goal: normal range
Native vitamin D: CKD 3-5D: measure 25OH vitamin D level correct vitamin D deficiency
Active Vitamin D: CKD 3-5D: calcitriol, alpha-calcidol CKD 5D: paricalcitol
PTH: CKD 5D: calcimimetic – cinacalcet
Goal: CKD 3-5: ??? (probably normal range)
CKD 5D: x upper normal level