Chronic Kidney Disease (CKD)

Notes

## Basic introduction:

  • CKD is defined as the existence of irreversibly advanced and usually progressive renal failure.
  • CKD is also defined based on GFR of <60 ml/min/1·73 m² for ≥ 3 months, irrespective of clinical diagnosis.
  • Accelerated progression of CKD is defined aa sustained decrease in GFR ≥ 25%  and a change in GFR category within 12 months, or a sustained decrease in GFR of 15 ml/min/1.73 m2/year
  • A loss of 75% of renal tissue causes a fall in GFR to only 50% of normal.
  • CKD has a high global prevalence of 11 - 13% with the majority cases being in stage 3

## Causes of CKD:

  • Chronic glomerulopathies
  • Chronic interstitial nephritis
  • Hypertension
  • Diabetes mellitus
  • Hypercalcemia
  • Neoplasms
  • Myeloma
  • Diseases affecting other body systems including renal e.g. Systemic lupus erythematosus
  • Hereditary predisposition to renal diseases such as polycystic kidneys

## Classification of CKD:

  • Stage 1: (normal) - eGFR >90 ml/min/1.73 m2 PLUS other evidence of chronic kidney damage.
  • Stage 2: (mild impairment) - eGFR 60-89 ml/min/1.73 m2 PLUS other evidence of chronic kidney damage.
  • Stage 3a: (moderate impairment) - eGFR 45-59 ml/min/1.73 m2.
  • Stage 3b: moderate impairment - eGFR 30-44 ml/min/1.73 m2.
  • Stage 4: (severe impairment) - eGFR 15-29 ml/min/1.73 m2.
  • Stage 5: (established renal failure) - eGFR < 15 ml/min/1.73 m2 or on dialysis

NB: eGFR - Estimated Glomerular Filtration Rate

Source: National Kidney Foundation https://www.kidney.org/professionals/explore-your-knowledge/how-to-classify-ckd

## Risk factors for CKD:

  • Hypertension
  • Diabetes mellitus
  • History of previous renal disease
  • Smoking
  • Cardiovascular disease
  • NSAIDS (especially long-term treatment

African, African-Caribbean or Asian race

Symptoms
  • It is asymptomatic at early stage
  • Chronic elevated blood urea and creatinine
  • Chronic hematuria
  • Chronic proteinuria
  • Chronic glomerulonephritis (confirmed by biopsy)
  • Hyperkalemia
  • Darkening of the skin
  • Excessive bleeding characterized by epistaxis and bleeding from the gum
  • Hypertension
  • Pulmonary edema
  • Heart failure
  • Pericarditis and cardiac tamponade
  • Bone pains and rarely fractures
  • Peripheral neuropathy
  • Encephalopathy that is characterized by confusion and convulsions
  • Renal defects after imaging
  • Sexual dysfunction
  • Acidosis
  • Anemia (mainly due to deficient erythropoietin production as a result of a reduction of functional renal mass)
  • Anorexia
  • Nausea
  • Headache
  • Hiccups
  • Nocturia
  • Polyuria
  • Pruritus
  • Vomiting
  • Stomatitis
  • Dysgeusia (feeling of bad taste)
Diagnosis
  • Clinical review
  • eGFR
  • Urinalysis, culture and sensitivity
  • Blood Urea & creatinine (though they are not so reliable as they can be about normal even after severe renal failure)
  • Electrolyte
  • FBC
  • Renal ultrasound
  • Additional tests to ascertain whether urinary tract is blocked or not are X-ray, CT scan, and MRI
Differential
  • Acute Kidney Injury (AKI)
  • Antiglomerular Basement Membrane Disease
  • Chronic Glomerulonephritis
  • Diabetic Nephropathy
  • Ischemic nephropathy
  • Multiple Myeloma
  • Nephrolithiasis
  • Nephrosclerosis
  • Nephrotic syndrome
  • Obstructive uropathy
  • Rapidly Progressive Glomerulonephritis
Prevention
  • Control underlying disorders
Management
  • Treatment of co-morbid illness such as hypertension, anemia and hyperkalemia
  • In case of hypocalcaemia give calcium carbonate tablets
  • Also give Alpha D3
  • SC inj. Erythropoietin 2,000 – 4,000 IU twice a week
  • Restriction salt, potassium, phosphate and protein intake
  • Dialysis (hemodialysis or peritoneal dialysis) or Renal transplant (when eGFR < 15 ml/min/1.73 m2)
  • Doses of most drugs need be adjusted
  • Maintaining sodium bicarbonate level at 23 mmol/L
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