Dr Chaitanya Vemuri

Kidney damage for >= 3months ,

as defined by structural / functional abnormalities of kidney with or without decreased GFR, and manifest by either : Pathologic abnormalities Markers of kidney damage, including abnormalities in composition of blood / urine or abnormalities on imaging GFR < 60 ml/min/1.73m2 for >=3 months, with / without kidney damage

 By Radiology USG / CT / MRI etc By Histology Renal Biopsy

 Microalbuminuria
Proteinuria Hematuria esp associated with proteinuria

Casts ( with cellular elements )

Cockcroft-Gault formula Ccr (ml/min) = (140-age) x weight *0.85 if female 72 x Scr

MDRD Study equation GFR (ml/min/1.73 m2) = 186 x (Scr)-1.154 x (age)-.203 x (0.742 if female) x (1.210 if African American)

STAGE 1

DESCRIPTION Kidney damage with normal / increased GFR Kidney damage with mildly decreased GFR Moderately decreased GFR Severely decreased GFR Kidney failure

GFR ( ml/min/1.73m2 ) >=90

60 89

3 4 5

30 59 15 29 < 15 / dialysis

STAGE 1

ACTION PLAN DIAGNOSIS AND TREATMENT SLOW PROGRESSION

2 3

ESTIMATE PROGRESSION EVALUATE AND TREAT COMPLICATIONS

PREPARE FOR RENAL REPLACEMENT THERAPY

RENAL REPLACEMENT

 Diagnosis
Measures to slow progression Estimate Progression Evaluation and Treatment of Complications Preparation for Renal Replacement Therapy

 History

Physical Examination

CLINICAL FACTORS
DIABETES MELLITUS HYPERTENSION AUTOIMMUNE DISEASES SYSTEMIC INFECTIONS URINARY TRACT INFECTIONS URINARY STONES

SOCIODEMOGRAPHIC FACTORS
OLDER AGE EXPOSURE TO CERTAIN CHEMICALS / ENVIRONMENTAL CONDITIONS LOW INCOME / EDUCATION

LOWER URINARY TRACT OBSTRUCTION

NEOPLASIA

FAMILY HISTORY OF CKD

RECOVERY FROM AKI REDUCTION IN KIDNEY MASS DRUGS LOW BIRTH WEIGHT

Tests & Diagnostics Blood Pressure Serum Creatinine

Significance / Goal < 130 / 80 mm Hg ; Use ACEI /ARB To estimate GFR; Historical values assist in determining acuity and progression of disease

Urinalysis with microscopy

Serum Electrolytes ( Na+, K+ )

Presence of RBCs / RBC casts and or Proteinuria further work up

Useful as crude surrogate of renal disease Help to guide antihypertensives Help to identify patients in need of medical nutrition education Assists in treatment of metabolic bone disease Evaluate for anemia

Calcium, Phosphorus, PTH, ALP, 25-OH VITAMIN D Complete Blood Count Peripheral Blood Smear

TSAT , S.Ferritin

Useful in evaluation of iron stores

Tests & Diagnostics Renal Ultrasound with or without Arterial Doppler

Significance / Goals Characterize Kidney number and size Echogenicity of kidneys Rule out presence of obstruction Rule out renovascular disease Especially useful for patients with nephrotic range proteinuria Ratio approximate values obtained by 24 hour collection Negative Hep B testing mandates vaccination

Cholesterol panel Random urine protein Random urine creatinine Hepatitis Serology

Serum Protein Electrophoresis Urine Protein Electrophoresis

Antinuclear antibody HIV Renal Biopsy

In adults with renal disease to rule out Myeloma

Warranted for adults with proteinuria / evidence for SLE Warranted in selected population Indicated in pts with hematuria and / proteinuria and lack of evidence of systemic disease

 Protein Restriction Reducing Intraglomerular Hypertension Reducing Proteinuria Control of Blood Glucose

Control of Blood Pressure

 Reduces symptoms associated with uremia Slows the rate of decline in renal function at earlier stages of

renal diseases
K/DOQI clinical practice guidelines recommend

daily protein intake between 0.60 0.75 g / Kg per day 50 % of protein intake should be of high biological value
As patient approaches CKD Stage V,

spontaneous protein intake decreases & patient enter a state of Protein Energy Malnutrition . Recommended protein intake is 0.9 g / Kg per day

 Increased intraglomerular filtration pressure & glomerular

hypertrophy - a response to loss of nephron number

It promotes ongoing decline of kidney function even if the inciting

process has been treated.

ACEI & ARBs Inhibit angiotensin induced vasoconstriction of efferent arteriole Reduces intraglomerular filtration pressure and proteinuria

 If monotherapy is not effective , combined therapy with

both ACEI & ARB can be tried

2nd line drugs : Calcium Channel Blockers

Diltiazem , Verapamil
Especially - Diabetic Nephropathy & Glomerular diseases

 Leading cause of Chronic Kidney Disease Control of Blood Glucose : excellent glycemic control

reduces the risk of kidney disease & its progression in both Type 1 & 2 Diabetes Mellitus Recommendations : FBS : 90 130 mg/dl HbA1C < 7%
Control of Blood Pressure & Proteinuria : ACEI & ARBs

 Hypertension : sodium and water retention

renin angiotensin system activation

Control of BP : to slow progression of CKD

to prevent extrarenal complications ( cardiovascular disease / stroke )

Goal : BP < 130 / 80 mm Hg

BP < 125 / 75 mm Hg ( DM / Proteinuria > 1g/day )

 Salt Restriction

Diuretics
Loop Diuretics : Furosemide 40 mg BD

Bumetanide 1mg BD Thiazides : less efficacious gfr < 30 40 ml/min Both ameliorate hyperkalemia seen with ACEI / ARB ACEI / ARB Check S.Creat & S.K+ within 1 -2 weeks Upto 30 % increase in creatinine is acceptable Beta blockers / CCB / Alpha blockers / Vasodilators

 Anemia
Bone Disorders Dyslipidemia

Cardiovascular disease

 Defined as Hemoglobin < 13.5 g/dl in males

< 12 g/dl in females

Normocytic normochromic anemia

as early as in Stage III CKD or universally by Stage IV CKD Primary cause : insufficient production of Erythropoetin Additional factors : iron deficiency folate / vit B12 deficiency chronic inflammation hyperparathyroidism / bm fibrosis

 Target Hb : 11 g/dl Target Iron status : TSAT : lower limit > = 20

S.Ferritin : ng/ml lower limit : 200 HD CKD 100 Non HD CKD > 500 not routinely recommended Check Hb monthly while on ESAs Iron studies monthly when started on ESA On stable ESA Therapy : Iron studies can be done 3 monthly

 Ferrous sulphate 325 mg bid tid

IV Iron Dextran
IV Iron Sucrose IV Sodium Ferric Gluconate Complex Folic acid and Vitamin B 12 supplements Erythropoetin Stimulating Agents : Epoetin alfa

Epoetin beta Darbepoetin alfa Epoetin alfa / beta : 50 -100 IU / Kg SC per week Darbepoetin alfa : 40 mcg SC every 2 weeks

 Osteitis Fibrosa Cystica

Osteomalacia Adynamic bone disease

Secondary

Mixed osteodystrophy

Hyperparathyroidism Vitamin D deficiency Acidosis Aluminium accumulation Osteoporosis in elderly Osteopenia caused by steroids

 Renal bone disease significantly increase mortality in

CKD patients
Hyperphosphatemia one of the most important risk

factors associated with cardiovascular disease in CKD patients

 K/DOQI recommends :

CKD Stage III & IV : S.Phosphorus : 2.7 - 4.6 mg / dl

CKD Stage V : S.Phosphorus : 3.5 - 5.5 mg / dl

CKD STAGE 3

GFR RANGE 30 59

INTACT PTH ( pg/ml ) 35 70

4
5

15 29
< 15 / Dialysis

70 110
150 300

CKD STAGE 3 4 5

GFR RANGE 30 -59 15-29 < 15 / dialysis

PTH LEVELS Every 12 months Every 3 months Every 3 months

S.Calcium & S.Phosphorus Every 12 months Every 3 months Every month

 Reduce dietary phosphate intake Phosphate binders : calcium carbonate

calcium acetate aluminium hydroxide magnesium carbonate ( rarely used ) sevelamer hydrochloride lanthanum carbonate The use of calcium salts is limited by development of hypercalcemia Calcium acetate poses a less problem as less calcium is absorbed

 Calcimimetics Cinacalcit : Agent that increase calcium sensitivity of the calcium

sensing receptor expressed by parathyroid gland Down regulating the parathyroid hormone secretion Reduce hyperplasia of parathyroid gland
Calcitriol 0.25 mcg OD Paricalcitol 1 mcg daily or 2mcg 3 times a week

 Vitamin D deficiency : < 5 ng/ml Ergocalciferol 50000 IU orally weekly for

12 weeks and then monthly thereafter

5 15 ng/ml Ergocalciferol 50000 IU orally weekly for

4 weeks and then monthly thereafter

16 30 ng/ml Monthly Ergocalciferol Acidosis : K/DOQI total Co2 >=22 mEq/L

Sodium bicarbonate 650 1300 mg bid tid

 A major risk factor for cardiovascular morbidity &

mortality
Prevalence of hyperlipidemia increases as renal functions

diminish
All patients with CKD must be evaluated for

Dyslipidemia
Fasting lipid profile annually

 Stage V CKD patients with dyslipidemia should always be

evaluated for secondary causes : Nephrotic syndrome Hypothyroidism Diabetes mellitus Excessive alcohol consumption Liver disease Drugs : oral contraceptives , haart etc
Goal : LDL Cholesterol < 100 mg / dl

 LDL : 100 129 mg/dl : Lifestyle changes

Not responded : Low dose statin

LDL >= 130 mg/dl : Lifestyle changes + Statins

TG >= 200 mg/dl : Lifestyle changes + Statins

 Control BP : ACEI / ARB Treat dyslipidemia : Lifestyle changes + Statins Good Glycemic control Treat anemia Correct hyperphosphatemia

Treat hyperparathyroidism
Correct hyperkalemia

 Hepatitis B vaccination : 3 doses (0,1,2 months )

higher dose ( 40 mcg / ml )

Pneumococcal vaccination : single dose

one time revaccination 5 yrs after initial vaccination

Influenza vaccination : recommended annually for adults

> 50 yrs age

 Patients of CKD Stage IV approaching Stage V should be referred

for Vascular access if hemodialysis is preferred Peritoneal dialysis catheter placement if peritoneal dialysis is preferred

AVF is most preferred access for HD patients Ideally created 6 months prior to start of HD Non dominant upper extremity And that arm is to be preserved no iv lines

AVG : 3-6 weeks prior to start of HD PD Catheter : 2 weeks prior to start of HD

 GFR not below 15 ml/min.1.73m2 but in presence of Intractable volume overload Hyperkalemia Hyperphosphatemia Hypercalcemia / Hypocalcemia Metabolic acidosis Anemia Uremic encephalopathy Uremic pericarditis Severe hypertension , acute pulmonary edema