Chronic Kidney Disease (CKD) updates haruncomc23@gmail.com

1. Organized by-
Department of medicine,Unit-6
Cumilla Medical College Hospital
Cumilla,Bangladesh.

2. Presented by-
Dr. Harun Ar Rashid
Cumilla Medical College Hospital

3.  Chronic kidney disease (CKD) refers to an
irreversible deterioration in renal function that
usually develops over a period of years.

4. Asymptomatic until GFR falls below 30 mL/min/1.73
m2.
When GFR falls below 15–20 mL/min/1.73 m2,
symptoms and signs are common and can affect
almost all body systems .

5. F e a t u r e s -
An early symptom is nocturia
Tiredness or breathlessness
(May be related to renal anaemia or fluid overload).
Pruritus
Anorexia
Weight loss
Nausea
Vomiting
Hiccups.

6. In very advanced renal failure -
 Kussmaul breathing
 Muscular twitching
 Fits
 Drowsiness
 Coma.

7.  Diabetes mellitus
 Interstitial diseases- Glomerular diseases
 Hypertension
 Systemic inflammatory diseases-SLE, vasculitis
 Renovascular disease
 Congenital and Inherited-Polycystic kidney disease,
Alport’s syndrome
 Unknown

8. To:
• Exclude AKI requiring rapid investigation (high urea
and creatinine).
• Identify the underlying cause
• Identify reversible factors (hypertension or urinary
tract obstruction)
• Screen for complications of CKD (anaemia and
renal osteodystrophy)
• Screen for cardiovascular risk factors.

9.  Urea and creatinine
 Urinalysis and quantification of proteinuria
 Electrolytes
 Calcium, phosphate, parathyroid hormone
 Albumin
 Full blood count
 Iron,folate,vitamin B12
 Lipids, glucose,HBA1C
 Renal ultrasound
 Hepatitis and HIV serology

10. The aims of management in CKD are to:
• Monitor renal function
• Prevent or slow further renal damage
• Limit complications of renal failure
• Treat risk factors for cardiovascular disease
• Prepare for RRT

11. Renal function should therefore be monitored every 6
months in patients with stage 3 CKD.
More frequently in patients who are deteriorating
rapidly or have stage 4 or 5 CKD.

12. Therapies for the primary cause of CKD.
Blood pressure control, reducing proteinuria is a key
target in patient with glomerular disease.

13.  ACEi/ARB(1st choice)
 Calcium channel blocker
Target blood pressure:
No albuminuria
(ACR < 3 mg/mmol)
140/90 mmHg
Moderate albuminuria
(ACR 3–30 mg/mmol)
130/80 mmHg
Heavy proteinuria
(PCR > 100 mg/mmol or ACR > 70 mg/mmol)
125/75 mmHg

14. ACEi and/or ARBs should be prescribed to all patients with
diabetic nephropathy and patients with CKD and
proteinuria.
Renal function should be checked within 7–10 days of
initiating or increasing the dose of an ACE inhibitor or
ARB.
In patients with serum potassium > 6.0 mmol/L, the dose
of ACE inhibitors or ARBs should be reduced or
discontinued entirely.

16. Causes:
• Deficiency of erythropoietin
• Toxic effects of uraemia on marrow precursor cells
• Reduced red cell survival
• Blood loss due to capillary fragility and poor
platelet function
• Reduced intake, absorption and utilisation of
dietary iron

17.  Target haemoglobin:10-12 gm/dl
 Iron supplementation:intravenously for those with
iron intolerance or in situations where adherence
may be difficult.
 Erythropoietin:With exclusion of iron deficiency and
other causes of anaemia,recombinant human
erythropoietin is given.

18.  Low-sodium diet (< 100 mmol/24 hrs).
 Dietary advice to reduce daily potassium intake to
below 70 mmol.
 In severe cases fluid intake should be restricted.
 Diuretics are commonly required.

19. Plasma bicarbonate concentrations should be
maintained above 22 mmol/L (starting dose is 1 g 8-
hourly, increasing as required).

20.  Hyperphosphataemia should be treated by dietary restriction of
foods with high phosphate content (milk, cheese, eggs and protein-
rich foods) and by the use of phosphate-binding drugs.
 Available drugs are- calcium carbonate, aluminium hydroxide,
lanthanum carbonate and polymer-based phosphate binders such
as sevelamer.
 The aim is to maintain serum phosphate values at or below 1.5
mmol/L if possible.
 Active vitamin D metabolites should be prescribed.

21.  Lipid lowering agent.

22. Preparations for starting RRT should begin at least 12
months before the predicted start date.
To provide the patient with psychological and social
support.
Physical preparations include establishment of timely
access for haemodialysis or peritoneal dialysis and
vaccination against hepatitis B.

23. Indications
 Fluid overload: Acute pulmonary oedema ,Intractable
dependent oedema resistant to diuretics, Severe
hypertension.
 Hyperkalaemia: High potassium (generally > 6.5
mmol/L).
 Uraemia: Pericarditis, Encephalopathy, Uraemic syndrome
including anorexia, nausea, lethargy etc.
 Metabolic acidosis: Severe acidosis (pH < 7.1),Chronic
acidosis resistant to bicarbonate therapy.

24. During treatments:
o Hypotension
o Cardiac arrhythmias
o Haemorrhage
o Air embolism
o Dialyser hypersensitivity
Between treatments:
o Pulmonary oedema
o Systemic sepsis

25.  Active malignancy, vasculitis, cardiovascular disease
and a high risk of recurrence of renal disease
(generally glomerulonephritis) are common
contraindications to transplantation.
 When these are absent, then we can perform renal
transplantation with preparation.

26. Thank You