CKD

1. Chronic Kidney Disease

2. Introduction
• CKD is common but silent and under recognised condition in Malaysia
• CKD is a strong risk factor for mortality and coronary events
• If CKD is detected early and treated early, the deteorarion of kidney
function can be reduced as 50%
• CKD is a progressive reduction of functioning renal tissue such that
the remaining kidney mass can no longer maintain the body’s
internal environment.

3. Etiology and Risk Factors
• Diabetes Mellitus – 1st
• Hypertension - 2nd
• Others
• Acute Renal Failure
• Obstruction
• Nephrotoxins
• Systemic
• SLE
• Polyarteritis

4. Risk Factors
• Diabetes Mellitus
• Hypertension
• Age over 60 years
• Cardiovascular Disease
• Family History CKD
• Exposure of Nephrotoxic Drugs

5. STAGING OF CKD
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6. Definition of CKD
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7. Staging of CKD
•Markers of kidney damage is defined as either:
o albuminuria (AER ≥30 mg/24 hours or ACR ≥3 mg/mmol)
o urine sediment abnormalities
o electrolyte and other abnormalities due to tubular disorders
o abnormalities detected by histology
o structural abnormalities detected by imaging
o history of kidney transplantation
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8. Classification of CKD
•Classification of CKD should be based upon cause, GFR category and
albumin category (CGA).
o Cause
‒ Presence or absence of systemic disease and location within the kidney of observed or
presumed HPE findings
oGFR category
oAlbuminuria category
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9. GFR category in CKD
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11. Delaying CKD
Progression
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12. * K/DOQI guidelines. AJKD 2002; 39 (Suppl 1): S1-S266.
CKD - Irreversible process
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13. CKD ≠ Dialysis
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14. Delay
progression
Manage CKD
complications
Manage CV
risk factors
Timely
preparation
for RRT
Avoid insult
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CKD management plan

15. Established
1. Optimal BP
control
2. Proteinuria
reduction
3. RAS blockers
4. Glycaemic
control
Need more
evidence
1. Life style
modifications
2. SGLT-2
inhibitors
3. Uric acid
reduction
Not proven
1. Dual RAS
blockade
2. Lipid lowering
3. Vitamin D
analogue
4. Pentoxyfylline
5. Traditional
medicine
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Strategies to delay CKD progression

16. Established strategies
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17. Optimal blood pressure control
• The majority of CKD patients (70 - 80%) have
hypertension (usually systolic) which is more severe than
non-CKD patients.9
• BP lowering has an impact on all-cause mortality,
cardiovascular (CV) events, stroke risk and progression of
kidney disease.
• Any class of antihypertensive agents can be used to
control BP in CKD.9
• However, some antihypertensive agents have additional
antiproteinuric effect [e.g. Angiotensin-Converting
Enzyme Inhibitor (ACEi)/Angiotensin Receptor Blocker
(ARB)].
9. MoH, Malaysia. Management of CKD in Adults. Putrajaya: MoH; 2011
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18. Blood pressure target
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19. Antihypertensive agents in CKD
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20. Glycaemic control for renoprotection
• Optimal glycaemic control should be attained to reduce the
complications of diabetes.
• Aggressive glycaemic control in patients with established CVD
may increase the risks of hypoglycaemia and death due to
impaired drug metabolism.9
• Regular blood glucose measurements are advised for more
accurate assessment of diabetic control as HbA1c maybe falsely
low in CKD due to anaemia.9
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21. Strategies requiring
more evidence
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22. Lifestyle modifications
•Dietary protein restriction
•Reduction of weight
•Low salt diet
•Smoking cessation
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23. Dietary protein restriction
•Proteinuria is an independent CV risk factor and
an independent predictor for renal disease
progression.9
•Protein restriction is one of the supportive
measures to delay CKD progression.9
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24. Sodium-glucose co-transporter-2 (SGLT-2)
inhibitors
•Potential agent
•Recent trials (EMPA-REG, CANVAS/CANVAS-R) on sodium-glucose co-
transporter-2 (SGLT2) inhibitors have been shown to improve CV
outcomes and may have renoprotective effect.39, 40
•Avoid if eGFR <45 ml/min due to reduced efficacy in lowering HbA1c.
•39. Wanner C, et al. N Engl J Med. 2016;375(4):323-34
•40. Neal B, et al. N Engl J Med. 2017;377(7):644-57
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25. Uric acid reduction
•There is emerging evidence to suggest uric acid reduction (e.g. by
allopurinol, febuxostat) is a potential strategy to delay CKD
progression.45, 46, 47
•However, more RCTs are needed to confirm the renoprotective effect.
45. Kanji T, et al. BMC Nephrol. 2015;16:58
46. Bose B, et al. Nephrol Dial Transplant. 2014;29(2):406-13
• 47. Sircar D, et al. Am J Kidney Dis. 2015;66(6):945-50
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26. Thank you
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