Chronic kidney disease is a spectrum of conditions associated with progressive kidney function decline and damage. It is increasingly prevalent due to rising rates of diabetes and hypertension. Management involves identifying the underlying cause, calculating GFR to stage severity, investigating for complications, and slowing progression. Treatment focuses on managing complications through diet, medication, and preparing patients for renal replacement therapies like dialysis and transplantation if kidney failure occurs. The goal is optimizing quality of life and outcomes through a coordinated multidisciplinary approach.

1. CHRONIC KIDNEY
DISEASE: APPROACH
AND MANAGEMENT
Chairperson
Dr Ardaman Singh
Seminar by
Dr Sandip Dhoot
1

2. Introduction
• Encompasses a spectrum of different
pathophysiologic processes associated with
abnormal kidney function, and a progressive
decline in glomerular filtration rate (GFR).
• As infectious diseases are decreasing, we are
facing increasing number of noninfectious
diseases like diabetes, HT and so also CKD
patients .
• Associated with increasing morbidity and
mortality, and increasing healthcare burden day
by day.
2

3. Approach
deranged RFT’s
acute chronic
- identify cause
- calculation of GFR
- stage
- look for uremia
- investigate
- look for progression
3

4. Patient with deranged RFT’s
• Obtain history and do physical examination
• Symptoms like loss of appetite and weight,
nausea, hiccups, peripheral edema, muscle
cramps, pruritus, and restless legs.
• Lab investigations and imaging
• Important because acute/subacute renal
diseases are potentially reversible and responds
to disease specific therapy.
• Rule out acute on chronic failure
4

5. Looking for etiologies of CKD
• Diabetic glomerular disease
• Hypertensive nephropathy
1)Primary glomerulopathy with
hypertension
2)Vascular and ischemic renal disease
• Glomerulonephritis
• Autosomal dominant polycystic kidney
disease
• Other cystic and tubulointerstitial
nephropathy 5

6. Calculation of GFR
• Modification of Diet in Renal Disease study
Estimated GFR (mL/min per 1.73 m2)
= 1.86 × (PCr)−1.154 × (age)−0.203
Multiply by 0.742 for women
Multiply by 1.21 for African Americans
• Cockcroft-Gault equation
Estimated creatinine clearance (mL/min) =
(140-age*body weight, kg)/72*Pcr (mg/dL)
Multiply by 0.85 for women
6

7. Staging of CKD
STAGE GFR, ml/min per 1.73 m2
0 >90
1 ≥90
2 60-89
3 30-59
4 15-29
5 <15
7

8. Investigations
• Urine c/e, serum creatinine are basic
investigations
• Others like serum electrolytes, Vitamin D, PTH,
Hb, iron, B12, folate
• Serial measurements and charting of renal
functions
• 24 hour urine albumin, albumin to creat ratio
• Hepatitis B, C and HIV
• Imaging studies like renal ultrasound
• Renal Biopsy 8

9. Treatment of CKD – action plan
STAGE DESCRIPTION GFR, mL/min
PER 1.73 m2
ACTION
1 Kidney damage
with normal or ↑
GFR
≥90 Diagnosis and
treatment, treatment of
comorbid conditions,
slowing
progression, CVD risk
reduction
2 Kidney damage
with mild ↓ GFR
60–89 Estimating progression
3 Moderate ↓ GFR 30–59 Evaluating and treating
complications
4 Severe ↓ GFR 15–29 Preparation for kidney
replacement therapy
5 Kidney failure <15 (or
dialysis)
Kidney replacement (if
uremia present)
9

10. Management of CKD
treatment aimed at specific cause
look and treat acute on chronic renal failure
slowing progression
management of complications
Preparation for Renal Replacement therapy
Renal Replacement therapy
10

11. Treatment of specific diseases
• Not as important as in acute/ subacute disease
• But early implmentation of disease specific
therapy helps to slow the progression
• For Diabetes – excellent glycemic control fasting
blood sugar (90-130mg/dL), HbA1c < 7%.
- review of oral hypoglycemic
agents
- insulin requirement decreases
• Early diagnosis and prompt treatment of
glomerulonephritis
• Other disease specific therapy 11

12. Treatment of acute on chronic failure
• sequentially measure and plot the rate of
decline of GFR in all patients, for early detection
• Causes include, ECFV depletion, uncontrolled
hypertension, urinary tract infection, new
obstructive uropathy, exposure to nephrotoxic
agents and reactivation or flare of the original
disease, such as lupus or vasculitis.
• Prevention and treatment is according to cause
12

13. Slowing progression
• Protein Restriction
- daily intake of 0.60-0.75 g/kg/d
- atleast 50% of high biologic value
- in stage 5, 0.90 g/kg/d and energy intake of
35 kcal/kg to avoid PEM
• Reducing Intraglomerular Hypertension and
Proteinuria
Control of systemic and glomerular hypertension
Target BP is 125/75
ACE Inhibitors and ARB’s, calcium channel blockers
diltiazem and verapamil
13

14. Pathophysiology of uremia
• Manifestations consequent to the accumulation
of toxins normally undergoing renal excretion,
including products of protein metabolism.
• consequent to the loss of other renal functions,
such as fluid and electrolyte homeostasis and
hormone regulation.
• progressive systemic inflammation
14

15. Management of complications
• Fluid and electrolyte disturbances
• Endocrine-metabolic disturbances
• Neuromuscular disturbances
• Cardiovascular and pulmonary disturbances
• Dermatologic disturbances
• Gastrointestinal disturbances
• Hematologic distrbances
• Immunologic disturbances
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16. Fluid and electrolyte abnormalities
16

17. FLUID, ELECTROLYTE, AND ACID-BASE
DISORDERS
• Volume expansion, hyponatremia
responds to fluid restriction,
loop diuretics + metolazone
• Hyperkalemia
• Hyperchloremic metabolic acidosis
• hyperphosphatemia
17

18. DISORDERS OF CALCIUM AND PHOSPHATE
METABOLISM
18

19. Treatment
• Optimal management is prevention
• low-phosphate diet as well as the appropriate
use of phosphate-binding agents
• calcium acetate and calcium carbonate
• Sevelamer
• Calcitriol analogues like paricalcitol
• Target PTH level between 150 and 300 pg/mL,
19

20. CARDIOVASCULAR ABNORMALITIES
• Leading cause of mortality in CKD
patients
• IHD, Heart failure, hypertension
• Increased risk due to shared risk factors and
CKD related factors
• CKD related factors include anemia,
hyperphosphatemia, hyperparathyroidism, sleep
apnea, and generalized inflammation
• Microalbuminuria is major risk factor
20

21. Management of CARDIOVASCULAR
ABNORMALITIES
• For hypertension,
- target is 125/75 mmHg
- salt restriction and diuretics first choice
- choice similar as general population
- ACE inhibitors and ARB’s slows
progression but cause hyperkalemia
• Hyperlipidemia, homocystinemia
- lifestyle changes, diet, exercises
- vitamin supplementation, statins
• Pericardial disease, heart failure
- urgent dialysis
21

22. HEMATOLOGIC ABNORMALITIES
• Anemia
- normocytic normochromic
- mainly d/to erythropoetin deficiency
- treatment with erythropoetin, supplementation
of iron, vit B12, folate and blood transfusions
• Abnormal hemostasis
- both increased bleeding tendencies and
thromboembolism
- desmopressin, cryoprecipitate
- avoid LMWH, use conventional heparin
22

23. NEUROMUSCULAR ABNORMALITIES
• Affects both central and peripheral nervous
system, autonomic nervous system and
muscular system
• Sensory distal polyneuropathy mainly in lower
limbs
• Restless leg syndrome
• Responds mainly to renal replacement therapies
23

24. GASTROINTESTINAL AND NUTRITIONAL
ABNORMALITIES
• Anorexia, nausea, vomitting, gastritis,
peptic ulcer and mucosal ulcerations
• Uremic fetor
• Protein energy malnutrition in advanced
CKD
• Treated with dietary and lifestyle
modification
24

25. Preparation for renal replacement
therapy
• Renal replacement therapy has extended lives
of thousands of CKD patients worldwide
• Social, psychological, and physical preparation
is necessary
• prepare patients with an intensive educational
program so that decisions will be more easier
and appropriate for them
• No arbitrary blood urea nitrogen or creatinine
level has been asigned for switching
• Most accepted criteria for switching are led by
National Kidney Foundation in KDOQI
guidelines 25

26. Indications for Renal replacement
therapy
• Clear indications include
1. pericarditis,
2. encephalopathy,
3. intractable muscle cramping,
4. anorexia, and nausea not attributable to
reversible causes,
5. evidence of malnutrition,
6. and fluid and electrolyte abnormalities,
principally hyperkalemia, that are refractory to
other measures.
• But nowadays concept of “healthy” start is
promoted
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28. Renal replacement therapy
• Dialysis
1)haemodialysis
2)peritoneal dialysis
• Kidney transplantation
1)living donor
2)deceased donor
28

29. Haemodialysis
29

30. Haemodialysis
• Most common therapeutic modality for ESRD
• Based on principles of solute diffusion across a
semipermeable membrane.
• three essential components are the dialyzer,
dialysate, and the blood delivery system.
• Dialysis access can be done through fistula,
graft or catheter.
• Nowadays, “fistula first” initiative is promoted
30

31. Goals of dialysis
• Removes both low and high molecular weight
solutes
• Dose of dialysis is derivation of the fractional
urea clearance during a single dialysis
treatment.
• Delivered dose of dialysis is considered as
quality assurance and measurement tool
• But dose should be individualised
• For majority 9 to 12 hours of dialysis, each
week, divided into three equal sessions are
required
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32. Complications of haemodialysis
1. Hypotension
• most common
• Managed with discontinuing ultrafiltration,
administration of isotonic or hypertonic saline
and salt poor albumin
2. High output cardiac failure in fistula
3. Muscle cramps
4. Anaphylactoid reactions
32

33. Peritoneal dialysis
• Dextrose containing solution is infused into
peritoneal cavity and allowed to dwell for set
period of time
• Toxic materials are removed through convective
and diffusive clearance
• Of two types,
1. Continous ambulatory (CAPD)
2. Continous cyclic (CCPD)
• Paients on peritoneal dialysis do well when they
retain residual kidney function
• Done mainly in developing countries d/to lower
expense
33

34. CAPD CCPD
34

35. Complications of peritoneal dialysis
• Peritonitis – intraperitoneal or oral antibiotics
• Catheter associated nonperitonitis infections (
tunnel infections)
• Weight gain
• Residual uremia
• Hypoproteinemia
• hyperglycemia
35

36. Transplantation of human kidney
• Transplantation is the treatment of choice in
advanced CKD
• Can be done from deceased donor or living
donor
• Living donor kidneys have better survival than
deceased donor kidneys
• Though donor no has increased, demand
exceeds supply
• Careful selection of recipient and donor
necessary
36

37. Recipient selection
• Life expectancy > 5 years
• Thorough evaluation of risks versus benefits
• An aggressive approach to diagnosis of
correctable coronary artery disease, presence of
latent or indolent infection (HIV, hepatitis B or C,
tuberculosis), and neoplasm
• Matching of ABO blood group antigens and HLA
1 & 2, but not Rh group
37

38. Donor selection
• Can be deceased or living
• Should be of same ABO blood group and HLA
antigens
• Should be free of malignant neoplastic disease,
hepatitis and HIV
• Selective renal arteriography on donors
• In united states Organ Procurement Transplant
Netwok regulates transplant.
38

39. Immunosupprssive treatment
Both cellular and humoral mechanisms play role in
kidney transplant rejection
Drugs
• Glucocorticoids
• Cyclosporine
• Tacrolimus
• Azathioprine
• Mycophenolate mofetil
• Sirolimus
39

40. Recent therapies
• Antilymphocyte globulin (ALG)
• Antibodies to IL-2 receptor,
basiliximab,
daclizumab
• Depleting T cell antibody -- alemtuzumab
40

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42. Management of recipient
• Most commonly diuresis occurs after transplant,
but watch for oliguria as it may signify ATN
• Rejection characterised by fever, swelling and
tenderness over allograft
• Serum creatinine level most sensitive and
reliable indicator
• Renal biopsy may be needed in some
• Patient at increased risk of unusual opportunistic
infections and malignancy
42

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44. Other complications in recipient
• Malignancy especially of skin and lips, cervix,
lymphoma’s such as non-Hodgkin’s lymphoma
• Hypercalcemia d/to preexisting
hyperparathyroidism
• hypertension
• Anemia
• Chronic hepatitis
• Myocardial infarction and stroke
44

45. Prevention of CKD
• Identify persons at risk of CKD at early stage
and treat aggressively
• Appropriate detection and treatment of various
glomerulonephritis
• Control of diabetes and hypertension
• Cautious use of nephrotoxic drugs
• Early detecion of polycystic kidney disease and
treatment
45

46. To summarise…..
• CKD is emerging as major public health
problem
• Early identification and treatment of
complications is of utmost important
• Though renal transplant is TOC in ESRD
patients, only dialysis is widely available in near
future.
• Peritoneal dialysis may play important role in
developing countries like India.
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