This document discusses chronic kidney disease (CKD), including its classification based on glomerular filtration rate (GFR), clinical findings such as lab tests and imaging, complications, and management options. It recommends referring patients with stage 3-5 CKD to a nephrologist and considering admission for those with decompensation of CKD-related problems or those needing initiation of renal replacement therapy when unstable for outpatient care.

2.  General Considerations
 Clinical Findings
 Complications
 Management options
 When to Refer
 When to admit

3. General Considerations
 Classification
Stage 1: Normal GFR;GFR >90
mL/min/1.73m2 with *other evidence of
chronic kidney damage.
Stage 2: Mild impairment; GFR 60-
89mL/min/1.73 m2 with *other evidence of
chronic kidney damage
Stage 3: Moderate impairment; GFR 30-59
mL/min/1.73 m2
Stage 4: Severe impairment: GFR 15-29
mL/min/1.73m2
Stage 5: Established renal failure (ERF):
GFR<15 mL/min/1.73 m2 or on dialysis
*The “other evidence of chronic kidney
damage”
may be one of the following:
• Persistent microalbuminuria
• Persistent proteinuria
• Persistent haematuria (after exclusion of other
causes, e.g. urological disease)
• Structural abnormalities of the kidneys
demonstrated on ultrasound scanning or other
radiological tests, eg. polycystic kidney disease,
reflux nephropathy
• Biopsy-proven chronic glomerulonephritis (most
of these patients will have microalbumuria or
proteinuria, and/or haematuria)

4. Clinical Findings
 Symptoms & Signs
 Laboratory Findings
 Imaging

5. Symptoms & Signs

6. Laboratory Investigations
Investigations in Categories
Graded in Different Levels
 Grade X – very basic
 Grade Y – desirable
 Grade Z – optional
Grade Y
 Urinary microalbumin
 Urinary protein: creatinine ratio
 Urinary alb:creatinine ratio
Grade Z
 PTH assays
 25 – hydroxyvitamin D
 Cystatin C
Grade X
 Blood urea
 Creatinine
 Serum electrolytes
 Urinary sediment
 Serum calcium
 Serum phosphate
 Acid base
 Anion gap
 Creatinine clearance
 Estimated GFR by equations or
 By using tables

7. Imaging
USS-small echogenic kidneys bilaterally (< 10 cm)
supports a diagnosis of chronic kidney disease, though normal or even
large kidneys can be seen with adult polycystic kidney disease, diabetic
nephropathy, HIV-associated nephropathy, multiple myeloma,
amyloidosis, and obstructive uropathy.
Radiologic evidence of renal osteodystrophy is another
helpful finding, since radiographic changes of secondary
hyperparathyroidism and chronic kidney disease mineral and bone
disorder do not appear unless parathyroid levels have been elevated for
at least 1 year.
Evidence of subperiosteal reabsorption along the radial
sides of the digital bones of the hand can confirm
hyperparathyroidism.

8. Complications
 Hyperkalemia
Potassium balance generally remains intact in chronic kidney disease until the GFR
is < 10–20 mL/min. However, an increased risk of hyperkalemia at higher GFRs.
 Acid–Base Disorders
 Cardiovascular Complications
Long-term complications of chronic kidney disease include a high risk of morbidity
and mortality of cardiovascular disease in comparison to the general population.
1. Hypertension
2. Pericarditis—With uremia, pericarditis may develop but is uncommon
3. Congestive heart failure—Patients with ESRD tend toward a high cardiac output.
 Hematologic Complications
1. Anemia—The anemia of chronic kidney disease is characteristically
normochromic and normocytic.
2. Coagulopathy—The coagulopathy of chronic kidney disease is mainly caused by
platelet dysfunction
 Neurologic Complications
Uremic encephalopathy does not occur until GFR falls below 5–15 mL/min.
 Disorders of Mineral Metabolism
 Endocrine Disorders

9. Management
 A. Medical Management
 B. Management of complications
 C. Dietary Management
 D. Dialysis
 E. Kidney Transplantation

10. Management
 A. Medical Management
Renoprotection ?
The multidrug approach -an international protocol
Goals of treatment
BP <120/80
Proteinuria <0.3 g/24 h
Treatment
Patients with chronic kidney disease and proteinuria >1 g/24 h:
ACE inhibitor increasing to maximum dose
Add angiotensin receptor antagonist if goals are not achieved
(In type 2 diabetes start with angiotensin receptor antagonist.)
Add diuretic to prevent hyperkalaemia and help to control BP
Add calcium-channel blocker (verapamil or diltiazem) if goals not achieved.
Additional measures
Statins to lower cholesterol to <4.5 mmol/L
Stop smoking (three-fold higher rate of deterioration in CKD)
Treat diabetes (HbA1c <7%, 53 mmol/mol)
Normal protein diet (0.8–1 g/kg bodyweight)

11. Management
C. Dietary Management
1. Protein restriction—Experimental models have shown that protein
restriction slows the progression to ESRD
2. Salt and water restriction—In advanced chronic kidney disease,
the kidney is unable to adapt to large changes in sodium intake.
3. Potassium restriction—Restriction is needed once the GFR has
fallen below 10–20 mL/min.
4. Phosphorus restriction—The phosphorus level should be kept in
the ‘normal’ range (below 4.6 mg/dL) predialysis, and between 3.5 and
5.5 mg/dL when on dialysis, with a dietary restriction of 800–1000
mg/d
5. Magnesium restriction—Magnesium is excreted primarily by the
kidneys.

12. Management
D. Dialysis
When conservative management of ESRD is inadequate, hemodialysis,
peritoneal dialysis, and kidney transplantation are alternatives.
According to the Kidney Disease Outcomes Quality Initiative (KDOQI)
guidelines;
dialysis should be started when a patient has a GFR of 10 mL/min or
serum creatinine of 8 mg/dL.
A diabetic patient should start when the GFR reaches 15 mL/min or
serum creatinine is 6 mg/dL.
Other indications for dialysis include
(1) uremic symptoms, such as pericarditis, encephalopathy, or
coagulopathy;
(2) fluid overload unresponsive to diuresis;
(3) refractory hyperkalemia;
(4) severe metabolic acidosis (pH < 7.20); and
(5) neurologic symptoms, such as seizures or neuropathy

13. Management
E. Kidney Transplantation
Up to 50% of all patients with ESRD are suitable for
transplantation.
Age is becoming less of a barrier. Two-thirds of kidney
transplants come from deceased donors, with the remainder
from living related or unrelated donors.
Immunosuppressive drugs include corticosteroids, azathioprine,
mycophenolate mofetil, tacrolimus, cyclosporine, and sirolimus.

14. Prognosis
 Mortality is higher for patients undergoing dialysis
than for those receiving a kidney transplant and versus
healthy age-matched controls. In general, uremia
develops and patients lose consciousness prior to
death. Arrhythmias can occur as a result of electrolyte
imbalance.
 The most common cause of death is cardiac
dysfunction (45%).
 For those who require dialysis to sustain life but elect
not to undergo dialysis, death ensues within days to
weeks
 survival for as long as 25 years is seen depending on
the disease entity

15. When to refer
 A patient with stage 3–5 chronic kidney disease
should be referred to a nephrologist for management
in conjunction with the primary care provider.
 A patient with other forms of chronic kidney disease
should have an initial visit with a nephrologist to
discuss future co-management needs.

16. When to admit
 Admission should be considered for patients with
decompensation of problems related to chronic kidney
disease, such as worsening of acid-base status,
electrolyte abnormalities, volume status that cannot
be appropriately treated in the outpatient setting.
 Admission is appropriate when a patient needs to start
renal replacement therapy, and is not stable for
outpatient initiation.

17. Summary
 General Considerations
 Clinical Findings
 Complications
 managements
 Admitting and referring of patients