CHRONIC KIDNEY DISEASE

BY

PROFESSOR IBRAHIM UMMATE

 Definition of CKD

Structural or functional abnormalities of the

kidneys for >3 months, as manifested by either:
1. Kidney damage, with or without decreased GFR, as
defined by
• pathologic abnormalities
• markers of kidney damage, including abnormalities in
the composition of the blood or urine or abnormalities in
imaging tests
2. GFR <60 ml/min/1.73 m2, with or without kidney
damage
 Causes of CKD
Nigeria USA
• Hypertension 35% Whites Blacks
• Chronic GN 28%
• Diabetes 12% • Diabetes 43.3% 42.5%
• Pyelonephritis 4% • Hypertension 19.4% 32.8%
• ADPKD 3% • Chronic GN 10.7% 8.5%
• Pyelonephritis 5.1% 2.2%
• Analgesics and toxins 3%
• Renovascular dx4.5% 0.5%
• Obstructive uropathy 2%
• ADPKD 3.1% 1.1%
• Alport syndrome 2% • Uncertain 4.3% 3.1%
• Sickle cell disease 1%
• Medullary sponge K 1%
• Unclassified 8%
 Classification of CKD by Diagnosis

• Diabetic Kidney Disease

• Glomerular diseases (autoimmune diseases, systemic infections,
drugs, neoplasia)
• Vascular diseases (renal artery disease, hypertension,
microangiopathy)
• Tubulointerstitial diseases (urinary tract infection, stones,
obstruction, drug toxicity)
• Cystic diseases (polycystic kidney disease)
• Diseases in the transplant (Allograft nephropathy, drug toxicity,
recurrent diseases, transplant glomerulopathy)
 Signs & Symptoms
• General • GI
– Previous nocturia – Anorexia
– Nausea/vomiting
– Fatigue & malaise
– Epigastric pain
– Cognitive impairment
• Skin
– Edema
– Pruritis
– Linsays nails – Scratch marks, excoriations
• Ophthalmologic – Pallor
– AV nicking – Salor facie
– Ureamic frost
• Cardiac
• Neurological
– HTN
– MS changes
– Heart failure – Restless leg syndrome
– Pericarditis – Myoclonus
– CAD – Seizures
 Evaluation for CKD
• Urine
• Blood – Urinalysis-Low SG
– Low serum HCO3 – Microscopy-Broad casts
– CBC with diff- Low PCV – Spot urine-microalbumin
– SMA-7 with Ca2+  and – 24-urine collection for
phosphorous  protein and creatinine cl
– PTH-Secondary or
Tertiary PTH 
– HBA1c • Ultrasound
– LFTs and FLP – Shrunken kidneys
– Uric acid and Fe2+ – Normal sized kidneys in
studies amyloid, HIVAN, LUPUS
Nephritis, RPGN, DN
• Biopsy
 GFR Calculations
• Cockcroft-Gault
– Men: CrCl (mL/min) = (140 - age) x wt (kg)
SCr x 0.81

– Women: multiply by 0.85

• MDRD: USUALLY WE USE COMPUTARISED

FORMULA TO CALCULAT IT :
– GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-1.154 x
(age)-0.203 x (0.742 if female) x (1.12 if African-American)
 Definition of ESRD vs Kidney Failure

• ESRD is a federal government defined term

that indicates chronic treatment by dialysis or
transplantation

• Kidney Failure: GFR < 15 ml/min/1.73 m2 or on

dialysis.
 Importance of Proteinuria in CKD
Interpretation Explanation

Marker of kidney Spot urine albumin-to-creatinine ratio >30 mg/g or

damage spot urine total protein-to-creatinine ratio >200 mg/g
for >3 months defines CKD
Clue to the type Spot urine total protein-to-creatinine ratio >500-
(diagnosis) of CKD 1000 mg/g suggests diabetic kidney disease,
glomerular diseases, or transplant glomerulopathy.

Risk factor for adverse Higher proteinuria predicts faster progression of

outcomes kidney disease and increased risk of CVD.
Effect modifier for Strict blood pressure control and ACE inhibitors are
interventions more effective in slowing kidney disease
progression in patients with higher baseline
proteinuria.

Hypothesized If validated, then lowering proteinuria would be a

surrogate outcomes goal of therapy.
and target for
interventions
 Management
• Identify and treat factors associated with
progression of CKD and Cardiovascular
outcomes
– HTN
– Proteinuria
– Anaemia
– Glucose control
 Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage Description GFR Evaluation Management
At increased
Test for CKD Risk factor management
risk
Diagnosis
Kidney
Comorbid Specific therapy, based on diagnosis
damage with
1 >90 conditions Management of comorbid conditions
normal or 
CVD and CVD Treatment of CVD and CVD risk factors
GFR
risk factors
Kidney
Rate of
2 damage with 60-89 Slowing rate of loss of kidney function 1
progression
mild  GFR
Moderate 
3 30-59 Complications Prevention and treatment of complications
GFR
Preparation for kidney replacement therapy
4 Severe  GFR 15-29
Referral to Nephrologist
5 Kidney Failure <15 Kidney replacement therapy
1
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
 Hypertension
• Target BP
– <130/80 mm Hg
– <125/75 mm Hg
• pts with proteinuria (> 1 g/d)

• Consider several anti-HTN medications with different

mechanisms of activity
– ACEs/ARBs
– Diuretics
– CCBs
– HCTZ (less effective when GFR < 20)
 Clinical Practice Guidelines for Management of
Hypertension in CKD
Type of Kidney Disease Blood Pressure Preferred Agents Other Agents
Target for CKD, with or to Reduce CVD Risk
(mm Hg) without and Reach Blood
Hypertension Pressure Target
Diabetic Kidney Disease

Nondiabetic Kidney ACE inhibitor Diuretic preferred,

Disease with Urine Total or ARB then BB or CCB
Protein-to-Creatinine
Ratio 200 mg/g
<130/80
Nondiabetic Kidney Diuretic preferred,
Disease with Spot Urine then ACE inhibitor,
Total Protein-to-Creatinine ARB, BB or CCB
ratio <200 mg/g None preferred
Kidney Disease in Kidney CCB, diuretic, BB,
Transplant Recipient ACE inhibitor, ARB
 Proteinuria
• Single best predictor of disease progression

• Normal albumin excretion

– <30 mg/24 hours
• Microalbuminuria
– 20-200 g/min or 30-300 mg/24 hours
• Macroalbuminuria
– >300 mg/24 hours
• Nephrotic range proteinuria
– >3 g/24 hours
 Metabolic changes with CKD
• Hemoglobin/hematocrit 
• Bicarbonate 
• Calcium
• Phosphate 
• PTH 
• Triglycerides 
 Metabolic changes…
• Monitor and treat biochemical abnormalities
– Anemia
– Metabolic acidosis
– Mineral metabolism
– Dyslipidemia
– Nutrition
 Anemia
• Common in CKD
• Caused by  Erythropoeitin,  Iron,  Folate,
Bone marrow suppression/fibrosis,
Haemolysis,
• HD pts have increased rates of:
– Hospital admission
– CAD/LVH
– Reduced quality of life
• Managing anemia Can improve energy levels,
sleep, cognitive function, and quality of life in
CKD pts
 Metabolic acidosis
• Muscle catabolism

• Metabolic bone disease

• Sodium bicarbonate
– Maintain serum bicarbonate > 22 meq/L
– 0.5-1.0 meq/kg per day
– Watch for sodium loading
• Volume expansion
• HTN
 Mineral metabolism
• Calcium and phosphate metabolism
abnormalities associated with:
– Renal osteodystrophy
– Calciphylaxis and vascular calcification
• 14 of 16 ESRD/HD pts (20-30 yrs) had
calcification on CT scan
• 3 of 60 in the control group
• Give phosphate binders- Caco3, AlHO,
Savelemaer, Lanthonum Carbonate
• Vit D analog- Calcitriol
 Dyslipidemia
• Abnormalities in the lipid profile
– Triglycerides
– Total cholesterol
• NCEP recommends reducing lipid levels in
high-risk populations
• Targets for lipid-lowering therapy considered
the same as those for the secondary
prevention of CV disease
 Nutrition
• Think about uremia
– Catabolic state
– Anorexia
– Decreased protein intake
 CV disease
• 70% of HD patients have concomitant CV
disease

• Heart disease leading cause of death in HD

patients

• LVH can be a risk factor

 Renal replacement therapy-PD
Indications and complications Contraindications
• Clinical indications • Relative
– Ureamic symptoms and signs non- – Large muscle mass – potentially
responsive inadequate dialysis
– Severe volume overload – Obesity –difficult with catheter insertion
– Ureamic pericarditis – Intestinal disease – potential to initiate
– Ureamic encephalopathy peritonitis
– Pulmonary edema – Respiratory disease – intolerance of
• Laboratory indications splinting of diaphragm by
– Urea  30mmol/l or  of >10mmol/l/day intraperitoneal fluid
– Creatinine  700umol/l or  of – Hernia- exacerbated by PDF if not
>100umol/l/day surgically corrected
– K  7mmol/l or  of >1mmol/l/day • Absolute
– PH <7.1 or HCO3 <10mmol/l – Abdominal wall stoma – high risk for
• Complication peritonitis
– Peritonitis – Diaphragmatic fluid leak – PDF causes
pleural effusion
– Linking /blockage catheter
– Adhesions – hinder flow of PDF
– Catheter turnel Infection
– Loss of peritoneal function or intergrity
– Peritoneal fibrosis
– PD not technically possible
– Infective dialysis
 Renal replacement therapy-HD
Indications Complications
• Clinical • Acute
– Ureamic symptoms and signs – Hypotension: 25-55%
non-responsive to treatment – Hypertension: 10%
– Severe volume overload – Cramps: 5 to 20%
– Ureamic pericarditis – Nausea and Vomiting: 5 – 15%
– Headache: 5%
– Ureamic encephalopathy
– Chest Pain: 2 to 5%
– Pulmonary edema
– Itching: 5%
• Laboratory – Fever and Chills: < 1
– Urea  30mmol/l or  of – DDS
>10mmol/l/day – First use syndrome
– Creatinine  700umol/l or  of • Long term
>100umol/l/day – DD
– K  7mmol/l or  of – Dialysis related bone disease
>1mmol/l/day – Anaemia
– PH <7.1 or HCO3 <10mmol/l – Infections
Thank you