CHRONIC KIDNEY DISEASE

Approach to scenario
Kidney damage or a persistent eGFR < 60 ml/min/1.73m2 for >3 months
1. Ensure pt stable / ABC’s
Clinical Manifestations 2. History / Physical
Historical features - volume
 Uremic Symptoms 3. Investigations
o Anorexia, nausea, vomiting, fatigue, ↓ mental acuity (early), nocturia, lassitude - biopsy
o Stomatitis, metalic taste in the mouth, pruritus (universal)
4. Management
o Neuromuscular (muscle cramps, coarse muscle twitching, asterixis)
- ABCs
o Peripheral sensorymotor neuropathy
- ACEI, diet, vits, EPO
o Convulsions (hypertensive or metabolic encephalopathy).
- binders
o Wih - advanced CKD (GI ulcers/bleed, ↓ sex hormones/drive, menstrual irreg.)
 Risk Factors - Old age, hypertension, proteinuria, high protein diet, dyslipidemia
 Ask about – Meds, PMHx (HTN, DM, AI ROS), Allergies, FHx, Hearing loss

Physical Examination Differential Diagnosis (VINDICATE)

 ABC’s, vital signs, monitoring (IV, O2, BP, telemetry) Pre-Renal
 General – nurtritional status  See causes of ARF
 Peripheral – edema, pulses, ulcers Renal
 HEENT – arcus, fundi  Vascular: HTN (malignant glomerulosclerosis,
 Cardiovascular (JVP, pulses, precordial IPA) – rub, volume status nephroangiosclerosis), Macrovascular
 Respiratory (IPPA) – edema, infiltrate (vasculopathy of renal arteries and veins)
 Abdominal (IPPA) – PCKD  Glomerular: Primary (IgA, FSGS, Membranous,
 Neuro/MSK (Sensory, motor, reflexes, rectal) – neuropathy Membranoproliferative, Idiopathic crescenteric),
Secondary (Diabetes, SLE, Post infectious GN,
Wegener’s, HUS, Amyloid)
 Tubulo-Interstitial: Autoimmune interstitial
Investigations nephritis (Sarcoid, Sjögren’s), Hypercalcemia
 Bloodwork  Hereditary: Alport's, Polycystic Kidney disease,
o CBC, lytes, urea, Cr, glucose, HbA1c, iron studies (ferritin, % saturation) medullary cystic kidney, Klippel-Feil, Nail-
o Ca, PO4, Mg, iPTH, albumin, fasting lipid profile, urinalysis Patella, nephronophthisis
o 24 hour urine (protein, creatinine), SPEP/UPEP Post-Renal
 Obstruction (congenital, calculi, malignancies),
 CXR  Vesicoureteric reflux, BPH
 Renal Ultrasound - Assesses renal size, parenchyma, obstruction Plus
 Renal Biopsy (see ARF for indications)  Consider causes of ARF and other aggrevating
factors (Na/water depletion, nephrotoxins, CHF,
Distinguishing Acute from Chronic infection, hypercalcemia, obstruction)
 Old Cr (>3 months of elevated creatinine suggests chronic) Stages of CKD
 modest hyperkalemia, Stage I—GFR >90 ml/min/1.73m2 (64%)
 Marked anemia / mineral metabolism abnormalities (↓ Ca, ↑ PO4, ↑ iPTH, ↓ vit D) Stage II—GFR 60-89 (31%)
 Renal osteodystrophy Stage III—GFR 30-59 (4.3%)
 small kidneys on renal U/S (except DM, amyloidosis, HIV, PCKD, myeloma, Stage IV—GFR 15-29 (0.2%)
malignant nephroangiosclerosis, RPGN), renal biopsy Stage V—GFR <15 or dialysis-dep. (0.2%)

Treatment
Management of CKD
 Treat aggravating and etiologic factors
 BP Control: Target BP <130/80. ACEI and ARBs 1st line. Diuretics 2nd line.
o Need to monitor closely (Cr and lytes q2w) 2o risk of precipitating ARF.
o If Cr ↑ >30% ↓ dose 50%; if Cr ↑ >50% rule out RAS. Accept K+ <5.6
 Dysdipidemia: Statins are just as effective for Stage 2-3 CKD as for the general population; questionable benefit for Stage 4-5 (4D)
 Lifestyle: Smoking cessation, limit EtOH to <2/day, regular aerobic/resistance exercise
 Dietary management: ↑ caloric intake with modest protein restriction (0.6 g/kg/d in DM or eGFR <25; 0.8 g/kg/day for eGFR 25-55)
 Multivitamins: Replavite
 Drug modification: Avoid nephrotoxic drugs (esp NSAIDs). Renal dose-adjustment of medications
 Immunization: flu shot and pneumovax for CKD stage 4-5
Management of CKD Complications
 eGFR >30
o Hyperkalemia: Restrict to 40 mEq/day if mild hyperkalemia (<6); use lasix/kayexelate 30g PO daily-QID as needed
o Volume Overload: Restrict Na+ (1.5g/d) if edematous; Restrict H2O if Na+ is <135 mmol/L
o Acidosis (serum HCO3 <15-20 mEq/L): NaHCO3 2g PO daily (uptitrate until venous HCO3 is >22 mmol/L or Na overload)
o Anemia: PO/IV iron ± erythropoietin for a target Hb 110-120g/L in women and 120-135 g/L in men and postmenopausal women
o Mineral metabolism: aim to normalize calcium and minimize phosphate with alfacalcidiol, calcium carbonate and PO 4 binders
 GFR <30 - Talk about RRT (HD vs. PD vs. transplant)
 GFR <20 - Arrange access (fistula > graft > catheter)
 GFR <15 - Consider initiation of RRT
o Dialysis Indications in CKD – Acute Indication, Uremic Symptoms (anorexia, nausea, vomiting, fatigue, pruritis, cramps),
Malnutrition (Alb <35g/L), eGFR <10-15% (DM when eGFR <15-20%), CR>1000 mcmol/L, Urea >30 mmol/L
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Summary of management of CKD guidelines from Canadian Society of Nephrology: 2008

Overview: Lifestyle, HTN (<140/80), HLD (LDL<2), Proteinuria, Anemia, AGMA,

High Phos, low Ca, high PTH
HD need
Treatment of hypertension in association with nondiabetic chronic kidney disease
 For patients with proteinuric chronic kidney disease (CKD) (urine albumin-to-creatinine ratio ≥ 30 mg/mmol), use ACEI or ARB if
intolerant.
 Blood pressure should be targeted to < 130/80 mmHg (grade C).
 For patients with nonproteinuric CKD (albumin-to-creatinine ratio < 30 mg/mmol), antihypertensive therapy should include either an
angiotensin-converting enzyme inhibitor (grade B), an angiotensin receptor blocker (grade B), a thiazide diuretic (grade B), a beta blocker
(in patients younger than age 60) (grade B), or a long-acting calcium channel blocker (grade B).
 In HTN with diabetic CKD use ACEI/ARB and target <130/80

Lifestyle
 Smoking cessation, weight loss if overweight, protein controlled diet (0.8-1g/kg/d), limit EtOH (<2 drinks/day), 30-60min moderate
intensity exercise per day (4-7X/week), salt restriction (<100mmol/day)

Glycemic control
 Targets for glycemic control, where they can be achieved safely, should follow standard Canadian Diabetes Association Guidelines
(hemoglobin A1c < 7.0%, fasting plasma glucose 4–7 mmol/L)
 Metformin is recommended for type 2 DM with Stage I and II CKD who have stable renal function unchanged over last 3 months and can
be continued in stable Stage III CKD

Dyslipidemia
 Fasting lipid profile should be measured in stage I – III CKD and in stage IV if it would change anything
 Profile should be checked 6 weeks after initiating therapy and q6-12 months after
 Statin therapy should be started in stage I –III CKD as per general population guidelines
 Statin therapy in stage IV should be titrated to LDL<2.0, cholesterol to HDL ratio <4
 Gemfibrozil as alternative to statin or in patients with high risk and low HDL<1
 Treat hypertriglyceridemia (>10) by adding gemfibrozil or niacin to decrease risk or pancreatitis
 Need only consider monitoring ALT/CK q3 months in stage IV CKD on mod/high dose statin
 Don’t combine statin and fibrate in stage IV due to risk of rhabdo

Proteinuria
 Screen for proteinuria with urine ACR (ACR>60mg/mmol indicate high risk of progression to ESRD)
 Patients with diabetes and ACR>2mg/mmol in men and 2.8mg/mmol in females should receive ACEI or ARB

Anemia
 Initial evaluation in CKD stages III-V with Hb<120 consists of WBC with diff, retic, Hb, plts, ferritin, transferrin sat, RBC indices
 In setting of anemia with replete iron stores, start epo at Hb<100, target Hb 110
 Iron should be maintained with ferritin>100 and transferrin sat>20%
 Start oral iron as first line therapy, if no response or do not tolerate oral then use IV

Mineral Metabolism
 Measure Ca, Phos, PTH in stage IV-V or in stage III with progressive decline in renal function
 Maintain Ca and Phos in normal range, PTH target unknown
 For hyperphosphatemia use dietary restriction followed by calcium containing phosphate binders if hypercalcemia not present
 Consider Vit D analogues if PTH>53pmol/L, discontinue if hypercalcemia/hyperphosphatemia/PTH<10.6

ESRD
 Patients with GFR<30 should be managed in multidisciplinary setting where possible
 No current recommendation for RRT based on GFR
 Patients with GFR<20 with progressive and irreversible damage over the last 6-12 months may be considered for living donor preemptive
renal transplantation
 Ensure advanced care planning discussed

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