Chronic Kidney Disease
Definition
• Evidence of
• Structural or functional abnormalities of the kidneys
(abnormal urinalysis, biochemistry, imaging studies or
histology)
• That persists for at least 3 months
• With or without decrease in GFR
Pathogenesis
• Hyperfiltration injury
• Hypertension
• Proteinuria
• Hyperhosphatemia
• Hyperlipidaemia
Presentations
• Asymptomatic with abnormalities in investigations
• Anorexia and lethargy
• Polydypsia and polyuria in the initial stage
• Failure to thrive and growth retardation
• Renal osteodystrophy
• Anaemia
• Acute on chronic renal failure
• Hypertension
Causes
• Congenital abnormalities (PU valves, reflux
nephropathy, renal dysplasia)
• Renal cystic disease (PCKD)
• Nephrotic syndrome
• Glomerulonephritis
• Atypical HUS
• Familial nephropathies (Alport syndrome)
• Following AKI
Complications
• Lethargy, malaise, LOA
• Reflux oesophagitis and peptic ulcer disease
• Uraemia and uraemic pericarditis
• Heart failure
• Pigmentation
• Renal osteodystrophy
• Delayed puberty
• Growth retardation
• Anaemia
• Metabolic acidosis
• Hypertension
• Electrolyte imbalance
Investigations
• FBC and blood picture – normochromic normocytic anaemia
• Blood urea – elevated
• Serum creatinine – elevated
• Serum electrolytes – hyperkalemia
• Serum Ca – low
• Serum PO4 – high
• Serum ALP – high
• Serum PTH – high
• Venous blood gas – metabolic acidosis
• Serum albumin – low
• Serum cholesterol – high
• UFR and U. alb/creatinine ratio
• Serum ferritin 3 monthly– reduced
• Lipid profile 6 monthly - increased
Management
Stage Management options
Stage I
Look for aetiology
Stage II Renoprotective measures
Stage III Correct biochemical and hematological
derangements
Stage IV Prepare for transplantation or dialysis
Stage V Transplantation or dialysis
Treatment goals
• Control proteinuria with ACEI and ARB
• Control hypertension
• Control dyslipidaemia
• Adequate hydration
• Avoid nephrotoxic medication
• Prevent UTIs
• Manage Complications
• Prepare for transplantation/ hemodialysis
Management of anaemia
• Normochromic normocytic anaemia with reduced
reticulocytes
• Commence treatment at following Hb levels
• <6 months <10g/dl
• 6-24 months <11g/dl
• >2 years <12g/dl
• Treatment
• Erythropoeitin 100U/kg/week SC (if on dialysis 50U/kg/3
times per weeks IV) – SE: hypertension, bone marrow
fibrosis
• Fe (with Vit. C) to maintain transferrin saturation >20%
and serum ferritin >200microgram/L
• Vit B and folate supplementation
Management of Renal
Osteodystrophy
• Due to reduced vit. D production and reduced PO4
excretion reduce calcium increased PTH
increased bone turnover renal osteodystrophy
• Management
• Keep Ca, PO4, and alkaline phosphatase levels normal
• Vit D supplementation as 1alpha cholecalciferol
• Phosphate binders – calcium carbonate
• Low phosphate diet – Reduced tuna, pork, chicken
Management of Hyperkalaemia
• Recognize early on ECG
• Tall T waves
• Wide QRS complexes
• ST depression
• Ventricular arrhythmias
• Increased PR interval
• Principles of management
• Stop all exogenous potassium
• Avoid diet and drugs causing high K levels
• Monitor vital signs and continuous ECG monitoring
• Reduce K levels
• Check pH
10% calcium gluconate 0.6-1ml/kg diluted 1:1 IV
over 5-10 mins slowly – can repeat
OR
Calcium chloride 0.2-.25ml/kg central IV or 10%
solution. Give slowly. Stop infusion if heart rate
drops more than 20bpm
- Insulin 0.1u/kg in 2ml/kg 25% dextrose IV
infusion over 15-20 mins followed by 10% glucose
5ml/kg/h with insulin 0.05-0.1 u/kg/h IV
- Correct acidosis if pH <7.35 with 8.4% sodium
bicarbonate 1-2ml/kg diluted 1:1 over 20mins
- Nebulized salbutamol 0.15mg/kg 4hrly
- Frusemide 1-5mg/kg IV bolus
- Calcium resonium – 1g/kg PO
- Peritoneal dialysis
- Renal replacement therapy (Hemodialysis)
• Management of acidosis
• Manage with oral sodium bicarbonate
• Management of hypertension
• Target : <90th C for age
• Use ACEI and ARB with caution as it can cause
hyperkalaemia and further reduction of GFR
• Effects: reduces proteinuria, reduces intraglomerular
pressure
• In crisis : use Hydralazine, Labetolol, sodium
nitroprusside
Nutrition
• Normal protein diet with high quality protein
• Normal calorie requirement for age
• Low cholesterol diet
• Low phosphate and potassium diet
Indications for dialysis
• GFR <10ml/min/1.73m2
• Refractory fluid overload
• Severe uraemic symptoms or BU >40mmol/l
• Biochemistry not controlled
• Refractory anaemia
