Makindo Medical Notes

Related Subjects: |Metabolic acidosis |Lactic acidosis |Acute Kidney Injury (AKI) / Acute Renal Failure |Renal/Kidney Physiology |Chronic Kidney Disease (CKD) |Anaemia in Chronic Kidney Disease |Analgesic Nephropathy |Medullary Sponge kidney |IgA Nephropathy (Berger's disease) |HIV associated nephropathy (HIVAN) |Balkan endemic nephropathy (BEN) |Autosomal Dominant Polycystic kidney disease

About

• Chronic Kidney Disease (CKD): A gradual and progressive loss of kidney function over time.
• Can progress to end-stage renal disease (ESRD), requiring renal replacement therapy (dialysis or transplantation).
• Associated with a high risk of cardiovascular and other systemic complications.

Stages of CKD

Suffixes

• P: Indicates significant proteinuria (e.g., Stage 3Ap).
• T: Denotes a renal transplant (e.g., Stage 3AT).
• D: Indicates the patient is on dialysis (e.g., Stage 5D).

Aetiology

• Hypertension, diabetes, and glomerulonephritis.
• Polycystic kidney disease, lupus nephritis, and obstructive uropathy.
• Hereditary or structural kidney diseases.

CKD is a major cardiovascular risk factor. Dialysis patients are approximately 20 times more likely to experience cardiovascular events. Goals of treatment include maintaining blood pressure <120/80 mmHg and proteinuria <0.3 g/24 hours.

Diagnosis

• History and Examination:
  • Assess for risk factors: diabetes, hypertension, family history of kidney disease.
  • Evaluate symptoms: fatigue, nocturia, oedema, changes in urine output, haematuria.
• Blood Tests:
  • Serum Creatinine: Used to calculate estimated glomerular filtration rate (eGFR).
  • Urea and Electrolytes (U&E): Monitor kidney function and electrolyte imbalances.
  • Full Blood Count (FBC): Evaluate for anaemia, which is common in CKD.
  • Lipid Profile: Assess cardiovascular risk.
  • HbA1c: Check glycaemic control in diabetic patients.
• Urine Tests:
  • Albumin-Creatinine Ratio (ACR): Detects proteinuria, a key marker of kidney damage.
  • Urinalysis: Look for haematuria, proteinuria, or signs of infection.
  • Urine Culture: Rule out urinary tract infections if clinically indicated.
• Imaging:
  • Renal Ultrasound: Identify structural abnormalities, renal stones, or hydronephrosis.
  • CT or MRI: For further evaluation of complex renal masses or obstructive uropathy.
• Specialist Tests:
  • Renal Biopsy: Indicated in cases of unexplained kidney disease, rapid progression, or suspected glomerulonephritis.
  • Autoimmune Screening: ANA, anti-dsDNA, ANCA for suspected systemic diseases like lupus or vasculitis.
  • Parathyroid Hormone (PTH): To assess secondary hyperparathyroidism in advanced CKD.

Comprehensive Management

1. General Measures

• Patient Education: Inform patients about CKD progression, lifestyle changes, and treatment goals.
• Regular Monitoring:
  • Stage 1–2 CKD: Monitor eGFR and ACR every 12 months.
  • Stage 3 CKD: Monitor eGFR and ACR every 6–12 months.
  • Stage 4–5 CKD: Monitor eGFR, ACR, and complications every 3–6 months.
• Lifestyle Modifications:
  • Low-salt diet (<2 g sodium/day).
  • Moderate protein intake (0.8–1 g/kg/day).
  • Encourage regular physical activity.
  • Smoking cessation.
  • Weight management for overweight or obese patients (BMI <25).

2. Blood Pressure and Cardiovascular Risk Management

• Blood Pressure Control: Target <120/80 mmHg.
  • Start ACE inhibitors (ACEIs) or ARBs for patients with proteinuria or hypertension.
  • Add diuretics for volume control and to prevent hyperkalaemia.
  • Add calcium-channel blockers (e.g., diltiazem) if BP remains uncontrolled.
• Statins: Use to lower LDL cholesterol to <2.5 mmol/L.
• Aspirin: Consider low-dose aspirin for secondary prevention of cardiovascular events.

3. Proteinuria Management

• Use ACEIs or ARBs as first-line therapy to reduce proteinuria.
• Monitor urine ACR and titrate medication to achieve target proteinuria <0.3 g/24 hours.

4. Anaemia Management

• Target haemoglobin levels: 11–12 g/dL.
• Correct iron deficiency with oral or intravenous iron.
• Consider erythropoietin-stimulating agents (e.g., epoetin alfa) for symptomatic anaemia unresponsive to iron supplementation.

5. Bone and Mineral Disorders

• Monitor and manage calcium, phosphate, and PTH levels.
• Prescribe phosphate binders (e.g., calcium carbonate, sevelamer) for hyperphosphataemia.
• Use vitamin D analogues (e.g., alfacalcidol) to correct secondary hyperparathyroidism.

6. Metabolic Acidosis

• Treat serum bicarbonate levels <22 mmol/L with sodium bicarbonate or sodium citrate.

7. End-Stage Renal Disease (ESRD) Planning

• Discuss options for renal replacement therapy:
  • Haemodialysis (HD).
  • Peritoneal dialysis (PD).
  • Pre-emptive renal transplantation for eligible candidates.
• Plan for vascular access (e.g., AV fistula) at least 6 weeks prior to dialysis initiation.

8. Acute Kidney Injury (AKI) Prevention

• Temporarily discontinue nephrotoxic drugs (e.g., NSAIDs, ACEIs, ARBs) during acute illness or dehydration.
• Monitor renal function and potassium closely during intercurrent illnesses.

9. Patient Follow-Up

• Regular reviews to monitor CKD progression, treatment efficacy, and emerging complications.
• Assess adherence to therapy and reinforce lifestyle modifications.

References

• NICE Guidelines on CKD
• UK Renal Association