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Chronic Kidney Disease
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Chronic Kidney Disease

Topics / Renal

Basics

According to the EML guidelines, chronic kidney disease (CKD) is defined as structural or functional kidney damage present for > 3 months, with or without a decreased glomerular filtration rate (eGFR). There are several marker/investigations one may perform to assist with the diagnosis of CKD.

Figure 1: Criteria for CKD.

Etiology

  1. Hypertension
  2. Diabetes Mellitus
  3. Glomerular Disease
  4. Polycystic Kidney Disease
  5. HIV/AIDS

Investigations

  1. Urine dipstick and Urinalysis: Proteinuria, haematuria
    1. Albumin-Creatinine Ratio
  2. Formal blood: elevated serum creatinine, low eGFR
    1. All patients with increased risk of CKD should be tested annually for the measurement of creatinine.
  3. Imaging: Abdominal ultrasound reveals the presence of small kidneys. However, there may be other etiologies of CKD that result in large kidneys.
  4. Biopsy: This is not often done, but there may be presence of several abnormalities on a renal biopsy

Classification

Figure 2: Prognosis of CKD by GFR and albuminuria categories: KDIGO 2012.

Patients who fall on the red area will benefit from referral to a higher level of care. 

Management

General

  1. Reduce salt intake
  2. Low protein diet is only indicated in CKD stage 4 and stage 5
  3. Reduce cardiovascular risk factors: reduce atherosclerosis by using HMG-CoA reductase inhibitors
  4. Avoid nephrotoxic drugs (e.g. NSAIDS, Aminoglycosides ) and remember to change to renal friendly regimes or dosages (e.g. Tenofovir, Metformin etc.)
  5. Screen for proteinuria: If the patient has a 1+ on urine dipstick, repeat on a collected midstream urine specimen on another occasion. If the proteinuria exists, then repeat the urine collection and send for spot urine protein-creatinine ratio (PCR). Significant proteinuria is PCR > 0.1 g/mmol. In diabetic patients, the screening is different.

Medical

  1. Treat the underlying cause.
  2. Manage the proteinuria with ACE-Inhibitors: Enalapril 5mg PO 12 hourly titrated up to 10mg 12 hourly if the patient tolerates it. You start with the lowest dose possible, and you titrate upwards until the proteinuria disappears. Remember that enalapril causes a hyperkalemia. This means that both the creatinine and the potassium need to be monitored.
    • Monitoring:
      • Monitor 1-2 weeks after treatment initiation if the eGFR is < 60. Monitor after 4 weeks after treatment initiation if the eGFR is > 60.
      • If the creatinine increases by more than 20% from the baseline, then you should stop the ACE inhibitor and refer the patient.
      • If the creatinine and the eGFR remain stable, then you may monitor the patient with regular clinic visits.
    • Contra-indications of ACE-I:
      •  Hyperkalemia
      • Hypersensitivity to ACE-I or ARB
      • Bilateral Renal Artery Stenosis
      • Pregnancy
      • Severe Renal Impairment (eGFR < 30)
      • Manage hyperlipidemia with HMG-CoA reductase inhibitors.
  1. Manage co-morbidities
    • Diabetic Mellitus:
      • Optimize control of disease
      • Replace metformin with insulin when the eGFR becomes < 30 (due to increased risk of lactic acidosis)
      • Replace oral sulphonylureas with insulin when the eGFR < 60 (due to increased risk of hypoglycemia)
      • Any patient with eGFR < 30 should preferably be managed with insulin.
    •  Hypertension
      • Optimize control of disease
      • Usually, if the patient has hypertension, then an ACE-Inhibitor is used together with a diuretic.
  2. Manage the fluid overload:
    • If there is any fluid overload, this should be managed. The patient should then be referred to the appropriate level of care.
      • Avoid giving any IV fluids.
      • Furosemide 40-80mg IV was given slowly. May be repeated after 1 hour if there is no response. For chronic treatment may use 40-80mg 12 hourly PO.
  3. Management of patinets with CKD Stage 3-5 NOT on dialysis:
    1. Manage the hyperphosphataemia and/or hypocalcaemia:
      • Calcium carbonnate 500mg  PO 8 hourly with meals. If the hyperphosphatemia persists you can increase the dose to 1g 8 hourly with meals.
      • If the hyperphosphatemia remains uncontrolled while the patient is on calcium carbonate: Aluminium hydroxide BP (300mg/5ml) PO 10ml 8 hourly (specialist initiated). Should not be used for more than 3 months to avoid dementia-associated aluminum toxicity. 
    2. Manage the normal/low serum phosphate and hypocalcemia:
      • Calcium carbonate 500mg  PO 8 hourly with meals. If the hyperphosphatemia persists you can increase the dose to 1g 8 hourly with meals.
    3. If the patien develops  h

Referral

  1. All cases of suspected chronic kidney disease stage 3-5 for assessment and planning.
  2. Al children
  3. All cases of CKD with haematuria, significant proteinuria, eGFR < 60 for initial assessment and planning or with an eGFR < 30.
  4. Uncontrolled hypertension or fluid overload.
  5. CKD associated with hyperlipemia
  6. Not reduction of the proteinuria with the ACE-Inhibitors.
  7. If the ACE-Inhibitors are not well tolerated.
  8. Patients who qualify for dialysis or transplantation or with complications should be referred as soon as possible.
Published on November 2, 2022
Dr RW Becerra Estevez
Dr RW Becerra EstevezMBChB (WSU)

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