Chronic kidney disease (CKD)By Dr.

Mujahid.A.AbbassWKUFOM

Definition CKD is Impaired renal function for >3 months based on abnormal

structure or function, or GFR <60mL/min/1.73m 2 for >3 months with or without evidence of kidney damage

Symptoms usually only occur once stage 4 is reached (GFR <30)

ESRF is defi ned as GFR <15 mL/min/1.73m 2or need for renal replacement therapy (RRT—dialysis or transplant).

Major causes of CKD Glomerular diseases

primary glomerular diseasesFocal and segmental glomerulosclerosis

Membranoproliferative glomerulonephritis

IgA nephropathy

Membranous nephropathy

Alport syndrome (hereditary nephritis)Secondary glomerular diseasesDiabetic nephropathyAmyloidosisAmyloidosisHIV-associated nephropathyCollagen-vascular diseases (eg, SLE)HCV-associated membranoproliferative glomerulonephritis

Tubulointerstitial nephritis

Drug hypersensitivityHeavy metalsAnalgesic nephropathyReflux/chronic pyelonephritisSickle cell nephropathyIdiopathicCystic diseasesPolycystic kidney diseaseMedullary cystic diseaseObstructive nephropathiesProstatic diseaseNephrolithiasisRetroperitoneal fibrosis/tumorCongenitalVascular diseasesHypertensive nephrosclerosisRenal artery stenosis

Reversible causes of kidney injury

ClassificationsStage GFR

(mL/min)Notes

1 >90 Slight GFR with other evidence of renal damage*

2 60-89 Slight GFR with other evidence of renal damage*

3 A 45-59 Moderate GFR with or without evidence of other renal

3 B 30-44 damage*

4 15-20 Severe GFR with or without evidence of renal damage*

5 <15 Established renal failure

Screening for risky patients with:

i. Diabetes mellitus ii. Hypertensioniii. Cardiovascular disease (IHD, peripheral vascular disease, cerebrovascular

disease)iv. Structural renal disease, known stones or BPHv. Recurrent UTIS or those with childhood history of vesicoureteric refl uxvi. Multisystem disorders which could involve the kidney, eg SLEvii. Family history of ESRF or known hereditary disease, eg APKDviii.Opportunistic detection of haematuria or proteinuria Some guidelines also

suggest routine screening in thoseix. Age >60yrs

Causes of anemia in CKD

Relative defiiency of erythropoietin

Diminished red blood cell survival

Bleeding diathesis

Iron defiiency

Hyperparathyroidism/bone marrow firosis

“Chronic inflmmation”

Folate or vitamin B12 defiiency

Hemoglobinopathy

omorbid conditions: hypo/hyperthyroidism, pregnancy,HIV-associated disease, autoimmune disease, immunosuppressive drugs

Evaluation 1-History :•Possible cause: ask about previous UTIS, LUTS (lower urinary tract symptoms, PMH of HTN, DM, IHD, systemic disorder, renal colic. Check drug history and family history (draw tree if positive). Systems review: always be on the lookout for more than is immediately obvious, possible rare causes, symptoms suggestive of systemic disorder or malignancy.

•Current state: aemic symptoms In women ask about amenorrhoea, in menimpotence. Symptoms become more common with progression through CKD stages 4 and 5 but if slow onset many patients remain asymptomatic. Check for oliguria, dyspnoea, ankle swelling.

Symptoms and signs of uremia.

Organ System Symptoms SignsGeneral Fatigue,weakness Sallow-appearing, chronically ill

Skin Pruritus, easy bruisability Pallor, ecchymoses, excoriations,edema, xerosis

ENT Metallic taste in mouth, Urinous breath epistaxisEye Pale conjunctiva

Pulmonary Shortness of breath Rales, pleural effusion

Cardiovascular Dyspnea on exertion,retrosternal pain on Inspiration (pericarditis) Hypertension, cardiomegaly, friction rubGastrointestinal Anorexia, nausea, vomiting, hiccups -----------Genitourinary Nocturia, erectile dysfunction Isosthenuria

Neuromuscular Restless legs, numbness and cramps in legsNeurologic Generalized irritability Stupor, asterixis, and inability to myoclonus, peripheral neuropathy concentrate, decreased libido

2-Examination : You are looking for:1Cause of ESRF/CKD, eg polycystic kidneys, signs of IHD, DM2Current mode of renal replacement therapy (RRT) and any complications, egtransplant + skin malignancy from immunosuppression3Previous types of RRT and any complications, eg arteriovenous fi stula + parathyroidectomy scarPeriphery:Hypertension, arteriovenous fi stula (thrill, bruit, has it been recentlyneedled?), signs of previous transplant—bruising from steroids, skin malignancyfrom immunosuppression.

Face: Pallor of anaemia, yellow tinge of uraemia, gum hypertrophy from ciclosporin, cushingoid appearance from steroids.

Neck : Current or previous tunnelled line insertion (if removed, look for a small scarover internal jugular, and a larger scar in ‘breast pocket’ area from the exit site),scar from parathyroidectomy.

Abdomen: PD catheter or sign of previous catheter (small midline scar just below umbilicus and small round scar to side of midline from exit site), signs of previous transplant (hockey-stick scar, palpable mass), ballotable polycystic kidneys ± liver.

Elsewhere: Signs of diabetic neuropathy, retinopathy, cardiovascular or peripheral vascular disease

3-Tests :i. Blood: Hb (normochromic, normocytic anaemia), ESR, U&E, glucose

(DM),low Ca2+, high PO43 –, high alk phos (renal osteodystrophy).high PTH if CKD stage 3 or more

ii. Urine: Dipstick, MC&S, albumin: creatinine ratio or protein : creatinine ratio

iii. Imaging: USS to check size, anatomy and corticomedullary dif erentiation. In CKD kidneys are usually small (<9cm) but can be enlarged in infi ltrative disorders (amyloid, myeloma), APKD and DM. If asymmetrical consider MAG3 renogram to look at contribution of each kidney to overall function

iv. Histology: Consider renal biopsy if rapidly progressive disease or unclear cause and normal sized kidneys.

Clinical action planStage Descrepion GFR,mL/minPer

1.73 m2Action

1 Kidney damage with normal or ↑ GFR ≥90 Diagnosis and treatment, treatment of comorbid conditions,slowing progression, CVD risk reduction

2 Kidney damage with mild ↓GFR 60–89 Estimating progression

3 Moderate ↓GFR 30–59 Evaluating and treating complications

4 Severe ↓ GFR 15–29 Preparation for kidney replacement therapy

5 Kidney failure <15 (or dialysis) Kidney replacement (if uremia present)

Essential of diagnosis:

▶ Decline in the GFR over months to years

▶ Persistent proteinuria or abnormal renal morphology may be present.

▶ Hypertension in most cases.

▶ Symptoms and signs of uremia when nearing endstage disease.

▶ Bilateral small or echogenic kidneys on ultrasound in advanced disease.

Treatments aim to• slowing tHe progression of CKd• reducing intraglomerular Hypertension and proteinuria• slowing progression of diabetic renal disease• Control of blood glucose• Control of blood pressure and proteinuria• protein restriction• Managing other Complections of CKD such as:

Medication dose adjustment preparation for renal replacement therapy(dialysis+transplantation) patient education

Calciphylaxis.

Complications

A. Cardiovascular Complications i. Hypertensionii. Coronary artery diseasiii. Heart failureiv. Pericarditis

B. Disorders of Mineral Metabolismi. renal osteodystrophy, ii. osteitis fibrosa cystica,iii. Adynamic bone diseaseiv. Osteomalacia

C. Hematologic Complications i- Anemia ii- Coagulopathy

D. Hyperkalemia E. Acid–Base DisordersF. Neurologic Complications

G. Endocrine Disorders