CHRONIC KIDNEY DISEASE

(CKD)
Definition of CKD

Structural or functional abnormalities of the

kidneys for >3 months, as manifested by
either:
1. Kidney damage, with or without decreased GFR,
as defined by
pathologic abnormalities
markers of kidney damage, including abnormalities in
the composition of the blood or urine or
abnormalities in imaging tests
2. GFR <60 ml/min/1.73 m2, with or without kidney
damage
Stages of CKD
Stage 1*: GFR >= 90 mL/min/1.73 m2
Normal or elevated GFR

Stage 2*: GFR 60-89 (mild)

Stage 3: GFR 30-59 (moderate)

Stage 4: GFR 15-29 (severe; pre-HD)

Stage 5: GFR < 15 (kidney failure)

Am J Kidney Dis 2002; 39 (S2): S1-246

GFR calculation

Cockcroft-Gault
Men: CrCl (mL/min) = (140 - age) x wt (kg)
72x SCr
Women: multiply by 0.85
MDRD
GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-
1.154 x (age)-0.203 x (0.742 if female) x (1.12 if African-

American)
The Mosteller formula
BSA (m) =
( [Height(cm) x Weight(kg) ]/ 3600)
e.g. BSA = SQRT( (cmx kg)/3600 )
High Risk for CKD
DM,HT, NS, CGN,KUB stone
exposure to nephrotoxic agent
Previous kidney disease
Autoimmune disease
Family history of renal disease
Cardiovascular disease
Elderly
Recurrent UTI
Staging in diabetes nephropathy
Risk factor for CKD progression
Blood pressure , hyperglycemia
Proteiuria
Extent of tubulointerstitial disease
Drugs : Nsaids
Vascular calcification (Cax Po4 products
>55)& , hyperphosphatemia
Dietary protein intake
History of AKI
Smoking ,Hyperlipidemia, genetic factor
Proteinuria

Normal albumin excretion

<30 mg/24 hours
Microalbuminuria
20-200 g/min or 30-300 mg/24 hours
Macroalbuminuria
>300 mg/24 hours
Nephrotic range proteinuria
>3 .5 g/24 hours/1.73 m2
CLINICAL MANIFESTATION
Fluid& electrolyte : Volume, Na , K , Met
acidosis , Uric acid ,Ca, Po4
CVD&pulmonary : HT, IHD, Pericarditis,
Uremic lung
Hemato:Normochromic normocytic anemia
GI :anorexia, N/V, PCM
Endrocrine : secondary hyperparathyroid
Neuromuscular: myoclonus, Seiuzure
Dermato ;Hyperpigment, Pruritus, Ecchymosis
CKD from AKI
Uremic symptom or azotemia > 3 months
Small size both kidneys(< 9cms)
Broad cast in urine
Renal osteodystrophy
Normochromic normocytic anemia
Renal osteodystrophy
1.Osteitis fibrosa cystica
- cause: hyperparathyroid
- lab : Hypercalcemia, high alk phosphatase
- X-rays
: subperiosteum erosion of long bone
: ground glass" or "salt and pepper of
skull
: brown tumors,
Renal osteodystrophy
2.Ostomalacia
calcium ,phosphate -low
alkaline phosphatase -variable
3.Osteosclerosis
4.Osteoporosis
calcium ,phosphate -normal
alkaline phosphatase-variable
Hx &PE in CKD
Urinary symptom, uremic symptom
PH :urinary stone ,UTI
FH: ADPKD
Co morbid chronic disease: DM,HT
,CHF,,gout
PE : BP, BMI, anemia , uremic odor
hyperpigmentation, abdomial mass
Puffy face, edema
Lab&Investigation in CKD
CBC
BUN /Cr, Elyte
Ca, Po4 Albumin,PTH
Lipid profile, LFT
Tsat %(SI/TIBC), ferritin
UA,UPCR
U/S Kidney
Prevalence of Abnormalities at each level of GFR

Hypertension* Hemoglobin < 12.0 g/dL

Unable to walk 1/4 mile Serum albumin < 3.5 g/dL
Serum calcium < 8.5 mg/dL Serum phosphorus > 4.5 mg/dL
90
Proportion of population (%)

80
70
60
50
40
30
20
10
0
15-29 30-59 60-89 90+
Estimated GFR (ml/min/1.73 m2)

*>140/90 or antihypertensive medication p-trend < 0.001 for each abnormality

 Cardiovascular Mortality in the General
Population and in ESRD Treated by Dialysis

Annual mortality (%)

100 Dialysis

10
General population
1
0.1 Male
Female
0.01 Black
White
2534 4554 6574 85
3544 Age (years) 7584
5564
CKD management
Stage 1
specific Rx , Rx comobid,
Rx CVD& CVD risk factor
Stage 2 estimate &slow progression
Stage 3 Evaluate&Rx complication
Stage 4 preparation for RRT
Stage 5 RRT(if uremic present)
CVD risk reduction

- highest risk factor for CVD

- keep LDL <100
- correct hypoalbumiemia
- Ca-Po4 product <55
- Rx salt &water retention
- Rx of anemia
PreESRD MANAGEMENT
Slow progression
-Intervention Prove effective :
Control BP(most effective )
< 140/90 mmHg if albuminuria < 30
mg/day
< 130/80 mmHg if albuminuria > 30
mg/day
Block RAAS
+ Control BS
PreESRD MANAGEMENT
Intervention inconclusion :
Protein restriction,
Rx anemia,
stop smoking
Rx of hyperlipidemia
Diet for CKD patient
Energy 30-35 meq/kgBW/day
Protein
CKD stage 1-3 =0.6-0.8 g/kgBW/day
CKD stage 4-5=0.6 g/kgBW/day
Low salt (Na < 2 gm/ day)
Restrict oral Fluid
Low K diet
Low P diet < 800mg/day
Low saturated fat
Evaluate & Rx of uremic
complication
- sodium &water restriction
2-3 / (1 = 4
)
=500-700 cc. / +
- diuretic use
Loop diuretic
Thiazide: GFR >30 mL/min/1.73 m2
K-sparing diuretic: Precaution in
GFR <30 mL/min/1.73 m2
or combine with ACEor ARB
Evaluate & Rx of uremic
complication
- Rx of hyperkalemia
low K diet, kalimate,kayexalate
- Rx of hypocalcemia
Calcium carbonate, vitamin D
- Rx of hyperphosphatemia
low phosphate diet
Calcium carbonate
Aluminium hydroxide (if CaxPo4 >55)
Evaluate & Rx of uremic
complication
-Rx of metabolic acidosis
sodamint, calcium carbonate
- Anti hypertensive drug
- Rx hyperparathyroid
control phosphate level
vitamin D
Evaluate & Rx of uremic
complication
- Anemia
Iron replacement
EPO
Folic acid
Second line : RBC transfusion
Renal replacement therapy
Hemodialysis
Peritonael dialysis
Kidney Transplantation