Untitled Quiz

Chronic Kidney Disease (CKD) Definition & Classification

• CKD is defined as kidney damage for ≥ 3 months, using histology, imaging or laboratory assessments, with or without decreased GFR, OR GFR < 60 mL/min/1.73 m2 for ≥ 3 months, with or without kidney damage.
• CKD is classified into five stages (G1-G5) based on estimated glomerular filtration rate (eGFR) and three stages (A1-A3) based on albumin:creatinine ratio (ACR).

Pathophysiology of Progressive Kidney Disease

• Reduced nephron mass (due to diabetes, hypertension, glomerulonephritis, etc.) leads to compensatory vasodilation of the afferent arteriole (by prostaglandins) and constriction of the efferent arteriole (by Angiotensin II).
• This causes increased blood flow, single nephron intra-glomerular capillary filtration pressure, and hyper-filtration (increased single nephron GFR).
• Sustained increases in plasma flow and hydrostatic pressure lead to hyper-filtration injury and glomerular sclerosis, resulting in continued loss of nephron function.

Diagnostic Criteria for Progressive Kidney Disease

• Progressive increase in serum creatinine (consider factors that may alter serum creatinine: decreased muscle mass & nutritional status).
• Decreased GFR
• In stage 1 and 2 CKD, reduced GFR is not enough for diagnosis.
• The markers of kidney damage that establish the diagnosis include: albuminuria (albumin excretion >30 mg/24 hr or albumin:creatinine ratio >30 mg/g [>3 mg/mmol]), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, and structural abnormalities detected by imaging.

Clinical Presentation of CKD

• CKD is often asymptomatic until stages 4 or 5.
• Early diagnosis requires a high level of suspicion in patients with chronic conditions such as hypertension or diabetes.
• Clinical presentation (signs and symptoms): fatigue, weakness, shortness of breath, mental confusion, nausea and vomiting, bleeding, loss of appetite, edema, weight gain, changes in urine output and consistency, "foaming" of urine (indicative of proteinuria), and itching.
• Laboratory test findings: decreased eGFR, decreased bicarbonate (metabolic acidosis), increased serum creatinine, increased BUN, increased potassium, increased phosphorus, decreased Hb/hematocrit (Hct) (TSat), decreased Transferrin saturation (anemia), decreased ferritin, increased ACR, increased blood pressure, decreased Vitamin D levels, decreased albumin, decreased glucose (malnutrition), and increased calcium (in early stages of CKD).

Goals of CKD Management

• Prevent or slow the progression of kidney disease.
• Evaluate and manage comorbid conditions.
• Review medication regimen regularly.
• Prevent and treat cardiovascular disease.
• Prevent and treat secondary complications of decreased kidney function.
• Prepare for kidney failure and kidney replacement therapy as needed.
• Replace kidney function with dialysis or transplantation, if needed.

Treatment of CKD

• General Approach: General approach includes non-pharmacologic recommendations for individuals with CKD, drug management, correction of hyperlipidemia, and management of diabetes, hypertension, and proteinuria.
• Non-pharmacologic recommendations: exercise 30 minutes five times a week to achieve a BMI < 25kg/m2, avoid smoking, and avoid excessive alcohol consumption.
• Drug management: The text details medication management considerations for patients with moderately to severe CKD, including information on Metformin, TZDs, Meglitinides, Incretin mimetic, Amylin Analog, and Dipeptidyl peptidase IV inhibitor, including their use with different GFR levels and dialysis conditions.
• Correction of Hyperlipidemia: Increased cholesterol (particularly LDL) correlates with the decline in kidney function, and increased triglycerides are prevalent in patients with CKD.
• Management of Diabetes: The text includes information on dietary protein restriction, blood pressure control, intensification of glycemic control, and management of microalbuminuria and albuminuria for patients with diabetes.
• Management of Hypertension: The text discusses the use of ACEI or ARB therapy for management of hypertension for patients with CKD.