Kidney_Block__2024_S2L3_4.pdf

Chronic Kidney Disease Presented by Ronald Castelino A/Prof in Clinical Pharmacy Renal Pharmacist, Blacktown Hospital, NSW [email protected]; [email protected] The University of Sydney Page 1  LEARNING OBJECTIVES – Understand the classification of CKD...

Chronic Kidney Disease Presented by Ronald Castelino A/Prof in Clinical Pharmacy Renal Pharmacist, Blacktown Hospital, NSW [email protected]; [email protected] The University of Sydney Page 1  LEARNING OBJECTIVES – Understand the classification of CKD – Identify risk factors for the development and progression of CKD – Describe the typical clinical presentation & complications in patients with CKD – Formulate strategies to slow the progression of CKD – Describe the management of CKD complications – Describe the different types of renal replacement therapies The University of Sydney Page 2  Chronic Kidney Disease (CKD) – CKD is defined as kidney damage or GFR below 60ml/min/1.73m2 for 3 months or more irrespective of the cause. – CKD is – a long-term health condition (months/years), preventable in many cases – glomerular & tubular damage – asymptomatic until much of the kidney function is lost compensatory and adaptive mechanisms maintain acceptable health until GFR is ~10 to 15 ml/min The University of Sydney Page 3  CKD Facts AUSTRALIA IS FACING A KIDNEY DISEASE CRISIS Kidney Health Australia 2019. National Strategic Action Plan for Kidney Disease. Available from kidney.org.au The University of Sydney Page 4 The University of Sydney From Johnson & Matthew, Australian Doctor 2010 Page 5 6 Approximately $647 million/year (2001 data) The University of Sydney Page 6 The University of Sydney Page 7 The University of Sydney Page 8 The University of Sydney Page 9 10 hyperkalaemia The University of Sydney Page 10 11 Uremic Symptoms The University of Sydney Page 11 The University of Sydney Page 12  General Management The University of Sydney Page 13  General Management The University of Sydney Page 14  Assess CVD risk The University of Sydney Page 15  Protect the kidney Optimum CKD management Manage consequences The University of Sydney Page 16  Hypertension – both symptomatic of advanced CKD and pathogenic lowering BP delays the rate of progression – ACEIs/AT2RAs are generally the best agents (esp in diabetic nephropathy), CCB (dihydropyridine) are also preferred. – most patients will require at least 2 drugs, probably more The University of Sydney Page 17  Hypertension – Key take home message: ACEis/ARBs are first line agents in patients with CKD but can also be nephrotoxic. – As long as kidney function does not deteriorate by more than 25% (eGFR) of baseline within 2 months of initiation they are ok to continue. – OR potassium does not exceed by 6mmol/L they are ok to continue. They are renoprotective in the long run – Refer to Antihypertensives Lecture The University of Sydney Page 18  Proteinuria/albuminuria – degree of proteinuria correlates with rate of progression , and is the most reliable prognostic factor in CKD – absence of significant proteinuria or remission indicates favourable prognosis – low-protein diets are not promoted (little benefit)- but avoid high protein diets (aim for 0.6-0.8g/kg/day) Management: – ACEI/ARBs, reduce salt, SGLT2i The University of Sydney Page 19  – CKD is associated commonly with substantial abnormalities of lipid metabolism, including increased LDL, TG, VLDL, and reduced levels of HDL cholesterol. – Dyslipidaemia is more severe in individuals with albuminuria – Management: – Evaluate lipid profile in newly diagnosed CKD – If aged ≥50 years with any stage of CKD (irrespective of lipid levels) Statin if eGFR is > 60 mL/min/1.73m2 Statin/ezetimibe combination if eGFR is ≤ 60 mL/min/1.73m2 – If aged < 50 years with any stage of CKD (irrespective of lipid levels): Statin if presence of one or more of: coronary disease, previous ischaemic stroke, diabetes or estimated 10-year incidence of fatal or non-fatal myocardial infarction above 10% Drugs for dyslipidaemia covered under CVD The University of Sydney Page 20  Glucose control Optimal blood glucose significantly reduces micro & macro albuminuria and risk of CKD in both T1DM and T2DM Management: Lifestyle modifications Oral hypoglycaemic agents Gliptins Incretin mimetic Insulin SGLT2 inhibitors The University of Sydney Page 21  – Ability to excrete Na+ maintained until GFR significantly reduced – once this threshold is reached Na+ and H20 retention common, causing oedema and worsening HTN – Na+ (2-4g/day) and H20 (~2L/day) restriction useful management (dependent on individual patient characteristics) – Diuretics (primarily K+ wasting) used frequently to reduce ECF volume & enhance antihypertensive effect of other agents – thiazides can be used in CKD Stages 1-3 (little diuresis with GFR