CHRONIC KIDNEY DISEASE INFO & TEMPLATE

OVERVIEW

CPG = an irreversible loss of renal function for at least three months.Oxford = kidney damage >= 3 months based on finding of abnormal structure

or GFR <60 mL/min/1.73m2 for >= 3months with or without evidence of kidney damage.UM express = 1. Azotemia – accum of nitrogenous product (chiefly urea) in blood – raised U & C

2. Uremia – manifestation of organ dysfunction a/w azotemia3. CRF – permanent GFR reduction / GFR sufficient to produce detectable alterations

in well-being & organ fx4. ESRF –final stage of CKD when pt can’t survive w/o transplant @ long term dialysis

[NKF-KDOQI Classification] based on three factors:

1. GFR (level of kidney function) 2. pathological changes (kidney damage)3. presence of the abnormality for at least

three months.

- Mild CKD. Asymptomatic.

- Moderate CKD. Usually asymptomatic.

- Anemia in some pt at 3B.- Most are non-progressive or

progress very slowly.

- Severe CKD. First symptom usually at GFR <20.

- Electrolytes problems as GFR falls

- Kidney failure. Significant symptoms & complications.

- Dialysis initiation varies but usually at GFR <10

The kidney damage is defined as either:a. Persistent microalbuminuriab. Persistent proteinuriac. Persistent haematuriad. Radiological evidence of structural abnormalities of the kidneyse. Biopsy proven glomerulonephritis

Asymptomatic. Only biochemical abn.

Loss of excretory, metabolic & endocrine fx of kidney. Leads to sx & sx

(referred as uremia)

ESRD/ESRF = when death is likely w/o RRT

HISTORY

If has prresenting complaint, elaborate dulu. Eg: thrombosed IJC while HD... Onset – CKD >= 3months Symptoms of CKD

o Usually assypmtomatic until GFR < 30 (stage 4)o Sometimes found at routine examination (raised urea & creatinine + HPT,anemia,

proteinuria)o Nocturia – early symptom –d2 loss of concentrating ability & increased oncotic load

per nephrono Polyuria, increased thirsto Tirednesso Breathlessness

Symptoms of ESRF (uremic manifestation)o Metabolic acidosis:

Protein energy malnutrition Loss of lean body mass (anorexia) Muscle weakness Kussmaul’s respiration (unusually deep respiration related to metabolic

acidosis)o Altered salt & water handling – fluid overload :

Peripheral edema (ankle swelling) Pulmonary edema (SOB) Ascites (Abdominal distension) Hypertension (headache)

o Anemic symptoms d2 decreased renal synthesis of erythropoietin: Fatigue Reduced excercise capacity Impaired cognitive & immune function New onset heart failure/more severe heart failure

o Other manifestations (more likely if inadequately dialysed) General - Fatigue, increased somnolence, FTT Neuro - altered consciousness, fits, Drowsiness, Coma – Encephalopathy;

hemiparesis – stroke CVS - chest pain, SOB – Pericarditis & can be complicated with cardiac

tamponade; Coronary artery disease; reduced effort tolerance, orthopnea -- symptoms of heart failure; intermittent claudication --peripheral vascular disease

GI – anorexia (malnutrition), hiccups, metallic taste (?), N & V, diarrhea Skin – dry skin, pruritus, ecchymosis Erectile dysfunction, decreased libido, amenorrhea, impotence/infertility Bone pain -- Renal osteodystrophy Restless leg syndrome/ muscular twitching bleeding tendency -- Platelet dysfunction

Identify causes/ risk factors for CKDo Common in Malaysia : long standing DM, HPTo h/o autoimmune disorders (IgA nephropathy most common), systemic infections,

drugs, neoplasia ------[Glomerular diseases]o h/o repetitive urinary tract infection, stones, drug toxicity, autoimmune,

nephrocalcinosis ----- [Tubulointerstial disease]o h/o large vessel disease, hypertension, microangiopathy, vasculitis ----[ Vascular

diseases]o h/o Stones (loin to groin pain, dysuria,etc) or anatomical problems of the urinary

tract --- [Urinary tract obstruction]o Symptoms of SLE (malar rash, arthritis etc) & vasculitis ----- [systemic inflammatory

disease]o Previous episode of acute renal failureo History of transplanted kidney – can have chronic rejection, drug toxicity, transplant

glomerulopathy o Hereditary Kidney Diseases, eg PCKD

in chronic cases, also ask about:o Course & progression

Progression of symptoms Progression of markers. Eg proteinuria, creatinine etc (esp educated pt) Addition of medication, fluid restrictions..

o Details about dialyisis HD/CAPD, frequency, done at.., compliance Int jugular catheter/ femoral catheter/AV Fistula/peritoneal dialysis catheter Complications of hemodialysis:

Hypotension, cardiac arrythmias, hemorrhage, air embolism, dialyser hypersensitivity, pulmonary edema, systemic sepsis

Complications of peritoneal dialysis: CAPD peritonitis, catheter exit site infection, sclerosing peritonitis

o Any other interventions done: Renal transplant, lagi..?

Functional impairment/statuso Change in quality of life (esp if started dialysis)o Psychosocial aspect

PMH o Comorbids, eg:

DM - Glucose control, .... HPT - Strict blood pressure control (understand target BP in CKD)... Illness leading to chronic use of NSAIDs & analgesics

o All follow ups & medications:

Current list of medications prescribed. Eg: ace-I, ARB, etc OTC drugs – worsen CKD

Family hxo Hereditary renal conditionso DM, HPT, Systemc illness, etc

Social hxo Smokingo Diet

PHYSICAL EXAMINATION

General – sallow (dirty brown), Kussmaul’s breathing, cushingoid, myoclonic jerks, hiccups

Vital signs – BP, pulsus paradoxus (in pericardial tamponade), arrythmia

Hands – palmar pallor, “half-and-half” nails (distal brown/red, prox pink/white) @ brown line pigmentation, leukonychia, asterixis, tinel’s sign (carpal tunnel synd)

Forearm – scratch marks(pruritus), bruising, hypertrichosis, vasculitis, AVF thrill

Face- anemia, band keratopathy (Ca deposit beneath corneal epith), gum hypertrophy, hypertensive/diabetic retinopathy

Neck – increased JVP (fluid overload @ pericardial tamponade), Dual/triple-lumen IJC,

CVS – pericardial rub, cardiomegaly, gallop rhythm, bibasal crept

Respi – Pleural effusion,, pulmonary edema

Abdomen – tenchkoff catheter, transplant scar, ballotable kidneys, hepatosplenomegaly, loin tenderness, prostatomegaly

Bone - vertebral tenderness

Legs – ankle edema, areflexia & reduced sensation (peripheral neuropathy) , restless legs

DDXAll stated causes of CKD

INVESTIGATIONS Urine dipstick(proteinuria/hematuria)Urine PCR / ACR24 hr urine protein & albuminFBC – normochromic anemia ; + anemic workup RP – raised urea & creatinine, hyperK+ Ca low, PO high; PTH highLFT – albumin low –malnutritionABG – metabolic acidosisLipid profileFBS, HbA1CHepatiis & HIV serology – if dialysis is plannedECG – if hyperK / elderly / risk factors for CVDRenal ultrasound – shrunken kidneys (kidneys enlarged in DM, PCKD, amyloidosis, myeloma, systemic sclerosis, asymetric renal vascular disease)CXR – cardiomegaly, pleural/pericardial effusion, pulmo edemaBone xrays – if indicated – renal osteodystrophy; consider DTPA scanRenal biopsy – if cause is unclear & normal sized kidneysOther tests – to exclude ddx/causes accordingly (if indicated). Eg: ESR, complement, autoantibodies

MANAGEMENT

Refer early to nephrologistTreat reversible causes: relieve obstruction, stop nephrotoxic drugs,…Aim: - retard progression of renal disease,

- reduce CVD risk - manage CKD-related complications

1. Treatment of Hypertension and Proteinuria in CKDa. Can use any type of anti-HPT In HPT w/o proteinuria (choice depends on co-morbid)b. ACE-I /ARB (renoprotective & cardioprotective) is 1st line in:

i. non-diabetic CKD + proteinuria ≥0.5 g/day + HPTii. non-diabetic CKD + proteinuria ≥1.0 g/day irrespective of HPT

iii. DM + albuminuria (micro- or macroalbuminuria) irrespective of CKD stage or HPT

c. Optimal Blood Pressure Range i. <140/90 (SBP range 120-139) mmHg.

ii. <130/80 (SBP range 120 - 129) mmHg:- in patients with proteinuria ≥1 gram/day- in patients with diabetic kidney disease.

d. Optimal Proteinuria Reductioni. <1 g/day for non-diabetic CKD

ii. Normoalbuminuria for DKD2. Monitoring of Renal Function

a. RP at 2 wks after start/adjust ACE-I/ARBb. reduce or discontinue ACEi/ARB if:

i. sustained rise in creatinine levels above 30% from baselineii. or eGFR reduces >25% from baseline

iii. or serum potassium is >5.6 mmol/l during the first two months after commencement of ACEi/ARB

**after excluding other precipitating factors and refer to a nephrologist/physician.

3. Optimal Glycaemic Control a. Target HbA1c ≤7% in DM but this should be individualised according to co-

morbidities.

4. Prevention of Coronary Artery Disease a. Statin for 1o & 2o prevention (start terus awal2)b. Aspirin for 2o prevention (avoid combination clopidogrel + aspirin in CKD unless..)

5. Dietary Interventiona. Refer dietitianb. Low protein diet (0.6 - 0.8 g/kg/day) with adequate energy intake (30 – 35

kcal/kg/day) for CKD Stage 3 – 5c. Sodium restriction (not more than 1 level teaspoon of salt added to food/day)

6. Lifestyle Modification !!!a. exercise, reduce excess weight and avoid smoking

7. Special Precautionsa. Review all prescribed medication regularly to ensure dose is appropriateb. Avoid NSAIDs including COX-2 Inhibitors (such as mefenamic acid, diclofenac,

ibuprofen, naproxen, indomethacin, ketoprofen, salicylic acid [high dose], meloxicam, celecoxib and etoricoxib)

c. Avoid radio-contrast agents if possible (use alternatives method @ contrasts)

d. Avoid Fleet (oral NaPO) in colono for CKD stage 4-5 (use macrogol)8. Others:

a. Anemia i. exclude IDA & chronic infection.

ii. consider erythropoietinb. Renal osteodystrophy

i. Treat if PTH high: Restrict dietary PO (milk,cheese,eggs) & give binders (Calcichew) ----bind PO in gut – reduce absorption

ii. Vit D analogues & Ca supplements (will reduce bone disease & hyperPTH)c. Edema

i. high dose loop diuretics. Eg: Frusemide 250mg-2g/24hrii. Restriction of fluid & sodium

d. Restless legsi. Clonazepam (0.5 – 2 mg daily) or Gabapentin

e. Pregnancyi. Can consider if mild renal impairment (creatinine <124 μmol/L) & well

controlled BP ii. Avoid if moderate to severe renal impairment

iii. All pregnant women with CKD should be co-managed by a multidisciplinary team

9. Prepare for renal replacement therapya. Options:

i. HDii. CAPD

iii. Transplantb. Indications for dialysis (AEIOU utk AKI sbnrnya..)

i. Acidemiaii. Electrolytes – resistant hyperK

iii. Intoxicationiv. Overload – fluid overload not responsive to diureticsv. Uremia – symptomatic uremia despite optimal treatment

vi. Significant impairment in quality of life

10. Manage depression & other psychosocial aspectsa. Support groupb. Refer social/ welfare bodiesc. If develops depression, consider refer psychiatrist/counsellors