CKD diagnosis and management

1. CKD Diagnosis and
Management
Dr. Ansuman Dash
Guide - Dr. B.N. Panda

3. Common Clinical Features
 Symptoms are often absent until renal failure
 There may be long term history or hypertension, diabetes or past h/o AKI
Vague symptoms like
 Loss of appetite & weight
 Nausea, weakness
 Hiccups
 Dyspnea
 Recurrent hypoglycemia
 Muscle cramps, restless legs
 Pruritus
 Signs like Edema, Peripheral neuropathy, Hypertension
 Pericardial friction rub, asterixis not attributable to other cause

4. Approach to patients of CKD
There is history of hypertension, diabetes, abnormal
urinalysis.
History of intake of drugs like NSAIDs, antimicrobials,
chemotherapeutic agents, ARVs, Lithium should be
elicited
Any family history of kidney disease with visual, auditory
or cutaneous manifestations helps in diagnosis of
heritable form of CKD

6. Any acceleration in the rate of decline should prompt a search
for superimposed acute or subacute processes that may be
reversible
1. ECFV depletion,
2. Uncontrolled hypertension,
3. Urinary tract infection,
4. New obstructive uropathy,
5. Exposure to nephrotoxic agents
6. Reactivation or flare of the original disease, such as lupus or
vasculitis

7. Diagnosing AKI on CKD

8. Investigations

9. CBC
RFT
Urine ACR
Serum Iron, Folate, Vit B12 levels
Serum calcium, phosphate, vit D and Parathyroid levels
Lipid profile
HIV, HBsAg and HCV
Autoimmune screening
Serum and urine protein electrophoresis
24 hr urine protein estimation

11. Imaging studies
Renal USG
Can verify presence of two kidneys
Estimate kidney size
Symmetry
Renal masses and obstructions
Bilaterally small kidneys suggests CKD of long duration
Kidney size maybe normal in CKD due to Diabetic
nephropathy, Amyloidosis, HIV nephropathy
Polycystic kidney disease presents as enlarged kidneys with
multiple cysts

12. Diagnosis of renovascular disease can be done by Doppler
sonography, MRI.
DEXA scan to assess the severeity of metabolic bone disease.
IF suspicious of reflux nephropathy, micturating
cystourethrogram may be indicated.
Oral phosphate-containing bowel preparations should not be
used in people with a GFR <60 ml/min/1.73 m2 (GFR categories
G3a-G5)
Measures to prevent contrast induced nephropathy
IV or Intrarterial dye to be avoided.
Avoidance of hypovolemia
Minimization of dye load
Choosing least nephrotoxic dyes

13. Kidney Biopsy
 Usually done by USG guided, Surgical or Laparoscopic approach
In patients with bilaterally small kidneys renal biopsy is
not advised because
 Technically difficult
 More chance of bleeding and other adverse effects
 More scarring. So disease may not be apparent
Contraindications :
 Uncontrolled hypertension
 Active UTI
 Bleeding diathesis
 Morbid obesity

14. MANAGEMENT

15. The medical care of patients with CKD should
focus on the following:
Delaying or halting the progression of CKD
Diagnosing and treating the pathologic
manifestations of CKD
Timely planning for long-term renal
replacement therapy

17. SLOWING THE PROGRESSION OF CKD:
Reducing Intraglomerular Hypertension and Proteinuria
 ARB or ACE-I be used in diabetic adults with CKD and urine albumin
excretion 30–300 mg/24 hours
 ARB or ACE-I be used in both diabetic and non-diabetic adults with
CKD and urine albumin excretion >300 mg/24 hours
 Target blood pressure -130/80 mmHg , 125/75 mm Hg if proteinuria
> 1 g/day
 ACE inhibitors and ARBs first line agents
 Adverse effects from these agents include cough and angioedema
with ACE inhibitors, anaphylaxis, and hyperkalemia,and reduced GFR
with either class

19. SLOWING PROGRESSION OF DIABETIC RENAL DISEASE
 Control of Blood Glucose
 Optimal blood glucose control significantly reduces the risk of developing
microalbuminuria, macroalbuminuria and/or overt nephropathy in people with
Type 1 or Type 2 diabetes.
 Preprandial glucose be kept in the 5.0–7.2 mmol/L, (90–130 mg/dL)
 Hemoglobin A 1C should be < 7%. HbA1C may be maintained above 7% if
is having recurrent hypoglycemia.
 Management
• Lifestyle modification
• Oral hypoglycemic
• Gliptins
• Incretin mimetic
• Insulin
 Metformin can be continued in people with GFR >45 ml/min/1.73 m2 (GFR categories G1-
G3a); its use should be reviewed in those with GFR 30–44 ml/min/1.73 m2 (GFR category
G3b); and it should be discontinued in people with GFR <30 ml/min/1.73 m2

20. SLOWING PROGRESSION OF DIABETIC RENAL DISEASE
 DIET
At least 50% of the protein intake be of high biologic value
Stage 4 & stage 5 CKD - 0.8 g/kg/day
Caloric requirement – 35cal/kg/day
Salt – 2 g of sodium equivalent to 5 g of NaCl/day except in salt
loosing nephropathies

21. MANAGING OTHER COMPLICATIONS OF
CHRONIC KIDNEY DISEASE

22. Management Of Fluid, Electrolyte and Acid
– Base Disorders
 Dietary salt restriction and use of loop diuretics.
 Salt supplementation and sodium rich diet may be required in rare
patients of salt loosing nephropathy.
 Intractable ECFV expansion despite salt restriction and diuretic therapy
maybe an indication to start renal replacement therapy.
Metabolic Acidosis
 RTA with Anion Gap metabolic acidosis responds to Sodium Bicarbonate
supplementation (1 or 2 tablets BD)
 Sodium Bicarbonate supplementation when serum bicarbonate level
below 20 – 23 mmol/l

23. Hyperkalemia
Dietary K+ restriction
Kaliuretic diuretics
K+ binding resins like Calcium resonium, Calcium
polystyrene sulphonate.
Cease ACE inhibitor/ARB/spironolactone if K+
persistently > 6.0 mmol/L not responding to above
therapies
Dialysis in case of intractable hyperkalemia

24. Disorders of Calcium and Phosphate Metabolism
 Low phosphate diet and use of phosphate – binding agents
 Calcium acetate and calcium carbonate bind to dietary phosphate in GI
tract.
 Adverse effect – Hypercalcemia.
 Sevelamer and Lanthanum are non calcium containing phosphate binders
that do not cause hypocalcemia.
 Calcitriol suppresses PTH secretion by both direct and indirect
mechanisms.
 Calcitriol also causes hypercalcemia and hyperphosphatemia.
 Cinacalcet (30-90mg/day) – Calcimimetic drug that causes dose dependent
reduction in PTH and plasma calcium concentration.

26. Hypertension
Goal is to prevent the extrarenal complications of HTN like
cardiovascular disease and stroke.
In CKD patients with diabetes or proteinuria > 1 g / day BP
should be reduced to below <130/80 mmHg
Salt restriction (<2 g of sodium/day)
ACE inhibitors and ARBs slow the decline in renal function
ACE inhibitors and ARBs are contraindicated in case of
renal artery stenosis and Hyperkalemia.
Can precipitate AKI on CKD

27.  ACEI and ARB should be continued if reduction in GFR is less than <25%
after 2 months.
 If the reduction in GFR is more than 25% below the baseline value, the
ACE inhibitor or ARB should be ceased.
 Caution should be exercised if baseline K+ is≥5.5 mmol/L, as rises in
serum K+ of approximately 0.5 mmol/L are expected.
 Both non-loop diuretics (e.g., thiazides) and loop diuretics (e.g.,
frusemide) are effective in all stages of CKD as adjunct antihypertensive
therapy.
 Beta-blockers may be useful in people with coronary heart
disease,tachyarrhythmias and heart failure.
 Calcium channel blockers may be used for people with angina, the
elderly and those with systolic hypertension

28. MANAGEMENT OF CARDIOVASCULAR DISEASE
• Lifestyle changes, including regular exercise at least 30 mins/day, 5
days a week
• Manage dyslipidemia
• If aged ≥50 years with any stage of CKD (irrespective of lipid levels):
- Statin if eGFR is > 60 mL/min/1.73 m2
- Statin or statin/ezetimibe combination if eGFR is <= 60mL/min/1.73
m2
• 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
• estimated 10-year incidence
of fatal or non-fatal myocardial
infarction above 10%

29. Pericardial Disease
Uremic pericarditis is an absolute indication
for urgent initiation of dialysis.
Hemodialysis should be performed without
heparin.
Pericardial drainage procedure in patients
with recurrent pericardial effusion with signs
of impending tamponade.

30. Anemia
 Recombinant human erythropoietin
 Iron supplementation is essential for optimal response to erythropoietin
 Once ESA commenced, maintain:
Ferritin 200-500 µg/L; TSAT 20-30%
 IV iron supplementation for GI intolerance or patients on hemodialysis.
 B12 and Folate supplementation should be done.
Anemia resistant to ESA in presence of adequate iron stores maybe due to
 Acute or chronic inflammation
 Inadequate dialysis
 Severe hyperparathyroidism
 Chronic blood loss

31. Blood transfusions increase the risk of
Hepatitis
Iron overload
Transplant sensitization
ESA in CKD maybe associated in with an increased
risk of stroke in those with type 2 DM and an
increased risk of thromboembolic events
Target Hb must be 10 - 11.5 g/dl

32. Abnormal Hemostasis
Abnormal bleeding time and coagulopathy in patients
with renal failure may be reversed temporarily with
• desmopressin(DDAVP),
• cryoprecipitate,
• blood transfusions, and
• EPO therapy.
Optimal dialysis will usually correct a prolonged
bleeding time.

33. Muscle cramps
 Encourage stretching and massaging of the affected area.
 Correction of electrolyte imbalance.
Pruritus
 Evening Primrose Oil, Skin emollients
 If both pruritus and restless legs are present, consider gabapentin
 For persistent pruritus, consider ultraviolet light B (UVB) therapy
Restless legs
 Dopaminergic agents or dopamine agonists
 Benzodiazepines
Sleep apnoea
 Weight reduction
 CPAP therapy

36. Renal Replacement Therapy

37. Criteria for initiating dialysis
Presence of uremic symptoms especially Uremic
pericarditis and uremic encephalopathy
Hyperkalemia unresponsive to conservative measures
Persistent ECFV expansion despite diuretic therapy
Acidosis refractory to medical therapy
Bleeding diathesis
GFR below 10 ml/min/ 1.73 m2

38. Treatment options in ESRD
Hemodialysis
Peritonial dialysis
1. Continuous ambulatory peritoneal dialysis
(CAPD)
2. Continuous cyclic peritoneal dialysis (CCPD)
Transplantation

39. IHD SLEDD CRRT
Mechanism and molecules
removed Dialysis – mostly low MWt
Small + middle molecules
with SLEDD/F
Small + middle molecules
with CVVHDF
Use
Ambulatory CRF
Hyperkalemia
Critically ill
Hyperkalemia
Critically ill
Non-ambulatory
Efficiency High Moderate Low
Urea clearance (mL/min) 150 80 30 (CVVHDF)
Hemodynamic stability
Poor
(hypotension common) Good Good
Duration 3-4 h 3x/week 6-12 h daily Continuous (24h/filter)
Anticoagulation Not needed
Usually not needed
(if filter clots lose 150 mL
blood)
Important
(if filter clots lose 150 mL
blood)

40. Transplantation
 Technique:
Source:
. Living related donor with HLA & ABO matching.
. Unrelated donor with HLA partial matching.
. Cadaveric kidney.
 Operative
. Nephrectomy
. The kidney is perfused with cold solution till transplantation(cold ischemic time)
. The kidney is placed in iliac fossa & anastomosed to iliac vessels & ureter is placed in
Bladder.
 Indications
All patients of ESRD without contraindications for transplantation & with available
donor.

41. Complications of transplantation
 Early complications
 Surgical complications
 Delayed or slow graft function
 Lymphocele
 Allograft rejection
 Hyper acute rejection (antibody-mediated rejection) : within
min. to hour of perfusion of allograft
- Due to preformed antibodies to the ABO & HLA antigens.
 Acute rejection – within 3 months of transplant
 Chronic rejection

42. Infectious complications
 Cytomegalovirus
BK virus
 Others
Hypertension- diet therapy, ACEI, CCB
Hematologic complications : anemia, leukopenia,
thrombocytopenia

43. Immunization in CKD patients
Hepatitis B Vaccine
Recombinant 40 microgram/ml IM in deltoid region at 0, 1, 2
and 6 months as earliest as possible in any stage of CKD
Anti HBs antibody titer should be assessed at 2months after
completing course and then annually. If titre below 10 mU/
ml , a booster dose should be given.
Pneumococcal vaccine
A single IM/SC dose of 0.5 ml of pneumococcal vaccine
should be administered to all dialysis patients of 2years of
age or older
Revaccination after 5 years.

44. Influenza Vaccine
 Influenza vaccine should be given IM annually before beginning of
influenza season to patients who are 6 months or older and on dialysis.
Hib Conjugate Vaccine
 0.5 ml IM
 Hib (HbOC) – One to three doses. Booster dose given at 15 months.
 Hib (PRP-OMP) – Two doses 1 month apart and booster at 12 months.
 Hib (PRP) – One dose only, no booster dose required
Live Attenuated Vaccine
 Usually contraindicated