1. Chronic Kidney Disease
Identification and Management

2. Chronic Kidney Disease
Early detection and education can help prevent the progression of kidney disease to kidney failure

3. Chronic Kidney Disease
KDOQI (Kidney Disease Outcomes Quality Initiative)
2002 National Kidney Foundation classification system
Stages of Chronic Kidney Disease
KDIGO (Kidney Disease: Improving Global Outcomes)
Updated, more clearly defined (2004)
Classified based on cause, GFR category and albuminuria category (2012)

4. Chronic Kidney Disease
Defined
Abnormalities in structure or function > 3 months with implications for health
eGFR < 60 ml/min/1.73m
A loss of half or more of the adult level of normal kidney function
albuminuria or proteinuria
Casts or blood in urine
Structural
Hydronephrosis, small kidneys, congenital kidneys, polycystic kidney disease
History of kidney transplant

5. Chronic Kidney Disease
What is GFR?
GFR (glomerular filtration rate) is equal to the total of the filtration rates of the functioning nephrons in the kidney.
In young adults it is approximately mL/min/1.73 m2 and declines with age.

6. Chronic Kidney Disease
MDRD (Modification of Diet in Renal Disease)
Preferred method for estimating GFR using the 4-variable equation based on Serum Creatinine, age, gender, and ethnicity.
Includes body surface area
eGFRs per 1.73m2
May be the best estimate for eGFR in older population
Current gold standard
More accurate than measured creatinine clearance from 24-hour urine collections or estimated by the Cockroft-Gault formula

7. Chronic Kidney Disease
Stages of disease
Limitations of CR
Age < 18 or >70
Gfr > 60
Extreme body size
Severe malnutrition
Paraplegia or quadriplegia
Does not adjust for Hispanic or Asian populations
Tends to overestimate gfr
Urinary creatinine excretion is lower in ckd, therefore overestimating gfr from serum creatinine.

8. Chronic Kidney Disease
Cockroft-Gault Formula
Does not includes body weight, reflecting muscle mass….main determinant of creatinine generation.
May overestimate individuals having ckd after age of 70 yrs, obese or edematous pts
Less accurate than mdrd and ckd-epi

9. Chronic Kidney Disease
CKD-Epidemiology Collaboration (CKD-EPI)
Uses the 4 variables found in MDRD equation, with addition of serum cystatin C to provide more accurate eGFR than MDRD in gfr >60
May raise the number of older individuals with ckd
CKD-EPI and MDRD Study equations can therefore be applied to determine level of kidney function, regardless of a patient’s size.

10. Chronic Kidney Disease
To use the free GFR calculator on the NKF web site: Go to
To download NKF’s new GFR calculator to your smartphone: Go to

12. Chronic Kidney Disease
Because of greater cardiovascular disease risk and risk of disease progression at lower eGFRs, CKD Stage 3 is sub-divided into Stages 3A (45–59 mL/min/1.73 m2) and 3B (30–44 mL/min/1.73 m2).

13. Chronic Kidney Disease Proteinuria
Proteinuria (most important marker of disease progression)
Ratio of the concentrations of urine albumin (mg/dl) to that of urine creatnine (g/dl) on a spot untimed specimen (or early morning?????)
Mg albumin/g creatinine (UACR)
Normal <30 mg albumin/g creatinine
Microalbuminemia > mg albumin /g creatinine
Macroalbuminemia > 300 albumin/ g creatinine
Ckd if 2 of 3 tests are abnormal

14. Chronic Kidney Disease Proteinuria
Albuminuria
Presence of excessive amounts of the protein albumin in urine
Microalbuminuria
UACR mg/mmol in men
UACR mg/mmol in women
Macroalbuminuria
UACR > 25mg/mmol in men
UACR > 35mg/mmol in women
(Urinary creatinine excretion is influenced by muscle mass, urinary creatinine excretion higher in men, on average, than women)
The preferred method: urinary albumin-to-creatinine ratio (UACR) in first void. Spot urine is acceptable if first void not practical.

15. Chronic Kidney Disease Proteinuria
Presence of excessive amounts of proteins in urine
Includes: albumin, low-molecular weight immunoglobulin's, lysozyme, insulin and microglobin
Total protein (mg/dl) to creatinine (g/dl) on a spot urine sample
Normal < 200 mg/g
Urine pr mg/dl 200
Urine cr mg/dl 100
Ratio 200/100 = 2gm protein/24hours
Increased excretion of protein leads to progression of ckd and increases cvd risks
Albuminuria and proteinuria are related, but not interchangeable.

18. Chronic Kidney Disease Risk Factors
Diabetes
44% of new cases of ckd
Hypertension
28% of new cases of ckd
Cardiovascular disease
Obesity
High cholesterol
Lupus
Family history of CKD
UTI/urinary stones
Systemic infections
Recovery from Acute Kidney Injury (AKI)
Exposure to certain drugs
Socio-demographic groups
Elderly
minority population
African American, Native American, Hispanic, and Asian.
Low income/education

19. Chronic Kidney Disease Diabetic Nephropathy
Blood pressure control
Goal
Diabetic or Non diabetic with Albumin-to-creatinine ratio > 30 mg/g <130/80
Diabetic or Non diabetic with albumin-to-creatinine ratio < 30gm/g <140/90
Protein restriction, individualize
Smoking cessation

20. Chronic Kidney Disease Diabetic Nephropathy
Hypoglycemics Agents
Sulfonylureas, biguanides, DPP-4 inhibitors, GLP-1 agonists, and insulin require dose adjustments
All second generation sulfonylureas can be used in ckd pts
Glyburide not recommended with crcl < 50%
Glipizide, no adjustment

21. Chronic Kidney Disease Hypertensive Nephropathy
Hypertensive Kidney Disease
Both a cause and consequence of the disease
Primarily: Inappropriate sodium reabsorption
Activation of RAAS
Erythropoietin administration
RAS
Extracellular fluid
Calcified arterial tree
Cardiovascular disease
Antiplatelet agents are recommended
BNP in gfr <60, interpret with caution

22. Chronic Kidney Disease Hypertensive Nephropathy
Management
RAAS blockade
Reduce proteinuria
Lowers systemic BP and intraglomerular pressure
More difficult d/t increase in vascular resistance and increased blood volume
Low sodium diet (DASH diet not recommended in CKD stage 3-5)
Combination of ace/arb significantly slowed disease progression, greater reduction in proteinuria
Use of non-dihydropyridine CCB have shown to decrease proteinuria (if failed ace/arb)

23. Chronic Kidney Disease Hypertensive Nephropathy
Diuretics
Enhances antihypertensive therapy
Decreasing tubular sodium reabsorption, increasing sodium excretion, reversing ECF volume expansion and lowering bp.
Thiazides (qd) for gfr > 30 (stage 1-3)
Loops (qd-bid) for gfr < 30 (stages 4 & 5)
Potassium sparing diuretics
Risk of hyperkalemia, esp with ACEI/ARB

25. Chronic Kidney Disease Complications
Chronic Kidney Disease-Metabolic Bone Disorder (CKD-MBD)
Systemic disorder
Renal osteodystrophy
Extraskeletal (vascular) calcification
Increases in morbidity and mortality of ckd pts
Abnormalities in
Calcium
Phosphorus
Parathyroid Hormone
Vitamin D
25(OH)D
1,25(OH)2D
Osteoporosis (ckd 1-3) versus renal osteodystrophy (later stages)

26. Chronic Kidney Disease Complications
GFR falls
Rise in phosphorus decrease in calcium
decreased production of calcitriol
Triggers increase in Parathyroid hormone (PTH) production
Increased absorption of Phosphorus in kidneys
Normalize phosphorus with high PTH

28. Chronic Kidney Disease Complications
Treat complications
High phosphorus
Low Phosphorus diet
Phosphorus Binders
Correct low Vitamin D levels
Ergocalciferol/cholecalciferol
Watch for high Calcium
Active Vitamin D to suppress PTH
Seen more in late stages of disease

29. Chronic Kidney Disease Complications
Anemia (hgb < 13g/dL in males, < 12g/dL in females)
A decline in production of erythropoietin (EPO)
Not measured, assumed
Check red cell indices, absolute reticulocyte count, vitamin B12 and folate levels, and iron panel
Goal
Hemoglobin???
Serum transferrin saturation (TSAT) > 30%
Serum ferritin <500ng/ml
Acute phase reactant, elevated with infection/inflammation

30. Chronic Kidney Disease Complications
Anemia Treatment
Iron therapy
Most common cause of anemia in ckd
Oral vs IV
Erythropoiesis-stimulating Agents (ESA)
Prevent need for transfusions
Improve QOL?
Based on weight
Not recommended in hgb > 10g/dL
Treat <10g/dL on individual basis

31. Chronic Kidney Disease Complications
Metabolic acidosis
Result of decreased production of ammonia by the kidney
Seen in stages 3-5
Treatment: supplement Bicarbonate
Complications
Bone loss
Anorexia
Hypoalbuminemia
Insulin resistance
Muscle wasting

32. Chronic Kidney Disease Diet
Sodium
Restriction reduces blood pressure and may reduce albuminuria
Dash diet, not rec. for ckd stage 3-5
High sodium diet limits effectiveness of ACEi/ARBs
Potassium
Low: loop diuretics
High: Common in stage 4/5 & aldactone/ACEi/ARB/BB/NSAIDS
Diet? Salt substitutes?
Constipation
Treatment
Kayexlate
education

33. Chronic Kidney Disease Diet
Phosphorus
High levels contribute to vascular calcification
High phosphorus is risk factor for cvd
high phosphorus leads to a more rapid decline in kidney function
Phosphate salts added to processed foods in form of additives and preservatives
These are > 90% absorbed versus 40-60% absorption from organic phosphorus (ie: beans, peas, nuts)
Beverages (clear)
Nutrition labeling
Treatment: Low phosphorus diet, phosphorus binders with meals

34. Chronic Kidney Disease Diet
Protein
Restriction should not be used in severe ckd
Restriction among selected patients
Restriction, controversial
g/kg per day
Provide a small reduction in rate of decline of gfr
Follow body weight, serum albumin, pre-albumin in advanced ckd
Monitored by dietician

35. Chronic Kidney Disease & Medications
Diuretics
Thiazide are recommended in those with gfr >30
Loop are recommended in those with gfr <30
Potassium-sparing should be used with caution in those with gfr < 30