1. Chronic kidney disease and pre-dialysis
Renal Pharmacy Beginners Guide lecture 2

2. Objectives
Provide an introduction to the management of chronic kidney disease
Key aims of treatment in CKD
Risk factors for CKD
Frequently prescribed medication

3. Key aims of CKD management
Identify patients early
Prevent or delay the progression
Prevent and manage complications
Reduce risk of cardiovascular disease

4. Risk factors for CKD Diabetes Hypertension Acute kidney injury
Cardiovascular disease
Structural renal tract disease
Multisystem disease known to affect kidneys including lupus

5. Monitor those on high risk drugs
Those prescribed drugs known to be nephrotoxic should have annual eGFR check.
Calcineurin inhibitors
Lithium
Non- steroidal anti-inflammatory drugs (NSAIDs)

6. Prevent or delay progression
Lifestyle advice
Regular exercise
Maintain healthy weight
Stop smoking
Blood pressure control
Target <140/90mmHg
Diabetic / proteinuria <130/80mmHg
Recommendations
Prescribe statins
-statement-3-Statins-for-people-with-CKD

7. Complications of CKD

8. Anaemia Consider renal anaemia when eGFR <45mL/min
Exclude other possible causes of anaemia
Correct iron stores
Prescribe erythropoietin stimulating agents (ESA)
Aim of treatment to achieve Haemoglobin of g/L
Supplied on homecare/admin on dialysis
Future clinical trials oral agents HIF inhibitors

9. Renal bone and mineral disorders
Abnormalities of calcium, phosphate, PTH and vitamin D metabolism
Abnormal bone turnover
Increased vascular calcification

10. Renal bone and mineral disorders
Hyperphosphatemia
Dietary advice to limit phosphate intake
Phosphate binders – take with food
Calcium acetate
Selvelamer
Lanthanum
Sucroferric oxyhydroxide
Aluminium hydroxide
binders-for-adults

11. Renal bone and mineral disorders
Vitamin D supplements
Alfacalcidol, calcitriol
Calcium mimetics
Cinacalcet, etelcalcetide
Renal association guidance for targets

12. Complications continues
Metabolic acidosis
Treat if eGFR <30mL/min and serum bicarbonate <20mmol/L
Oral sodium bicarbonate
May slow progression
Review if renal replacement initiated

13. Symptom control Oedema Muscle cramps Restless legs Itching Diuretics
Quinine
Restless legs
Clonazepam
Itching
Moisturising
Menthol in aqueous cream
Antihistamines

14. Summary
Overview of the management of patients with chronic kidney disease
Identify patients at risk of chronic kidney disease
Modify risk factors for progression
Overview of frequently prescribed medication

15. Further reading NICE guidelines
Renal association guidelines
Pharmaceutical journal /Clinical pharmacy articles
International resources-KDIGO, KDOQI
RPG information leaflets

16. Thank you