Chronic Kidney Disease - Clinicals, Diagnosis, and Management

Nephrology

Clinicals - History

Fact Explanation
Duration of the disease Kidney disease can be either acute or chronic kidney disease. Chronic kidney disease is a condition with kidney damage, manifested by abnormal albumin excretion or decreased kidney function,characterized by irreversible loss of renal function lasting for more than three months. It is associated with increased incidence of cardiovascular disease, hyperlipidemia, anemia and metabolic bone disease. National Kidney Foundation has developed criteria, to identify the five stages of the disease according to the estamated GFR values. Once there is a significant impairment of renal function, the deterioration occurs irrespective of the underlying kidney disorder. Hypertension and proteinuria are two main factors in the progression of CKD. Duration of the disease
Kidney disease can be either acute or chronic kidney disease. Chronic kidney disease is a condition with kidney damage, manifested by abnormal albumin excretion or decreased kidney function,characterized by irreversible loss of renal function lasting for more than three months. It is associated with increased incidence of cardiovascular disease, hyperlipidemia, anemia and metabolic bone disease. National Kidney Foundation has developed criteria, to identify the five stages of the disease according to the estamated GFR values. Once there is a significant impairment of renal function, the deterioration occurs irrespective of the underlying kidney disorder. Hypertension and proteinuria are two main factors in the progression of CKD.
Features of uremia : impaired consciousness, pruritus, darkening of the skin, nausea, vomiting, hiccups Impaired excretion of waste products is associated with elevation of blood urea giving rise to various adverse symptoms and signs. Features of uremia : impaired consciousness, pruritus, darkening of the skin, nausea, vomiting, hiccups
Impaired excretion of waste products is associated with elevation of blood urea giving rise to various adverse symptoms and signs.
Fractures and bone pain There can be abnormal bone and mineral metabolism, extra-skeletal calcification in patients with CKD. kidney is important for the phosphate excretion and 1-α-hydroxylation of vitamin D. In CKD, the level of phosphate is increaed and the level of vitamin D is reduced. There is a spectrum of manifestations i these patiebts which is renal osteodystrophy. Secondary hyperparathyroidism develops, lesding to frequent fractures and bone pain. Fractures and bone pain
There can be abnormal bone and mineral metabolism, extra-skeletal calcification in patients with CKD. kidney is important for the phosphate excretion and 1-α-hydroxylation of vitamin D. In CKD, the level of phosphate is increaed and the level of vitamin D is reduced. There is a spectrum of manifestations i these patiebts which is renal osteodystrophy. Secondary hyperparathyroidism develops, lesding to frequent fractures and bone pain.
Shortness of breath on exertion, fatigue and lethargy Anamia is a frequent finding in chronic kidney disease patients, that increases the risk of poor outcome. Various factors are contributing to the developmant of anaemia in these patients. Iron and erythropoietin deficiencies and hyporesponsiveness to the actions of erythropoietin (requirement for high doses of erythropoietin in order to raise blood Hb level in the absence of iron deficiency), reduced bone marrow production of the erythroblasts, increased red cell destruction and poor dietary intake are some of the mechanisms involved in the pathogenesis of anaemia. Increased levels of inflammatory cytokines increase the level of hepcidin, It impairs the intestinal iron absorption and iron transport from the reticuloendothelial system to bone marrow. Drugs such as ACE inhibitors and angiotensin receptor antagonists may also contributes to the anaemia by transient lowering of the level of haemoglobin. Shortness of breath on exertion, fatigue and lethargy
Anamia is a frequent finding in chronic kidney disease patients, that increases the risk of poor outcome. Various factors are contributing to the developmant of anaemia in these patients. Iron and erythropoietin deficiencies and hyporesponsiveness to the actions of erythropoietin (requirement for high doses of erythropoietin in order to raise blood Hb level in the absence of iron deficiency), reduced bone marrow production of the erythroblasts, increased red cell destruction and poor dietary intake are some of the mechanisms involved in the pathogenesis of anaemia. Increased levels of inflammatory cytokines increase the level of hepcidin, It impairs the intestinal iron absorption and iron transport from the reticuloendothelial system to bone marrow. Drugs such as ACE inhibitors and angiotensin receptor antagonists may also contributes to the anaemia by transient lowering of the level of haemoglobin.
Recurrent infections Chronic kidney disease patients are vulnerable to frequent infections due to the impaired immune function and vascular compromise. Immune deficiency is due to the impairment in structure and function of the innate immune system,and adaptive immunity including T and B lymphocytes. Recurrent infections
Chronic kidney disease patients are vulnerable to frequent infections due to the impaired immune function and vascular compromise. Immune deficiency is due to the impairment in structure and function of the innate immune system,and adaptive immunity including T and B lymphocytes.
History of myocardial infarction, angina and stroke Cardiovascular diseases are the leading causes of death in patients with CKD, particularly in patients with diabetes. Low Hb concentration is an recognized risk factor for the development of heart failure, and cardiovascular diseases. Uremia, inflammation, obesity, erythropoiesis-stimulating agents and iron therapy are the other contributory factors for the increase cardiovascula disease risk. Coronary artery calcification is also more frequent in these patients ddue to the abnormal mineral metabolism with high phosphorus, calcium-phosphorus product, and PTH. History of myocardial infarction, angina and stroke
Cardiovascular diseases are the leading causes of death in patients with CKD, particularly in patients with diabetes. Low Hb concentration is an recognized risk factor for the development of heart failure, and cardiovascular diseases. Uremia, inflammation, obesity, erythropoiesis-stimulating agents and iron therapy are the other contributory factors for the increase cardiovascula disease risk. Coronary artery calcification is also more frequent in these patients ddue to the abnormal mineral metabolism with high phosphorus, calcium-phosphorus product, and PTH.
History of diabetes mellitus Diabetes mellitus is a main risk factor for the development of CKD. Diabetei nephropathy is a recognised complication of diabetes mellitus, in both type 1 and 2. History of diabetes mellitus
Diabetes mellitus is a main risk factor for the development of CKD. Diabetei nephropathy is a recognised complication of diabetes mellitus, in both type 1 and 2.
Dyslipidaemia This is an independent risk factor for both cardiovascular disease and for progressive chronic renal failure. Dyslipidaemia
This is an independent risk factor for both cardiovascular disease and for progressive chronic renal failure.
Features of thromboembolism :severe leg pain, dificulty in breathing Chronic kidney disease patients are vulnerable for venous thromboembolism due to various factors such as activation of procoagulation, enhanced platelet activation and aggregation, decreased anticoagulation in the body, and decreased activity of fibrinolytic system. Features of thromboembolism :severe leg pain, dificulty in breathing
Chronic kidney disease patients are vulnerable for venous thromboembolism due to various factors such as activation of procoagulation, enhanced platelet activation and aggregation, decreased anticoagulation in the body, and decreased activity of fibrinolytic system.
Abnormalities of the urinary tract Congenital renal hypodysplasia with or without urinary tract abnormalities is the cause of chronic kidney disease in more than 60% of children. Reflux nephropathy is associated with vesicoureteric reflux disease. Abnormalities of the urinary tract
Congenital renal hypodysplasia with or without urinary tract abnormalities is the cause of chronic kidney disease in more than 60% of children. Reflux nephropathy is associated with vesicoureteric reflux disease.
History of features suggestive of glomerulonephritis eg: recurrent episodes of haematuria IgA nephropathy and nephritic syndrome can occasionally lead to CKD. Focal segmental glomerulosclerosis responsible for the majority of CKD due to the glomerulonephritis. History of features suggestive of glomerulonephritis eg: recurrent episodes of haematuria
IgA nephropathy and nephritic syndrome can occasionally lead to CKD. Focal segmental glomerulosclerosis responsible for the majority of CKD due to the glomerulonephritis.
Features of psychological problems : Fatigue, changes in appetite and sleep pattern CKD is a chronic medical condition associated with various psychological comorbidities. Biological changes and complications associated with chronic medical disorders may precipitate these problems. Chronic disaese patients are vulnerable to depression, anxiety, substance abuse and suicide. It might also adversly affect the adherence to medication and recommended treatment strategies. Features of psychological problems : Fatigue, changes in appetite and sleep pattern
CKD is a chronic medical condition associated with various psychological comorbidities. Biological changes and complications associated with chronic medical disorders may precipitate these problems. Chronic disaese patients are vulnerable to depression, anxiety, substance abuse and suicide. It might also adversly affect the adherence to medication and recommended treatment strategies.

Clinicals - Examination

Fact Explanation
Pallor Anaemia is a common finding in chroniC kidney disease patients. Pallor
Anaemia is a common finding in chroniC kidney disease patients.
Peripheral oedema There is increased sodium and water retention in these patients. They will also have low serum protein contributing to the development of oedema. Peripheral oedema
There is increased sodium and water retention in these patients. They will also have low serum protein contributing to the development of oedema.
Features of nutritional deficiency :Koilonoychia, glossitis, angular stomatitis Dietary deficiency, low intestinal absorption, and gastrointestinal bleeding may cause iron-deficiency anemia. Vitamin B12 and folic acid deficiency is also found due to the reduced dietary intake. Features of nutritional deficiency :Koilonoychia, glossitis, angular stomatitis
Dietary deficiency, low intestinal absorption, and gastrointestinal bleeding may cause iron-deficiency anemia. Vitamin B12 and folic acid deficiency is also found due to the reduced dietary intake.
Features of uremia :altered level of consciousness, scratch marks, pigmentation of the body Impaired excretion of waste products is associated with elevation of blood urea giving rise to various adverse symptoms and signs. Features of uremia :altered level of consciousness, scratch marks, pigmentation of the body
Impaired excretion of waste products is associated with elevation of blood urea giving rise to various adverse symptoms and signs.
Ballotable masses Polycystic kidney disease is a inherited condition in an autosomal dominant fashion and is a cause of CKD. Ballotable masses
Polycystic kidney disease is a inherited condition in an autosomal dominant fashion and is a cause of CKD.
Abdominal surgical scars Due to renal replacement with kidney transplant. Abdominal surgical scars
Due to renal replacement with kidney transplant.
High blood pressure This can be an associated comorbidity or a side effect of the medications such as erythropoietin stimulating agents. High blood pressure
This can be an associated comorbidity or a side effect of the medications such as erythropoietin stimulating agents.
Features of heart failure : Dyspnea on exertion, elevated jugular venous pressure, shifted cardiac apex, bibasal fine crepitations Heart failure is a common complication among the patients with CKD. Anemia may also aggravate tissue hypoxia, and then the heart failure. Features of heart failure : Dyspnea on exertion, elevated jugular venous pressure, shifted cardiac apex, bibasal fine crepitations
Heart failure is a common complication among the patients with CKD. Anemia may also aggravate tissue hypoxia, and then the heart failure.
Features of glomerulonephritis : Recurrent episodes of reduced urine output, hypertension and periorbital oedema CKD may be due to the glomerulonephritis. Features of glomerulonephritis : Recurrent episodes of reduced urine output, hypertension and periorbital oedema
CKD may be due to the glomerulonephritis.
Features of dabetes mellitus : peripheral neuropathy, joint deformity, ulcers, amputation stumps Diabetes mellitus is a leading cause of chronic kidney disease. Features of dabetes mellitus : peripheral neuropathy, joint deformity, ulcers, amputation stumps
Diabetes mellitus is a leading cause of chronic kidney disease.
Features of pericardial tamponade : pericardial friction rub This is usually due to uremia causing increased vascular permeability and serositis that result in pericarditis, it is a haemorrhagic pericarditis due to the rupture of the vessles in the area of pericarditis. Features of pericardial tamponade : pericardial friction rub
This is usually due to uremia causing increased vascular permeability and serositis that result in pericarditis, it is a haemorrhagic pericarditis due to the rupture of the vessles in the area of pericarditis.
Low mood, anxiety Depression and anxiety are commonly associated with chronic disaeses. It may be related to biological changes and complications of the disease. Low mood, anxiety
Depression and anxiety are commonly associated with chronic disaeses. It may be related to biological changes and complications of the disease.

Investigations - Diagnosis

Fact Explanation
Albuminuria Both macro and micro albuminuria increases the risk ofdisease progression and mortality among the patients with CKD. Microalbuminuria (urine albumin excretion 30 mg/ 24hr) increases the cardiovascular disease risk. Albuminuria
Both macro and micro albuminuria increases the risk ofdisease progression and mortality among the patients with CKD. Microalbuminuria (urine albumin excretion 30 mg/ 24hr) increases the cardiovascular disease risk.
Estimated Glomerular filtration rate (GFR) This is calculated with the serum creatinine concentration, using either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations. The level of estimated GFR <60 ml/min per 1.73 m2 is associated with incraesed mortality in CKD patients. MDRD equation overestimates renal function when assesing the GFR. According to the eGFR value, the 5 stages of the CKD are, Stage 1: normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, stage 2: eGFR between 60 to 89 mL/min per 1.73 m2, stage 3: eGFR between 30 to 59 mL/min per 1.73 m2, stage 4: eGFR between 15 to 29 mL/min per 1.73 m2, and stage 5: eGFR of < 15 mL/min per 1.73 m2. Estimated Glomerular filtration rate (GFR)
This is calculated with the serum creatinine concentration, using either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations. The level of estimated GFR <60 ml/min per 1.73 m2 is associated with incraesed mortality in CKD patients. MDRD equation overestimates renal function when assesing the GFR. According to the eGFR value, the 5 stages of the CKD are, Stage 1: normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, stage 2: eGFR between 60 to 89 mL/min per 1.73 m2, stage 3: eGFR between 30 to 59 mL/min per 1.73 m2, stage 4: eGFR between 15 to 29 mL/min per 1.73 m2, and stage 5: eGFR of < 15 mL/min per 1.73 m2.
Creatinine clearance Calculated from urine creatinine concentration within a 24 hour period, butserum creatinine have a less practical value when compared to eGFR. Creatinine clearance
Calculated from urine creatinine concentration within a 24 hour period, butserum creatinine have a less practical value when compared to eGFR.
Blood urea (BUN) Impaired renal functions are associated with increased accumulation of waste products in the blood such as urea. BUN, >15 mmol/L is considered as abnormal. Blood urea (BUN)
Impaired renal functions are associated with increased accumulation of waste products in the blood such as urea. BUN, >15 mmol/L is considered as abnormal.
Serum electrolytes Hyperkalemia is the most common clinically significant electrolyte abnormality in these patients. Hyponatremia, hypocalcemia, and hypermagnesemia may develop during the dialysis therapy. Serum electrolytes
Hyperkalemia is the most common clinically significant electrolyte abnormality in these patients. Hyponatremia, hypocalcemia, and hypermagnesemia may develop during the dialysis therapy.
Imaging modalities : ultrasound scan, x-ray USS is useful to screen for hydronephrosis, shrunken small kidneys in advanced kidney failure, normal sized kidneys in diabetic nephropathy and vascular abnormalities. Autosomal dominant adult polycystic kidney diseasecan be diagnosed by ultrasonographic scanning (USS) or by using DNA markers linked to the PKD1 locus. Doppler-derived renal resistive index has been used to estimate the risk of progression in CKD. It is also used in transplant reciepients to evaluate the prognosis. X-ray can be used to evaluate the ureteric stones, dialatation of the pelvicalyceal system and bone disease in advanced chronic kidney disease. Imaging modalities : ultrasound scan, x-ray
USS is useful to screen for hydronephrosis, shrunken small kidneys in advanced kidney failure, normal sized kidneys in diabetic nephropathy and vascular abnormalities. Autosomal dominant adult polycystic kidney diseasecan be diagnosed by ultrasonographic scanning (USS) or by using DNA markers linked to the PKD1 locus. Doppler-derived renal resistive index has been used to estimate the risk of progression in CKD. It is also used in transplant reciepients to evaluate the prognosis. X-ray can be used to evaluate the ureteric stones, dialatation of the pelvicalyceal system and bone disease in advanced chronic kidney disease.
CT/MRI and radionuclide imaging Magnetic resonance imaging (MRI) and Computed tomography (CT)are used for the evaluation of renal abnormalities. Cysts, malignancies, polycystic kidney disease can be detected using these methods. Usually MRI is performed only after detection of the renal lesion by ultrasound or CT. Gadolinium enhancement is used to measure the kidney volume. It is an important marker to determine disease progression and overall prognosis. CT/MRI and radionuclide imaging
Magnetic resonance imaging (MRI) and Computed tomography (CT)are used for the evaluation of renal abnormalities. Cysts, malignancies, polycystic kidney disease can be detected using these methods. Usually MRI is performed only after detection of the renal lesion by ultrasound or CT. Gadolinium enhancement is used to measure the kidney volume. It is an important marker to determine disease progression and overall prognosis.
Renal biopsy Diagnosis of vasculitis and rapidly progressive glomerulonephritis may need by renal biopsy. Renal biopsy
Diagnosis of vasculitis and rapidly progressive glomerulonephritis may need by renal biopsy.
Serum Cystatin C levels Serum cystatin C can be used as a marker of renal failure and is able to replace the serum creatinine (Scr) in glomerular filtration rate (GFR) estimation.
GFR estimate usind serum cystatin levels is accurate as Scr used estimate and is not ralated to the muscle mass.
Serum Cystatin C levels
Serum cystatin C can be used as a marker of renal failure and is able to replace the serum creatinine (Scr) in glomerular filtration rate (GFR) estimation.
GFR estimate usind serum cystatin levels is accurate as Scr used estimate and is not ralated to the muscle mass.

Investigations - Management

Fact Explanation
Haemoglobin Hb needs to be checked with the treatment for anaemia. Erythropoietin stimulating agents raise the level of haemoglobin by 1–2 g/dl over 4–8 week periods. Hb level should be measured every other week initially and monthly thereafter. If there is increase in Hb more than 1g/dl within a 4-week period, thay can have increased risk for cardivasular events. Hb levels >12 g/dl is associated with increased thrombotic events. Haemoglobin
Hb needs to be checked with the treatment for anaemia. Erythropoietin stimulating agents raise the level of haemoglobin by 1–2 g/dl over 4–8 week periods. Hb level should be measured every other week initially and monthly thereafter. If there is increase in Hb more than 1g/dl within a 4-week period, thay can have increased risk for cardivasular events. Hb levels >12 g/dl is associated with increased thrombotic events.
Serum creatinine , blood urea and serum eletrolytes Impaired renal functions are associated with increased accumulation of waste products in the blood such as urea and creatinine. The most common and clinically significant electrolyte abnormality seen in chronic renal failure is hyperkalemia. Hyponatremia, hypocalcemia, and hypermagnesemia may develop during the dialysis therapy. Serum creatinine , blood urea and serum eletrolytes
Impaired renal functions are associated with increased accumulation of waste products in the blood such as urea and creatinine. The most common and clinically significant electrolyte abnormality seen in chronic renal failure is hyperkalemia. Hyponatremia, hypocalcemia, and hypermagnesemia may develop during the dialysis therapy.
Serum phosphorus level Should be maintained between 2.7 and 4.6 mg/dL in patients with stages 3 and 4 CKD, and between 3.5 and 5.5 mg/dL in individuals with stage 5. Serum phosphorus level
Should be maintained between 2.7 and 4.6 mg/dL in patients with stages 3 and 4 CKD, and between 3.5 and 5.5 mg/dL in individuals with stage 5.
C reactive protein Inflammation increases the CRP level. Elevated CRP can be used as a predictor for the outcome. C reactive protein
Inflammation increases the CRP level. Elevated CRP can be used as a predictor for the outcome.
Full blood count Low haemoglobin is found due to the anaemia. Anaemia in CKD is defined as an Hb level <13.5 g/dl in men and 12.0 g/dl in women. There may be reduction in the mean corpuscular haemoglobin level and mean corpuscular volume, in association with the anaemia of chronic disease. Full blood count
Low haemoglobin is found due to the anaemia. Anaemia in CKD is defined as an Hb level <13.5 g/dl in men and 12.0 g/dl in women. There may be reduction in the mean corpuscular haemoglobin level and mean corpuscular volume, in association with the anaemia of chronic disease.
Blood picture There my be microcytic hypochromic blood picture or normocytic normochromic blood picture due to the anaemia of chronic disease. Blood picture
There my be microcytic hypochromic blood picture or normocytic normochromic blood picture due to the anaemia of chronic disease.
Serum ferritin level Iron deficiancy could be either absolute or relative. Absolute iron deficiency is found when serum ferritin level <100 ng/ml or a transferrin saturation of <20%. Relative variety is where serum ferritin level ≥100 ng/ml and a reduction in iron saturation. Serum ferritin level
Iron deficiancy could be either absolute or relative. Absolute iron deficiency is found when serum ferritin level <100 ng/ml or a transferrin saturation of <20%. Relative variety is where serum ferritin level ≥100 ng/ml and a reduction in iron saturation.
Arterial blood gas analysis Metabolic acidosis is seen among CKD patients. Arterial blood gas analysis
Metabolic acidosis is seen among CKD patients.
Parathyroid hormone, phosphorus level and serum calcium level Elevated parathyroid hormone and increaesd phosphorus level is seen due to the secondary hyperparathyroidism. Serum calcium may be normal or high due to the secondary hyperparathyroidism. Parathyroid hormone, phosphorus level and serum calcium level
Elevated parathyroid hormone and increaesd phosphorus level is seen due to the secondary hyperparathyroidism. Serum calcium may be normal or high due to the secondary hyperparathyroidism.
Fasting plasma glucose/HbA1c Diabetes mellitus is an independent risk factor for the CKD. Assessment of sugar level is important as a preoperative measure. Fasting plasma glucose/HbA1c
Diabetes mellitus is an independent risk factor for the CKD. Assessment of sugar level is important as a preoperative measure.
Electrocardigram Left-ventricular hypertrophy , is found in association with heart failure. This LVH develops even in the mild stage of disease and progreeses as the disease progresses. Electrocardigram
Left-ventricular hypertrophy , is found in association with heart failure. This LVH develops even in the mild stage of disease and progreeses as the disease progresses.
Chest x-ray Preop assessment should includes chesy x-ray particularly in patients with cardiac and respiratory problems. Chest x-ray
Preop assessment should includes chesy x-ray particularly in patients with cardiac and respiratory problems.
Echocardiography, Chest radiographY, Pulmonary functions, noninvasive vascular studies, abdominal and renal ultrasonography, serologic tests for HIV infection, hepatitis B and hepatitis C, cytomegalovirus (CMV) infection, and other viral infections These tests are done prior to the kidney transplant to assess the fitness for the procedure. Echocardiography, Chest radiographY, Pulmonary functions, noninvasive vascular studies, abdominal and renal ultrasonography, serologic tests for HIV infection, hepatitis B and hepatitis C, cytomegalovirus (CMV) infection, and other viral infections
These tests are done prior to the kidney transplant to assess the fitness for the procedure.
Estimated GFR Estimated GFR Ias used to stage the disease as mentioned above. Stage 1: normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, stage 2: eGFR between 60 to 89 mL/min per 1.73 m2, stage 3: eGFR between 30 to 59 mL/min per 1.73 m2, stage 4: eGFR between 15 to 29 mL/min per 1.73 m2, and stage 5: eGFR of < 15 mL/min per 1.73 m2. Estimated GFR
Estimated GFR Ias used to stage the disease as mentioned above. Stage 1: normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, stage 2: eGFR between 60 to 89 mL/min per 1.73 m2, stage 3: eGFR between 30 to 59 mL/min per 1.73 m2, stage 4: eGFR between 15 to 29 mL/min per 1.73 m2, and stage 5: eGFR of < 15 mL/min per 1.73 m2.

Management - Supportive

Fact Explanation
Patient education As the patient is vulnerable for lot of complications they should be told about the potential complications, available treatment options including renal replacement therapy. Patient education
As the patient is vulnerable for lot of complications they should be told about the potential complications, available treatment options including renal replacement therapy.
Physical activity American College of Sports Medicine and American Heart Association, recomends that risk of cardiovascular events, in individuals with chronic illnesses can be reduced by performing moderate-intensity physical activity, 30 min, 5 times weekly. Physical activity
American College of Sports Medicine and American Heart Association, recomends that risk of cardiovascular events, in individuals with chronic illnesses can be reduced by performing moderate-intensity physical activity, 30 min, 5 times weekly.
Diet and nutrition These patients are vulnerable for malnutrition due to the inadequate nutrient intake and ineffective nutrient utilization. Uremic malnutrition, is a state develops due to the poor dietary intake. Serum prealbumin levels less than 30 mg/dL suggest protein depletion. Restriction of dietary phosphorus is advised when phosphate or parathyroid hormone levels begin to rise. Potassium level affects the ingestion of fruits and vegetables. Diet and nutrition
These patients are vulnerable for malnutrition due to the inadequate nutrient intake and ineffective nutrient utilization. Uremic malnutrition, is a state develops due to the poor dietary intake. Serum prealbumin levels less than 30 mg/dL suggest protein depletion. Restriction of dietary phosphorus is advised when phosphate or parathyroid hormone levels begin to rise. Potassium level affects the ingestion of fruits and vegetables.
Vitamin supplimentation Supplementation with calciferols is recomended in CKD patients with low vitamin D levels. Supplementation of 25-(OH)-vitamin D is required initially and calcitriol replacement is needed in Stage 3. Hyperhomocysteinemia is a risk factor for atheresclerosis in these patients and therefore pyridoxine and folic acid supplementaion is useful in CKD patients. Vitamin supplimentation
Supplementation with calciferols is recomended in CKD patients with low vitamin D levels. Supplementation of 25-(OH)-vitamin D is required initially and calcitriol replacement is needed in Stage 3. Hyperhomocysteinemia is a risk factor for atheresclerosis in these patients and therefore pyridoxine and folic acid supplementaion is useful in CKD patients.
Symptomatic management Cardiovascular diseases are the leading causes of death in patients with CKD, particularly in patients with diabetes. Heart failure and pulmonary oedema are potential complications in these patients. Respiratory tract infections are also common. Hiccups may need treatment with ranitidine. Symptomatic management
Cardiovascular diseases are the leading causes of death in patients with CKD, particularly in patients with diabetes. Heart failure and pulmonary oedema are potential complications in these patients. Respiratory tract infections are also common. Hiccups may need treatment with ranitidine.

Management - Specific

Fact Explanation
Management of anaemia Hb target in CKD patients is usually 11–12 g/dl and should not exceed 13 g/dl. It should be individualized treatment depending on the symptoms, and Hb level.Initially the underlying cause for the anaemia needs to be evaluated. Absolute iron deficiency is treated with either oral or intravenous iron therapy. Eg:- Oral ferrous gluconate, fumarate, and sulfate and intravenous iron dextran, ferric sodium gluconate, iron sucrose, if they are not tolerating the oral preparations due to the side effects. Erythropoietin stimulting agents/ recombinant human erythropoietin (epo) such as epoetin-α 10,000 units once weekly or darbepoetin-α 0.75 μg/kg every other week subcutaneously are also effective in the treatment of anaemia, and these agents raise the level of haemoglobin by 1–2 g/dl over 4–8 week periods. Dosing interval may be adjusted from weekly to once monthly according to the response. These agents increase the risk of hypertension and therefore is not recomended to use in patients with uncontrolled blood pressure. Management of anaemia
Hb target in CKD patients is usually 11–12 g/dl and should not exceed 13 g/dl. It should be individualized treatment depending on the symptoms, and Hb level.Initially the underlying cause for the anaemia needs to be evaluated. Absolute iron deficiency is treated with either oral or intravenous iron therapy. Eg:- Oral ferrous gluconate, fumarate, and sulfate and intravenous iron dextran, ferric sodium gluconate, iron sucrose, if they are not tolerating the oral preparations due to the side effects. Erythropoietin stimulting agents/ recombinant human erythropoietin (epo) such as epoetin-α 10,000 units once weekly or darbepoetin-α 0.75 μg/kg every other week subcutaneously are also effective in the treatment of anaemia, and these agents raise the level of haemoglobin by 1–2 g/dl over 4–8 week periods. Dosing interval may be adjusted from weekly to once monthly according to the response. These agents increase the risk of hypertension and therefore is not recomended to use in patients with uncontrolled blood pressure.
Management of bone disease As the secondary hyperparathyroidism develops, serum phosphate level will rise with distortion of the bone architecture. This bone ditortion can happen even when the serum phosphorus lees are normal, therefore phosphate binders are recomended to start when eGFRs is below 50 mL/min per 1.73 m2.
Aluminium based, calcium based phosphate binders are available. There is new one called nonabsorbable agent sevelamer which is calcium and aluminium free.
Vitamin D and calcimimetics will suppress parathyroid hormone secretion. Calcimimetics down-regulates the parathyroid hormone secretion and reducing hyperplasia of the parathyroid gland.
Management of bone disease
As the secondary hyperparathyroidism develops, serum phosphate level will rise with distortion of the bone architecture. This bone ditortion can happen even when the serum phosphorus lees are normal, therefore phosphate binders are recomended to start when eGFRs is below 50 mL/min per 1.73 m2.
Aluminium based, calcium based phosphate binders are available. There is new one called nonabsorbable agent sevelamer which is calcium and aluminium free.
Vitamin D and calcimimetics will suppress parathyroid hormone secretion. Calcimimetics down-regulates the parathyroid hormone secretion and reducing hyperplasia of the parathyroid gland.
Management of metabolic acidosis Metabolic acidosis in patients with chronic kidney disease is due to the lack of tubular bicarbonate production, that is important to neutralizes the acid net production. This acidosis will further contributes to the decline in renal function. Oral supplementation of the bicarbonate therefore reduces the progression of deterioration. Management of metabolic acidosis
Metabolic acidosis in patients with chronic kidney disease is due to the lack of tubular bicarbonate production, that is important to neutralizes the acid net production. This acidosis will further contributes to the decline in renal function. Oral supplementation of the bicarbonate therefore reduces the progression of deterioration.
Management of hypercalcemia Intravenous bisphosphonates areused for the initial management of hypercalcaemia, and treatment can be continuedwith oral, drugs to prevent relapses. Management of hypercalcemia
Intravenous bisphosphonates areused for the initial management of hypercalcaemia, and treatment can be continuedwith oral, drugs to prevent relapses.
Management of proteinuria Reduction of intraglomerular pressure and thus the proteinuria, can be achieved by ACEI inhibitors and angiotensin 2 receptor blockers. They also diminish the local release of cytokines, chemokines and activation of inflammatory pathways, and reduce the glomerular hypertrophy and sclerosis, tubulointerstitial inflammation, and fibrosis. Management of proteinuria
Reduction of intraglomerular pressure and thus the proteinuria, can be achieved by ACEI inhibitors and angiotensin 2 receptor blockers. They also diminish the local release of cytokines, chemokines and activation of inflammatory pathways, and reduce the glomerular hypertrophy and sclerosis, tubulointerstitial inflammation, and fibrosis.
Management of hyperurecemia Patients with CKD can develop hyperuricemia as the disease progresses withreduction in the GFR. Allopurinol has shown to be effective in the management of hyperurecemia. Management of hyperurecemia
Patients with CKD can develop hyperuricemia as the disease progresses withreduction in the GFR. Allopurinol has shown to be effective in the management of hyperurecemia.
Management of cormorbidities Hypertension, hyperlipidaemia, heart disease and diabetes mellitus need to be well contorlled to acheive retardation of the disease progression in CKD. Diabetes is associated with adverse outcomes in all stages of CKD. Management of cormorbidities
Hypertension, hyperlipidaemia, heart disease and diabetes mellitus need to be well contorlled to acheive retardation of the disease progression in CKD. Diabetes is associated with adverse outcomes in all stages of CKD.
Management of cardiovascular problems Blood pressure control is done with a target blood pressure of less than 130/85 mm Hg for all patients with kidney disease and less than 125/75 mmHg for patients with urinary protein excretion greater than 1g/24h. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, are the first-line agents in patients with proteinuric (> 1 gm/24h), progressive diabetic and nondiabetic renal disease as they have recognized renal protective effect. Calcium-channel blockers except dihydropyridine type and beta-blockers are are safe and often combination therapy may be needed when blood pressure is >160/100 mmHg in adults. Management of cardiovascular problems
Blood pressure control is done with a target blood pressure of less than 130/85 mm Hg for all patients with kidney disease and less than 125/75 mmHg for patients with urinary protein excretion greater than 1g/24h. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, are the first-line agents in patients with proteinuric (> 1 gm/24h), progressive diabetic and nondiabetic renal disease as they have recognized renal protective effect. Calcium-channel blockers except dihydropyridine type and beta-blockers are are safe and often combination therapy may be needed when blood pressure is >160/100 mmHg in adults.
Management of dyslipidaemia Patients with LDL cholesterol levels between 100 and 129 mg/dL are initially put on lifestyle changes, failing which a low-dose statin therapy is started. Patients with LDL ≥ 130 mg/dL can be started on low dose of statin, and patients with TG ≥ 200 mg/dL, low dose statin which is increased as needed to achieve target levels is recomended. Management of dyslipidaemia
Patients with LDL cholesterol levels between 100 and 129 mg/dL are initially put on lifestyle changes, failing which a low-dose statin therapy is started. Patients with LDL ≥ 130 mg/dL can be started on low dose of statin, and patients with TG ≥ 200 mg/dL, low dose statin which is increased as needed to achieve target levels is recomended.
Renal replacement therapy Renal replacement therapy comprised of dialysis and kidney transplant. Peritoneal dialysis (PD) and hemodialysis (HD) are the methods of dialysis. Renal transplant may be either live related or unrelated donor or cadeveric transplant. Renal replacement therapy
Renal replacement therapy comprised of dialysis and kidney transplant. Peritoneal dialysis (PD) and hemodialysis (HD) are the methods of dialysis. Renal transplant may be either live related or unrelated donor or cadeveric transplant.
Dialysis There are main two types of dialysis :peritoneal dialysis (PD) and hemodialysis (HD). Vascular access type of HD using an arteriovenous fistula (AVF) or an arteriovenous graft (AVG) is significantly associated with patient survival. but central venous catheters are associated with greater risk of sepsis, and mortality. Electrolyte imbalances, infections, dialysis equlibrium syndrome, and haemorrhage are the potential complications of the dialysis. Acidosis, Changes in calcium and phosphorus metabolism, lipid disorders, serositis, pericarditis, gout, pseudogout, impotence, infertility, spontaneous abortion and arteriovenous malformations are the other less frequent complications due to the treatment of dislysis. Dialysis
There are main two types of dialysis :peritoneal dialysis (PD) and hemodialysis (HD). Vascular access type of HD using an arteriovenous fistula (AVF) or an arteriovenous graft (AVG) is significantly associated with patient survival. but central venous catheters are associated with greater risk of sepsis, and mortality. Electrolyte imbalances, infections, dialysis equlibrium syndrome, and haemorrhage are the potential complications of the dialysis. Acidosis, Changes in calcium and phosphorus metabolism, lipid disorders, serositis, pericarditis, gout, pseudogout, impotence, infertility, spontaneous abortion and arteriovenous malformations are the other less frequent complications due to the treatment of dislysis.
Kidney transplant Renal transplantation is indicated for the patients with endstage renal failure. This will eliminate the need for time consuming, disterssing treatment options and may be more comfortable to the patient. It may be live donor or cadeveric transplant and live donor may be either related or unrelated. Younger donor and recipient age, reduced cold ischaemia time and well matched HLA reduces the risk of rejection of the transplant. Cyclosphorine based triple therapy (cyclosphorine combined with azathioprine and corticosteroids)is usually used as the immunosuppresants after the surgery. It has to be lifelong. Metastatic cancer, ongoing or recurring infections, serious cardiac or peripheral vascular disease, hepatic insufficiency is some of the contraindications to renal transplant. Kidney transplant
Renal transplantation is indicated for the patients with endstage renal failure. This will eliminate the need for time consuming, disterssing treatment options and may be more comfortable to the patient. It may be live donor or cadeveric transplant and live donor may be either related or unrelated. Younger donor and recipient age, reduced cold ischaemia time and well matched HLA reduces the risk of rejection of the transplant. Cyclosphorine based triple therapy (cyclosphorine combined with azathioprine and corticosteroids)is usually used as the immunosuppresants after the surgery. It has to be lifelong. Metastatic cancer, ongoing or recurring infections, serious cardiac or peripheral vascular disease, hepatic insufficiency is some of the contraindications to renal transplant.

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