Chronic kidney disease: Difference between revisions

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== Definition ==
==Background==


===Definition===
* Structural or functional kidney disorder lasting at least [3 months]


*Structural or functional kidney disorder lasting at least [3 months]
== KDIGO Classification ==


===KDIGO Classification===
Defined as 3 or more months of either GFR < 60 or 1 or more marker of kidney damage:


* Defined as 3 or more months of either GFR < 60 or 1 or more marker of kidney damage:
* Proteinuria
** Proteinuria
* Urine sediments
**Urine sediments
* Tubular electrolyte disorder
**Tubular electrolyte disorder
* Kidney transplant
**Kidney transplant
* Structural disease
**Structural disease
*Categories & grades:
**'''Grade 1:''' GFR ≥90 (normal) with a marker of kidney disease
**'''Grade 2:''' GFR 60-89 with a marker of kidney disease
**'''Grade 3a:''' GFR 45-59
**'''Grade 3b:''' GFR 30-44
**'''Grade 4:''' GFR 15-29
**'''Grade 5:''' GFR <15, ESRD


===Epidemiology===
=== Categories & Grades ===


*8% of population have GFR < 60
* Grade 1: GFR ≥90 (normal) with a marker of kidney disease
*4% of population have proteinuria despite normal GFR
* Grade 2: GFR 60-89 with a marker of kidney disease
* Grade 3a: GFR 45-59
* Grade 3b: GFR 30-44
* Grade 4: GFR 15-29
* Grade 5: GFR <15, ESRD


==Differential Diagnosis==
[[File:M172640ff1_Appendix_Figure_Prognosis_of_CKD_by_categories_of_GFR_and_albuminuria.jpeg|CKD grade]]


*Diabetes
== Epidemiology ==
*Cardiovascular disease/HTN
**Ischemic nephropathy
**Nephrosclerosis
*Glomerulonephritis
*PCKD
*Drugs, especially lithium, cyclosporine, tacrolimus, tenofivir
*Other disease associations
**Inflammatory bowel disease: oxalate nephropathy
**Rheumatoid arthritis: amyloidosis
**Cirrhosis: Type 2 hepatorenal syndrome
**Solid tumours: membranous nephropathy
**Severe CHF: cardiorenal syndrome
**Post-AKI: incomplete recovery of ATN in hospital


==Investigations==
* 8% of population have GFR < 60
* 4% of population have proteinuria despite normal GFR


===Laboratory===
== Differential Diagnosis ==


*GFR
* Diabetes
**MDRD underestimates the GFR in healthy patients
* Cardiovascular disease/HTN
**CKD-Epi is the newer equation and possibly more accurate
** Ischemic nephropathy
**Radioisotopic GFR is the gold standard, inulin clearance is the gold standard for research
** Nephrosclerosis
**Cystatin C may complement or replace creatinine in the future
* Glomerulonephritis
*Urinalysis, though "protein" only picks up albumin
* PCKD
*Urine ACR and PCR
* Drugs, especially lithium, cyclosporine, tacrolimus, tenofivir
* Other disease associations
** Inflammatory bowel disease: oxalate nephropathy
** Rheumatoid arthritis: amyloidosis
** Cirrhosis: Type 2 hepatorenal syndrome
** Solid tumours: membranous nephropathy
** Severe CHF: cardiorenal syndrome
** Post-AKI: incomplete recovery of ATN in hospital


===Imaging===
== Investigations ==


*Abdominal ultrasound
=== Laboratory ===


==Management==
* GFR
** MDRD underestimates the GFR in healthy patients
** CKD-Epi is the newer equation and possibly more accurate
** Radioisotopic GFR is the gold standard, inulin clearance is the gold standard for research
** Cystatin C may complement or replace creatinine in the future
* Urinalysis, though "protein" only picks up albumin
* Urine ACR and PCR


*Education re: dialysis and transplant
=== Imaging ===
*Refer to nephrology when:
**GFR drops by 5+ per year
**Acute on chronic kidney injury
**eGFR < 30 (Stage 4)
**Proteinuria >1g/day
**Difficulty controlling BP
*BP control
**ACEi + CCB + diuretic
**If albuminuria, target <130/80, else <140/90
*Proteinuria
**If proteinuria >500mg/d or ACR>30mg/mmol, start ACEi/ARB regardless of BP
**If diabetes and microalbuminuria, start ACEi/ARB
*Metabolic acidosis (normal anion gap)
**Oral sodium bicarbonate 0.5-1 mEq/kg/d to maintain bicarb between 23-29 mmol/L
*Avoid nephrotoxic mediation like NSAIDs


=== Initial Investigations ===
* Abdominal ultrasound


* Urinalysis to help diagnose glomerulonephritis or AIN
== Management ==
* ACR, a component of the KFRE score
* Urea, to help rule out volume depletion
* Urine electrolytes, with low urine Na (FENA<1%) suggesting volume depletion
* Ultrasound of the kidneys to assess for structural kidney disease and renal stones, plus or minus arterial Dopplers if suspecting renovascular disease
* Serum protein electrophoresis
* 24-hour urine protein and urine electrophoresis, if urine ACR >300 mg/mmol (<3 g/d)
* CK, to rule out rhabdomyolysis
* ANCAs, if UA shows blood and protein and there's a rapid decline in kidney function
* CBC with blood film, looking for evidence of a [[TMA]]


=== Routine Investigations ===
* Education re: dialysis and transplant
* Refer to nephrology when:
** GFR drops by 5+ per year
** Acute on chronic kidney injury
** eGFR &lt; 30 (Stage 4)
** Proteinuria &gt;1g/day
** Difficulty controlling BP
* BP control
** ACEi + CCB + diuretic
** If albuminuria, target &lt;130/80, else &lt;140/90
* Proteinuria
** If proteinuria &gt;500mg/d or ACR&gt;30mg/mmol, start ACEi/ARB regardless of BP
** If diabetes and microalbuminuria, start ACEi/ARB
* Metabolic acidosis (normal anion gap)
** Oral sodium bicarbonate 0.5-1 mEq/kg/d to maintain bicarb between 23-29 mmol/L
* Hold ACEi/ARB when AKI, any illness causing dehydration, surgery, contrast study, planning pregnancy
* Avoid nephrotoxic mediation like NSAIDs


* Annually for patients with stage 2 or higher: creatinine, Na/K/Cl/CO2, ACR
=== Complications ===
* Every 3-6 months for patients with stage 4 or higher:
** Na/K/Cl/CO2, creatinine, urea
** Ca/Mg/PO4/albumin/PTH
** ACR
** CBC, ferritin, transferrin saturation


=== Sick Day Medications ===
* '''Anemia:''' treat iron deficiency before adding Epo, targetting 105-115
* '''Hypocalcemia:''' give calcium between meals or rocaltrol (if the hyperphosphatemia is treated)
* '''Hyperphosphatemia:''' give a phosphate binder like calcium or Renagel with meals
* '''Metabolic bone disease:''' maintain normal phosphate with diet, binders, and vitamin D
* '''Acidosis:''' supplement bicarb when &lt; 22
* '''Hyperkalemia''' from poor GFR, ACEi, DM
* '''Pruritis:''' moisturizers, steroids, antihistamines


* Some medications should be held during an acute illness, before surgery, or with IV contrast
== Prognosis ==
* Includes ACEi, ARB, aldosterone antagonists, SGLT-2 inhibitors, diuretics, NSAIDs, metformin, sulfonylureas, and direct renin inhibitors
* Hold ACEi/ARB when planning pregnancy


===Complications===
* GFR declines linearly over time

* Progression predicted by
*'''Anemia:''' treat iron deficiency before adding Epo, targetting 105-115
** Previous rate of progression
*'''Hypocalcemia:''' give calcium between meals or rocaltrol (if the hyperphosphatemia is treated)
** Hypertension **
*'''Hyperphosphatemia:''' give a phosphate binder like calcium or Renagel with meals
** Proteinuria **
*'''Metabolic bone disease:''' maintain normal phosphate with diet, binders, and vitamin D
** Metabolic acidosis
*'''Acidosis:''' supplement bicarb when &lt; 22
* High risk of cardiovascular mortality compared to general population
*'''Hyperkalemia''' from poor GFR, ACEi, DM
** 30 year olds on dialysis have same risk as 80 year olds in the general population
*'''Pruritis:''' moisturizers, steroids, antihistamines
** Risk increases with a decreasing GFR

==Prognosis==

*GFR declines linearly over time
*Progression predicted by
**Previous rate of progression
**Hypertension **
**Proteinuria **
**Metabolic acidosis
*High risk of cardiovascular mortality compared to general population
**30 year olds on dialysis have same risk as 80 year olds in the general population
**Risk increases with a decreasing GFR

== Further Reading ==

* An approach to treating older adults with chronic kidney disease. ''CMAJ''. 2023;195(17):E612-E618. doi: [https://doi.org/10.1503/cmaj.221427 10.1503/cmaj.221427]


[[Category:Nephrology]]
[[Category:Nephrology]]

Latest revision as of 14:08, 2 May 2023

Background

Definition

  • Structural or functional kidney disorder lasting at least [3 months]

KDIGO Classification

  • Defined as 3 or more months of either GFR < 60 or 1 or more marker of kidney damage:
    • Proteinuria
    • Urine sediments
    • Tubular electrolyte disorder
    • Kidney transplant
    • Structural disease
  • Categories & grades:
    • Grade 1: GFR ≥90 (normal) with a marker of kidney disease
    • Grade 2: GFR 60-89 with a marker of kidney disease
    • Grade 3a: GFR 45-59
    • Grade 3b: GFR 30-44
    • Grade 4: GFR 15-29
    • Grade 5: GFR <15, ESRD

Epidemiology

  • 8% of population have GFR < 60
  • 4% of population have proteinuria despite normal GFR

Differential Diagnosis

  • Diabetes
  • Cardiovascular disease/HTN
    • Ischemic nephropathy
    • Nephrosclerosis
  • Glomerulonephritis
  • PCKD
  • Drugs, especially lithium, cyclosporine, tacrolimus, tenofivir
  • Other disease associations
    • Inflammatory bowel disease: oxalate nephropathy
    • Rheumatoid arthritis: amyloidosis
    • Cirrhosis: Type 2 hepatorenal syndrome
    • Solid tumours: membranous nephropathy
    • Severe CHF: cardiorenal syndrome
    • Post-AKI: incomplete recovery of ATN in hospital

Investigations

Laboratory

  • GFR
    • MDRD underestimates the GFR in healthy patients
    • CKD-Epi is the newer equation and possibly more accurate
    • Radioisotopic GFR is the gold standard, inulin clearance is the gold standard for research
    • Cystatin C may complement or replace creatinine in the future
  • Urinalysis, though "protein" only picks up albumin
  • Urine ACR and PCR

Imaging

  • Abdominal ultrasound

Management

  • Education re: dialysis and transplant
  • Refer to nephrology when:
    • GFR drops by 5+ per year
    • Acute on chronic kidney injury
    • eGFR < 30 (Stage 4)
    • Proteinuria >1g/day
    • Difficulty controlling BP
  • BP control
    • ACEi + CCB + diuretic
    • If albuminuria, target <130/80, else <140/90
  • Proteinuria
    • If proteinuria >500mg/d or ACR>30mg/mmol, start ACEi/ARB regardless of BP
    • If diabetes and microalbuminuria, start ACEi/ARB
  • Metabolic acidosis (normal anion gap)
    • Oral sodium bicarbonate 0.5-1 mEq/kg/d to maintain bicarb between 23-29 mmol/L
  • Avoid nephrotoxic mediation like NSAIDs

Initial Investigations

  • Urinalysis to help diagnose glomerulonephritis or AIN
  • ACR, a component of the KFRE score
  • Urea, to help rule out volume depletion
  • Urine electrolytes, with low urine Na (FENA<1%) suggesting volume depletion
  • Ultrasound of the kidneys to assess for structural kidney disease and renal stones, plus or minus arterial Dopplers if suspecting renovascular disease
  • Serum protein electrophoresis
  • 24-hour urine protein and urine electrophoresis, if urine ACR >300 mg/mmol (<3 g/d)
  • CK, to rule out rhabdomyolysis
  • ANCAs, if UA shows blood and protein and there's a rapid decline in kidney function
  • CBC with blood film, looking for evidence of a TMA

Routine Investigations

  • Annually for patients with stage 2 or higher: creatinine, Na/K/Cl/CO2, ACR
  • Every 3-6 months for patients with stage 4 or higher:
    • Na/K/Cl/CO2, creatinine, urea
    • Ca/Mg/PO4/albumin/PTH
    • ACR
    • CBC, ferritin, transferrin saturation

Sick Day Medications

  • Some medications should be held during an acute illness, before surgery, or with IV contrast
  • Includes ACEi, ARB, aldosterone antagonists, SGLT-2 inhibitors, diuretics, NSAIDs, metformin, sulfonylureas, and direct renin inhibitors
  • Hold ACEi/ARB when planning pregnancy

Complications

  • Anemia: treat iron deficiency before adding Epo, targetting 105-115
  • Hypocalcemia: give calcium between meals or rocaltrol (if the hyperphosphatemia is treated)
  • Hyperphosphatemia: give a phosphate binder like calcium or Renagel with meals
  • Metabolic bone disease: maintain normal phosphate with diet, binders, and vitamin D
  • Acidosis: supplement bicarb when < 22
  • Hyperkalemia from poor GFR, ACEi, DM
  • Pruritis: moisturizers, steroids, antihistamines

Prognosis

  • GFR declines linearly over time
  • Progression predicted by
    • Previous rate of progression
    • Hypertension **
    • Proteinuria **
    • Metabolic acidosis
  • High risk of cardiovascular mortality compared to general population
    • 30 year olds on dialysis have same risk as 80 year olds in the general population
    • Risk increases with a decreasing GFR

Further Reading

  • An approach to treating older adults with chronic kidney disease. CMAJ. 2023;195(17):E612-E618. doi: 10.1503/cmaj.221427
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