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
⚫
* Urine sediments
⚫
* Tubular electrolyte disorder
⚫
* Kidney transplant
⚫
* Structural disease


⚫
*Proteinuria
⚫
=== Categories & Grades ===
⚫
*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


⚫
*Grade 1: GFR ≥90 (normal) with a marker of kidney disease
[[File:M172640ff1_Appendix_Figure_Prognosis_of_CKD_by_categories_of_GFR_and_albuminuria.jpeg|CKD grade]]
⚫
*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 ==
===Epidemiology===


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


== Differential Diagnosis ==
==Differential Diagnosis==


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


== Investigations ==
==Investigations==


=== Laboratory ===
===Laboratory===


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


=== Imaging ===
===Imaging===


* Abdominal ultrasound
*Abdominal ultrasound


== Management ==
==Management==


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


=== Complications ===
===Complications===


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


== Prognosis ==
==Prognosis==


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


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

Revision as of 20:02, 2 August 2020

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
  • Hold ACEi/ARB when AKI, any illness causing dehydration, surgery, contrast study, planning pregnancy
  • Avoid nephrotoxic mediation like NSAIDs

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
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