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
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[[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
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*Diabetes
−
* Cardiovascular disease/HTN
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*Cardiovascular disease/HTN
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** Ischemic nephropathy
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**Ischemic nephropathy
−
** Nephrosclerosis
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**Nephrosclerosis
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* Glomerulonephritis
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*Glomerulonephritis
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* PCKD
 +
*PCKD
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* Drugs, especially lithium, cyclosporine, tacrolimus, tenofivir
 +
*Drugs, especially lithium, cyclosporine, tacrolimus, tenofivir
−
* Other disease associations
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*Other disease associations
−
** Inflammatory bowel disease: oxalate nephropathy
 +
**Inflammatory bowel disease: oxalate nephropathy
−
** Rheumatoid arthritis: amyloidosis
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**Rheumatoid arthritis: amyloidosis
−
** Cirrhosis: Type 2 hepatorenal syndrome
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**Cirrhosis: Type 2 hepatorenal syndrome
−
** Solid tumours: membranous nephropathy
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**Solid tumours: membranous nephropathy
−
** Severe CHF: cardiorenal syndrome
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**Severe CHF: cardiorenal syndrome
−
** Post-AKI: incomplete recovery of ATN in hospital
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**Post-AKI: incomplete recovery of ATN in hospital
   
−
== Investigations ==
 +
==Investigations==
   
−
=== Laboratory ===
 +
===Laboratory===
   
−
* GFR
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*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
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*Urine ACR and PCR
   
−
=== Imaging ===
 +
===Imaging===
   
−
* Abdominal ultrasound
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*Abdominal ultrasound
   
−
== Management ==
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==Management==
   
−
* Education re: dialysis and transplant
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*Education re: dialysis and transplant
−
* Refer to nephrology when:
 +
*Refer to nephrology when:
−
** GFR drops by 5+ per year
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**GFR drops by 5+ per year
−
** Acute on chronic kidney injury
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**Acute on chronic kidney injury
−
** eGFR < 30 (Stage 4)
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**eGFR < 30 (Stage 4)
−
** Proteinuria >1g/day
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**Proteinuria >1g/day
−
** Difficulty controlling BP
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**Difficulty controlling BP
−
* BP control
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*BP control
−
** ACEi + CCB + diuretic
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**ACEi + CCB + diuretic
−
** If albuminuria, target <130/80, else <140/90
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**If albuminuria, target <130/80, else <140/90
−
* Proteinuria
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*Proteinuria
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** 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)
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*Metabolic acidosis (normal anion gap)
−
** Oral sodium bicarbonate 0.5-1 mEq/kg/d to maintain bicarb between 23-29 mmol/L
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**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 ===
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===Complications===
   
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* '''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
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*'''Hyperkalemia''' from poor GFR, ACEi, DM
−
* '''Pruritis:''' moisturizers, steroids, antihistamines
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*'''Pruritis:''' moisturizers, steroids, antihistamines
   
−
== Prognosis ==
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==Prognosis==
   
−
* GFR declines linearly over time
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*GFR declines linearly over time
−
* Progression predicted by
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*Progression predicted by
−
** Previous rate of progression
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**Previous rate of progression
−
** Hypertension **
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**Hypertension **
−
** Proteinuria **
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**Proteinuria **
−
** Metabolic acidosis
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**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 16:02, 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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