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 10:08, 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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