Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated

glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 square meters, persisting for 3
months or more. It is a state of progressive loss of kidney function ultimately resulting in the
need for renal replacement therapy (dialysis or transplantation). This activity reviews the
etiology, evaluation, and management of chronic kidney disease and emphasizes the roles of the
interprofessional team in caring for patients with chronic kidney disease.
Objectives:
 Describe the risk factors for developing chronic kidney disease.
 Review the pathophysiology of chronic kidney disease.
 Outline the treatment and management options available for chronic kidney disease.
 Explain interprofessional team strategies for enhancing care coordination and
communication to advance the management of chronic kidney disease and improve
patient outcomes.

Introduction
Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated
glomerular filtration rate (eGFR) less than 60 ml/min/1.73 mt2, persisting for 3 months or more,
irrespective of the cause.[1] It is a state of progressive loss of kidney function ultimately
resulting in the need for renal replacement therapy (dialysis or transplantation). Kidney damage
refers to pathologic abnormalities either suggested by imaging studies or renal biopsy,
abnormalities in urinary sediment, or increased urinary albumin excretion rates. The 2012
KDIGO CKD classification recommends details about the cause of the CKD and classifies it into
6 categories based on glomerular filtration rate (G1 to G5 with G3 split into 3a and 3b). It also
includes the staging based on three levels of albuminuria (A1, A2, and A3), with each stage of
CKD being sub-categorized according to the urinary albumin-creatinine ratio in (mg/gm) or
(mg/mmol) in an early morning “spot” urine sample.[2]
The 6 categories include:
 G1: GFR 90 ml/min per 1.73 m2 and above
 G2: GFR 60 to 89 ml/min per 1.73 m2
 G3a: GFR 45 to 59 ml/min per 1.73 m2
 G3b: GFR 30 to 44 ml/min per 1.73 m2
 G4: GFR 15 to 29 ml/min per 1.73 m2
 G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis
The three levels of albuminuria include an albumin-creatinine ratio (ACR)
 A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol)
 A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol)
 A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol).
The improved classification of CKD has been beneficial in identifying prognostic indications
related to decreased kidney function and increased albuminuria. However, a downside of the use
of classification systems is the possible overdiagnosis of CKD, especially in the elderly.

Etiology
The causes of CKD vary globally, and the most common primary diseases causing CKD and
ultimately end-stage renal disease (ESRD) are as follows[3]:
 Diabetes mellitus type 2 (30% to 50%)
 Diabetes mellitus type 1 (3.9%)
 Hypertension (27.2%)
 Primary glomerulonephritis (8.2%)
 Chronic Tubulointerstitial nephritis (3.6%)
 Hereditary or cystic diseases (3.1%)
 Secondary glomerulonephritis or vasculitis (2.1%)
 Plasma cell dyscrasias or neoplasm (2.1)
 Sickle Cell Nephropathy (SCN) which accounts for less than 1% of ESRD patients in the
United States[4]
CKD may result from disease processes in any of the three categories: prerenal (decreased renal
perfusion pressure), intrinsic renal (pathology of the vessels, glomeruli, or tubules-interstitium),
or postrenal (obstructive).
Prerenal Disease
Chronic prerenal disease occurs in patients with chronic heart failure or cirrhosis with
persistently decreased renal perfusion, which increases the propensity for multiple episodes of an
intrinsic kidney injury, such as acute tubular necrosis (ATN). This leads to progressive loss of
renal function over time.
Intrinsic Renal Vascular Disease
The most common chronic renal vascular disease is nephrosclerosis, which causes chronic
damage to blood vessels, glomeruli, and tubulointerstitium.
The other renal vascular diseases are renal artery stenosis from atherosclerosis or fibro-muscular
dysplasia which over months or years, cause ischemic nephropathy, characterized by
glomerulosclerosis and tubulointerstitial fibrosis.[5]
Intrinsic Glomerular Disease (Nephritic or Nephrotic)
A nephritic pattern is suggested by abnormal urine microscopy with red blood cell (RBC) casts
and dysmorphic red cells, occasionally white blood cells (WBCs), and a variable degree
of proteinuria.[6] The most common causes are post-streptococcal GN, infective endocarditis,
shunt nephritis, IgA nephropathy, lupus nephritis, Goodpasture syndrome, and vasculitis. [7]
A nephrotic pattern is associated with proteinuria, usually in the nephrotic range (greater than 3.5
gm per 24 hours), and an inactive urine microscopic analysis with few cells or casts. It is
commonly caused by minimal change disease, focal segmental glomerulosclerosis, membranous
GN, membranoproliferative GN (Type 1 and 2 and associated with cryoglobulinemia), diabetic
nephropathy, and amyloidosis.
Some patients may be assigned to one of these two categories.
Intrinsic Tubular and Interstitial Disease
The most common chronic tubulointerstitial disease is polycystic kidney disease (PKD). Other
etiologies include nephrocalcinosis (most often due to hypercalcemia and hypercalciuria),
sarcoidosis, Sjogren syndrome, reflux nephropathy in children and young adults, [8]
There is increased recognition of the relatively high prevalence of CKD of unknown cause
among agricultural workers from Central America and parts of Southeast Asia called
Mesoamerican nephropathy,[9]
Postrenal (Obstructive Nephropathy)
Chronic obstruction may be due to prostatic disease, nephrolithiasis or abdominal/pelvic tumor
with mass effect on ureter(s) are the common causes. Retroperitoneal fibrosis is a rare cause of
chronic ureteral obstruction

Epidemiology
The true incidence and prevalence of CKD are difficult to determine because of the
asymptomatic nature of early to moderate CKD. The prevalence of CKD is around 10% to 14%
in the general population. Similarly, albuminuria (microalbuminuria or A2) and GFR less than
60 ml/min/1.73 mt2 have a prevalence of 7% and 3% to 5%, respectively.[10]
Worldwide, CKD accounted for 2,968,600 (1%) of disability-adjusted life-years and 2,546,700
(1% to 3%) of life-years lost in 2012.[3]
Kidney Disease Outcomes Quality Initiative (KDOQI) mandates that for labeling of chronicity
and CKD, patients should be tested on three occasions over a 3-month period with 2 of the 3
results being consistently positive.[11]
Natural History and Progression of CKD
CKD diagnosed in the general population (community CKD) has a significantly different natural
history and the course of progression compared to the CKD in patients referred to the nephrology
practices (referred CKD).
Community CKD is seen mainly in the older population. These individuals have had lifelong
exposure to cardiovascular risk factors, hypertension, and diabetes which can also affect the
kidneys. The average rate of decline in GFR in this population is around 0.75 to 1 ml/min/year
after the age of 40 to 50 years. [12] In a large study of community-based CKD by Kshirsagar et
al., only 1% and 20% of patients with CKD stages G3 and G4 required renal replacement therapy
(RRT), however, 24% and 45% respectively died predominantly from cardiovascular disease
(CVD), suggesting that cardiac events rather than progressing to ESRD is the predominant
outcome in community-based CKD.[13]
In contrast to community CKD, patients with referred CKD present at an early age because of
hereditary (autosomal dominant polycystic kidney disease ADPKD) or acquired nephropathy
(glomerulonephritis, diabetic nephropathy, or tubulointerstitial disease) causing progressive renal
damage and loss of function. The rate of progression in referred CKD varies according to the
underlying disease process and between individual patients. Diabetic nephropathy has shown to
have a rapid rate of decline in GFR averaging around 10 ml/min/year. In nondiabetic
nephropathies, the rate of progression is usually faster in patients with chronic proteinuric GN
than in those with a low level of proteinuria. Patients with ADPKD and renal impairment, CKD
stage G3b and beyond, may have a faster rate of progression compared to other nephropathies. In
patients with hypertensive nephrosclerosis, good blood pressure control and minimal proteinuria
are associated with very slow progression.
Risk Factors for Progression of CKD
Non-Modifiable CKD Risk Factors
Older age, male gender, a non-Caucasian ethnicity which includes African Americans, Afro-
Caribbean individuals, Hispanics, and Asians (South Asians and Pacific Asians) all adversely
affect CKD progression.
Genetic factors which affect CKD progression have been found in different Kidney diseases. In a
population-based cohort study by Luttropp et al., single nucleotide polymorphisms in the
genes TCF7L2 and MTHFS were associated with diabetic nephropathy and CKD progression. In
the same study, polymorphisms of genes coding for mediators of renal scarring and renin-
angiotensin-aldosterone system (RAAS) were found to influence CKD progression.[14]
Modifiable CKD Risk Factors
These include systemic hypertension, proteinuria, and metabolic factors.[15]
Systemic hypertension is one of the main causes of ESRD worldwide and the second leading
cause in the United States after diabetes. The transmission of systemic hypertension into
glomerular capillary beds and the resulting glomerular hypertension is believed to contribute to
the progression of glomerulosclerosis.[16] Night-time and 24-hour blood pressure measurement
(ABPM) appear to correlate best with the progression of CKD. Systolic rather than diastolic BP
seems to be predictive of CKD progression and has also been associated with complications in
CKD.
Multiple studies in patients with diabetic and nondiabetic kidney diseases have shown that
marked proteinuria (albuminuria A3) is associated with a faster rate of CKD progression. Also, a
reduction in marked proteinuria by RAS blockade or by diet is associated with a better renal
outcome. However, in large intervention studies like Avoiding Cardiovascular Events Through
Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH)[17] and
Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial
(ONTARGET),[18] significant declines in GFR were noted despite a marked reduction in
albuminuria. Therefore, moderate level albuminuria (A2) is not a reliable surrogate marker for
CKD progression, and reduction in albuminuria can be associated with both improving and
worsening of CKD progression.
Multiple studies have linked the RAAS system in the pathogenesis of hypertension, proteinuria,
and renal fibrosis throughout CKD. Subsequently, interventions targeting RAAS have proved
effective in slowing the progression of CKD. This has led to the widespread use of RAAS
blockers in proteinuric and diabetic kidney disease.
Obesity and smoking have been related to the development and progression of CKD. Also,
metabolic factors such as insulin resistance, dyslipidemia, and hyperuricemia have been
implicated in the development and progression of CKD.[19][20]
Recommendations for CKD Screening
Screening, mostly targeting high-risk individuals is being implemented worldwide. The KDOQI
guidelines recommend screening high-risk populations which include individuals with
Hypertension, Diabetes mellitus, and those older than 65 years. This should include urinalysis, a
urine albumin-creatinine ratio (ACR), measurement of serum creatinine and estimation of GFR
preferably by chronic kidney disease epidemiology collaboration (CKD-EPI) equation. It is the
most cost-effective approach, and there is no evidence to justify screening asymptomatic
individuals in the general population for CKD.

Pathophysiology
Unlike acute kidney injury (AKI), where the healing process is complete with complete
functional kidney recovery, chronic and sustained insults from chronic and progressive
nephropathies evolve to progressive kidney fibrosis and destruction of the normal architecture of
the kidney. This affects all the 3 compartments of the kidney, namely glomeruli, the tubules, the
interstitium, and the vessels. It manifests histologically as glomerulosclerosis, tubulointerstitial
fibrosis, and vascular sclerosis.
The sequence of events which lead to scarring and fibrosis are complex, overlapping, and are
multistage phenomena.
 Infiltration of damaged kidneys with extrinsic inflammatory cells
 Activation, proliferation, and loss of intrinsic renal cells (through apoptosis, necrosis,
mesangiolysis, and podocytopenia)
 Activation and proliferation of extracellular matrix (ECM) producing cells including
myofibroblasts and fibroblasts
 Deposition of ECM replacing the normal architecture
Mechanisms of Accelerated Progression of CKD
 Systemic and intraglomerular hypertension
 Glomerular hypertrophy
 Intrarenal precipitation of calcium phosphate
 Altered prostanoid metabolism
All these mechanisms lead to a histological entity called focal segmental glomerulosclerosis.[21]
Clinical risk factors for accelerated progression of CKD are proteinuria, hypertension, black
race, and hyperglycemia. Also, environmental exposures such as lead, smoking, metabolic
syndrome, possibly some analgesic agents, and obesity have also been linked to accelerated
progression of CKD.[22]

History and Physical

Early CKD stages are asymptomatic, and symptoms manifest in stages 4 or 5. It is commonly
detected by routine blood or urine testing. Some common symptoms and signs at these stages of
CKD are:
 Nausea
 Vomiting
 Loss of appetite
 Fatigue and weakness
 Sleep disturbance
 Oliguria
 Decreased mental sharpness
 Muscle twitches and cramps
 Swelling of feet and ankles
 Persistent pruritus
 Chest pain due to uremic pericarditis
 Shortness of breath due to pulmonary edema from fluid overload
 Hypertension that's difficult to control
 Physical examination is often not helpful, but patients may have
 Skin pigmentation
 Scratch marks from pruritus
 Pericardial friction rub due to uremic pericarditis
 Uremic frost, where high levels of BUN result in urea in sweat
 Hypertensive fundal changes suggesting chronicity

Evaluation
Establishing Chronicity
When an eGFR of less than 60 ml/min/1.73m is detected in a patient, attention needs to be paid
to the previous blood and urine test results and clinical history to determine whether this is a
result of AKI or CKD that has been present but asymptomatic. The following factors would be
helpful.
1. History of long-standing chronic hypertension, proteinuria, microhematuria, and
symptoms of the prostatic disease
2. Skin pigmentation, scratch marks, left ventricular hypertrophy, and hypertensive fundal
changes
3. Blood test results of other conditions like multiple myeloma, systemic vasculitis would
be helpful.
4. Low serum calcium and high phosphorus levels have little discriminatory value, but
normal Parathyroid hormone levels suggest AKI rather than CKD
 5. Patients who have very high blood urea nitrogen (BUN) values greater than 140 mg/dl,
serum creatinine greater than 13.5 mg/dl, who appear relatively well and still passing
normal volumes of urine are much more likely to have CKD than acute kidney disease.
Assessment of Glomerular Filtration Rate
For patients in whom the distinction between AKI and CKD is unclear, kidney function tests
should be repeated in 2 weeks of the initial finding of low eGFR below 60 ml/min/1.73 m.
If previous tests confirm that the low eGFR is chronic or the repeat blood test results over 3
months are consistent, CKD is confirmed.
If eGFR based on serum creatinine is known to be less accurate, then other markers like cystatin-
c or an isotope-clearance measurement can be undertaken.
Assessment of Proteinuria
KDIGO recommends that proteinuria should be assessed by obtaining an early morning urine
sample and quantifying albumin-creatinine ratio (ACR). The degree of albuminuria is graded
from A1 to A3, replacing previous terms such as microalbuminuria.
Some patients may excrete proteins other than albumin and urine protein-creatinine ratio (PCR)
may be more useful for certain conditions.[23]
Imaging of Kidneys
If an ultrasound examination of kidneys shows small kidneys with reduced cortical thickness,
increased echogenicity, scarring, or multiple cysts, this suggests a chronic process. It may also be
helpful to diagnose chronic hydronephrosis from obstructive uropathy, cystic enlargement of the
kidney in ADPKD.
Renal ultrasound Doppler can be used in suspected renal artery stenosis to evaluate the renal
vascular flow
Computerized tomography: A low dose of non-contrast CT is used to diagnose renal stone
disease. It is also used to diagnose suspected ureteric obstruction which cannot be seen by
ultrasonography.
Renal angiography has its role in the diagnosis of polyarteritis nodosa where multiple aneurysms
and irregular areas of constriction are seen.
Voiding cystourethrography is mainly used when chronic vesicourethral reflux is suspected as
the cause of CKD.[8] It is used to confirm the diagnosis and estimate the severity of reflux.
Renal scans can give sufficient information about the anatomy and function of kidneys. They are
used predominantly in children as they are associated with lesser radiation exposure compared to
CT scan. Radionuclide renal scans are used to measure the difference in function between the
kidneys.
Establishing an Accurate Diagnosis
An accurate cause of CKD needs to be established such as when there is an underlying treatable
condition that requires appropriate management, for example, lupus nephritis, ANCA vasculitis,
among others. In addition, certain diseases carry a higher frequency of recurrence in the kidney
after transplantation and accurate diagnosis will influence later management. A kidney biopsy is
used to diagnose the etiology of CKD, and it also gives information about the extent of fibrosis
in the kidney.

Treatment / Management
General Management
 Adjusting drug doses for the level of estimated glomerular filtration rate (GFR)
 Preparation of renal replacement therapy by placing an arteriovenous fistula or graft
Treat the Reversible Causes of Renal Failure
The potentially reversible causes of acute kidney injury like infection, drugs that reduce the
GFR, hypotension such as from shock, instances that cause hypovolemia such as vomiting,
diarrhea should be identified and intervened.
Patients with CKD should be evaluated carefully for the use of intravenous contrast studies, and
any alternatives for the contrast studies should be utilized first. Other nephrotoxic agents
such as aminoglycoside antibiotics and NSAIDs should be avoided.
Retarding the Progression of CKD
The factors which result in progression of CKD should be addressed such as hypertension,
proteinuria, metabolic acidosis, and hyperlipidemia. Hypertension should be managed in CKD
by establishing blood pressure goals. Similarly, the proteinuria goal should be met.
Multiple studies have shown that smoking is associated with the risk of developing
nephrosclerosis and smoking cessation retards the progression of CKD.[24]
Protein restriction has also been shown to slow CKD progression. However, the type and amount
of protein intake are yet to be determined.
Bicarbonate supplementation for the treatment of chronic metabolic acidosis has been shown to
delay the CKD progression as well. [25] Also, intensive glucose control in diabetics has been
shown to delay the development of albuminuria and also the progression of albuminuria to overt
proteinuria.[26]
Preparation and Initiation of Renal Replacement Therapy
Once the CKD progression is noted, the patient should be offered various options for renal
replacement therapy.
 Hemodialysis (home or in-center)
 Peritoneal dialysis (continuous or intermittent)[27]
 Kidney transplantation (living or deceased donor): It is the treatment of choice for ESRD
given better long-term outcomes.
 Patients who do not want renal replacement therapy should be provided with information
about conservative and palliative care management.
  The hemodialysis is performed after stable vascular access is placed in a nondominant
arm. In this arm, intravenous cannulas are avoided to preserve the veins. The preferred
vascular access is AV fistula. The other hemodialysis access options are AV graft and
tunneled hemodialysis catheters. The patency rates of AV fistula is good, and infections
are very infrequent. Higher flows can be achieved through AV fistula, and there is less
chance of recirculation.
 Peritoneal dialysis is performed after placing a peritoneal catheter.[27]
Indications for Renal Replacement Therapy
 Pericarditis or pleuritis (urgent indication)
 Progressive uremic encephalopathy or neuropathy, with signs such as confusion,
asterixis, myoclonus, and seizures (urgent indication)
 A clinically significant bleeding diathesis is attributable to uremia (urgent indication)
 Hypertension is poorly responsive to antihypertensive medications
 Fluid overload is refractory to diuretics
 Metabolic disorders that are refractory to medical therapy such as hyperkalemia,
hyponatremia, metabolic acidosis, hypercalcemia, hypocalcemia, and hyperphosphatemia
 Persistent nausea and vomiting
 Evidence of malnutrition
Renal transplantation is the best treatment option of ESRD due to its survival benefit compared
to long-term dialysis therapy. The patients with CKD become eligible to be listed for Deceased
donor renal transplant program when the eGFR is less than 20 ml/min/1.73m2
Conservative management of ESRD is also an option for all patients who decide not to pursue
renal replacement therapy. Conservative care includes the management of symptoms, advance-
care planning, and provision of appropriate palliative care. This strategy is often underutilized
and needs to be considered for very frail patients with poor functional status with numerous
comorbidities. For facilitating this discussion a 6-month mortality score calculator is being used
which includes variables such as age, serum albumin, the presence of dementia, peripheral
vascular disease, and (yes/no) answer to a question by a treating nephrologist "would I be
surprised if this patient died in the next year?"
When to Refer to a Nephrologist
Patients with CKD should be referred to a nephrologist when the estimated GFR is less than 30
ml/min/1.73 mt2. This is the time to discuss the options of renal replacement therapy.

Differential Diagnosis
 Acute kidney injury
 Alport syndrome
 Antigiomerular basement membrane disease
 Chronic glomerulonephritis
 Diabetic nephropathy
  Multiple myeloma
 Nephrolithiasis
 Nephrosclerosis
 Rapidly progressive glomerulonephritis
 Renal artery stenosis
Go to:

Staging
The 6 categories include:
 G1: GFR 90 ml/min per 1.73 m2 and above
 G2: GFR 60 to 89 ml/min per 1.73 m2
 G3a: GFR 45 to 59 ml/min per 1.73 m2
 G3b: GFR 30 to 44 ml/min per 1.73 m2
 G4: GFR 15 to 29 ml/min per 1.73 m2
 G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis
The 3 levels of albuminuria include albumin-creatinine ratio (ACR):
 A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol)
 A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol)
 A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol)

Prognosis
Significant racial and ethnic differences exist in the incidence and prevalence rates of ESRD.
The highest incidence is found in African Americans; followed by American Indians and Alaska
Natives; followed by Asian Americans, Native Hawaiians, and other Pacific Islanders; followed
by whites. Hispanics have higher incidence rates of ESRD than non-Hispanics.
Early-stage CKD and ESRD are associated with increased morbidity and health care utilization
rates. A review of the USRDS 2009 annual data report suggests that the number of
hospitalizations in ESRD patients is 1.9% per patient-year. In a study by Khan SS et al., the
prevalence of cardiovascular disease, cerebrovascular disease, and peripheral vascular disease in
earlier stages of CKD was comparable to those in the US dialysis population. It was also found
that patients with CKD had 3-fold higher rates of hospitalization and hospital days spent per
patient-year compared to the general US population.[28] CKD patients are at a higher risk of
hospitalization and cardiovascular diseases and the risk increases with a decline in GFR.
Patients with CKD and particularly end-stage renal disease (ESRD) are at increased risk of
mortality, particularly from cardiovascular disease. A review of USRDS 2009 data suggests that
5-year survival probability in a patient on dialysis is only around 34%.

Complications
Treatment of Complications of Chronic Kidney Disease
Patients with CKD have diminished ability to maintain a fluid balance after a rapid sodium load
and becomes more apparent in stages IV and V of CKD. These patients respond to sodium
restriction and a loop diuretic. The 2012 KDIGO guidelines recommend all CKD patients should
be sodium restricted to less than 2 gm per day.
Hyperkalemia in CKD can occur specifically in oliguric patients and in whom where aldosterone
secretion is diminished. Dietary intake of potassium, tissue breakdown and hypoaldosteronism
could result in hyperkalemia. Drugs such as ACE inhibitors and nonselective beta-blockers could
also result in hyperkalemia.
Metabolic acidosis is a common complication of advanced CKD due to the increased tendency of
kidneys in CKD to retain H. Chronic metabolic acidosis in CKD would result in osteopenia,
increased protein catabolism, and secondary hyperparathyroidism. These patients should be
treated with bicarbonate supplementation to target serum bicarbonate of equal to 23.
CKD is a significant risk factor for CVD and risk increases with increased severity of the CKD.
Considerable evidence indicates a significant association between Epicardial adipose tissue
(EAT) thickness and the incidence of CVD events in CKD patients. In CKD patients, EAT
assessment could be a reliable parameter for cardiovascular risk assessment.[29].
Bone and Mineral Disorders
Hyperphosphatemia is a frequent complication of CKD due to a decreased filtered load of
phosphorous. This leads to increased secretion of a Parathyroid hormone (PTH) and causes
secondary hyperparathyroidism. Hyperparathyroidism results in the normalization of
phosphorous and calcium but at the expense of bone. This results in renal osteodystrophy.
Therefore, phosphorus binders along with dietary restriction of phosphorus are used to treat
secondary hyperparathyroidism.
Hypertension is a manifestation of volume expansion in CKD. Patients in CKD do not always
have edema to suggest volume expansion. Therefore, all patients with CKD should have a loop
diuretic added to control the blood pressure which needs to be titrated before considering
an increase in antihypertensive therapy.
Anemia in CKD is usually normocytic normochromic. It is primarily due to reduced
erythropoietin production from reduced functioning renal mass and also due to reduced red cell
survival. Hemoglobin should be checked at least yearly in CKD 3, every 6 months in CKD IV
and V, and every 3 months in dialysis patients. Erythropoietin stimulating agents (ESA) in CKD
patients should be considered when Hb is less than 10 and provided iron saturation is at least
25% and ferritin greater than 200 ng/mL. In dialysis patients, the goal Hb concentration is 10 to
11.5 gm/dl.
Treatment of Complications of ESRD
Malnutrition in ESRD is due to anorexia and poor protein intake. The diet in ESRD should
provide at least 30 to 35 Kcal/kg per day. A low plasma albumin concentration is suggestive of
malnutrition.
Uremic bleeding is a complication resulting from impaired platelet function. It results in
prolonged bleeding time. Asymptomatic patients are not treated. However, correction of uremic
platelet dysfunction is needed during active bleeding, need for a surgical procedure. Some
interventions used are desmopressin (dDAVP), cryoprecipitate, estrogen, and initiation of
dialysis.
Uremia can present as uremic pericarditis and is an indication for initiation of dialysis. Uremic
pericarditis is treated with dialysis and responds well.
Complications of Renal Transplantation
Complications related to cardiovascular, renal, neurologic, and gastrointestinal systems.[30][31]
Common complications include hypertension, dyslipidemia, coronary artery disease from new-
onset diabetes mellitus and renal failure, left ventricular hypertrophy, arrhythmias,[31] and heart
failure. Neurologic complications include stroke and posterior reversible encephalopathy
syndrome, central nervous system (CNS) infections, neuromuscular disease, seizure disorders,
and neoplastic disease. GI complications include infection, malignancy (posttransplant
lymphoproliferative disorder), mucosal injury, mucosal ulceration, perforation, biliary tract
disease, pancreatitis, and diverticular disease.

Consultations
 Nephrology should be consulted for all patients with CKD where GFR is less than 30
ml/min/1.73 m.
 Urology consultation is needed for obstructive uropathy.
 Relieve obstruction with retrograde ureteral catheters or percutaneous nephrostomy.
 Interventional radiology consults for placement of permanent tunneled hemodialysis
catheter.
 Vascular surgery is suggested for placing arterio-venous fistula(AVF) or grafts (AVG)
along with peritoneal dialysis catheters.
Go to:

Deterrence and Patient Education

All high-risk groups of patients such as Diabetic patients, hypertensives, should not only be
screened for CKD but also be counseled about the symptoms and signs of CKD. Patients with
CKD should be taught about the following interventions at home
Eighty percent to 85% of patients with CKD have hypertension, and they should be instructed to
measure blood pressure daily and to keep a log of blood pressure, daily weights. They should be
prescribed a diuretic as a part of an antihypertensive regimen.
Teaching patients with advanced CKD of home administration of subcutaneous erythropoietin
stimulating agents.
There should be a discussion held with patients by nutritionists or physicians about low protein
diet which may slow the progression of CKD and potassium-containing foods.
All patients with advanced CKD should be instructed about the need to control phosphorus
levels. They should be instructed to take phosphate binders with each meal.
CKD patients who are pregnant should be educated that pregnancy may worsen the CKD
and how reduced kidney function can adversely affect pregnancy.
Go to:

Pearls and Other Issues

1. Chronic kidney disease (CKD) is defined as kidney damage or an estimated glomerular
filtration rate (eGFR) less than 60 ml/min/1.73 m persisting for three months or more
irrespective of the cause.
2. CKD is usually asymptomatic till stages IV and V.
3. The KDOQI guidelines recommend screening high-risk populations which include
individuals with hypertension, diabetes mellitus, and those older than 65 years with a
urinalysis, a urine albumin-creatinine ratio (ACR), measurement of serum creatinine, and
estimation of GFR preferably by chronic kidney disease epidemiology collaboration
(CKD-EPI) equation.
4. Calcium and phosphorus are not useful to distinguish AKI from CKD. However, normal
PTH suggests AKI rather than CKD.
5. Systemic hypertension, proteinuria, hyperlipidemia, and metabolic acidosis cause
progression of CKD and need to be treated aggressively.
6. Bicarbonate supplementation to reach a serum bicarbonate target equal to 23 delays the
progression of CKD.
7. All CKD patients need to be evaluated for anemia, hypertension, metabolic acidosis, and
bone and mineral disorders.
Go to:

Enhancing Healthcare Team Outcomes

CKD has a multitude of manifestations and is optimally managed by an interprofessional team of
health care professionals who practice at a single location such as a CKD clinic. These clinics
focus on guideline-driven kidney care, evaluate and treat complications, suggest patient lifestyle
modifications, and provide adequate patient education regarding the various modalities of
dialysis. Fishbane et al. compared a standard care model with a healthy transitions program
where a nurse care manager works with a protocol-driven informatics system that provides daily
reports with incomplete steps of the process for each patient.[32] It showed a reduction in
hospitalizations, increased use of AV fistulas, a decrease in emergent dialysis, and less use of
catheters. Such models decrease the overall cost of health care by saving billions of dollars.
The interprofessional CKD clinics have access to a nutritionist who assesses the nutritional status
of a patient and also formulates a meal plan. Similarly, a pharmacist performs a medication
check and screens for nephrotoxic medications and adjusts the non-nephrotoxic medications to
the patient’s renal function. The nurse practitioner evaluates the blood pressure and adjusts the
blood pressure medications accordingly. The primary care provider educates the patient on the
importance of discontinuing smoking, eating healthy and maintaining healthy body weight. The
dialysis nurse assists the team by providing education on how to look after the dialysis catheters
or AV fistulas. A vascular access nurse also evaluates appropriate patients for hemodialysis
access. Finally, a renal transplantation nurse provides information on the procedure and the
criteria for selecting patients for the procedure.
Evidence shows that an interprofessional approach to chronic renal failure avoids duplication of
studies, is cost-effective, results in less patient morbidity, and ensures better outcomes.[33]