CHRONIC KIDNEY

DISEASE
DEFINITION
Structural or functional abnormalities of the kidneys for >3 months, as
manifested by either:

1. Kidney damage, with or without decreased GFR, as defined by

• pathologic abnormalities
• markers of kidney damage, including abnormalities in the
composition of the blood or urine or abnormalities in imaging
tests

2. GFR <60 ml/min/1.73 m2, with or without kidney damage

CKD-CVD-Diabetes Link: CKD is a
Disease Multiplier
Non-modifiable risk factors for progression
• Age
• Gender
• Race
• Genetics
• Loss of renal mass
• Diabetes
• Hypertension
• History of AKI
• Frequent NSAID use

Floege et al. Comprehensive Nephrology, 2010.

Modifiable risk factors for progression

• Hypertension
• Glycemia
• Family history of kidney
• Proteinuria disease, diabetes, or
• Obesity
• Albuminuria hypertension
• Lipid • Age 60 or older (GFR
• Chronic kidney disease
• Smoking declines normally with
• Cardiovascular disease
• Uric acid age)
• Renin-angiotensin • Race/U.S. ethnic minority
system status

Floege et al. Comprehensive Nephrology, 2010.

BMJ 2002;325:85-90.
Causes of CKD
• Diabetes (18,6%)
• Glomerulonephritis (12,5%)
• Reflux nephropathy (10,2%)
• Renovascular (6,9%)
• Hypertension (6,8%)
• Polycystic kidney disease (6,7%)

Stein A, et al. Vital Nephrology

Evaluation of chronicity
• In people with GFR < 60 (GFR categories G3a-G5) or
markers of kidney damage, review past history and
previous measurements to determine duration of kidney
disease.
• If duration is > 3 months, CKD is confirmed. Follow
recommendations for CKD.
• If duration is not > 3 months or unclear, CKD is not confirmed.
Patients may have CKD or acute kidney diseases (including AKI) or
both and tests should be repeated accordingly.

KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
International 2013.
Evaluation of cause
• Evaluate the clinical context, including personal and family
history, social and environmental factors, medications,
physical examination, laboratory measures, imaging, and
pathologic diagnosis to determine the causes of kidney
disease.

KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
International 2013.
• We recommend using serum creatinine and a GFR
estimating equation for initial assessment.
• We suggest using additional tests (such as cystatin C or a
clearance measurement) for confirmatory testing in
specific circumstances when eGFR based on serum
creatinine is less accurate. (2B)
• We recommend that clinicians:
• Use a GFR estimating equation to derive GFR from serum
creatinine (eGFRcreat) rather than relying on the serum creatinine
concentration alone.
• Understand clinical settings in which eGFR creat is less accurate.

KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
International 2013.
Progression of CKD
• Assess GFR and albuminuria at least annually in people
with CKD. Assess GFR and albuminuria more often for
individuals at higher risk of progression, and/or where
measurement will impact therapeutic decisions
• Recognize that small fluctuations in GFR are common
and are not necessarily indicative of progression.

KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
International 2013.
• Define CKD progression based on one of more of the
following:
• Decline in GFR category (>90 [G1], 60–89 [G2], 45–59 [G3a], 30–
44 [G3b], 15–29 [G4], o15 [G5]). A certain drop in eGFR is defined
as a drop in GFR category accompanied by a 25% or greater drop
in eGFR from baseline.
• Rapid progression is defined as a sustained decline in eGFR of
more than 5.
• The confidence in assessing progression is increased with
increasing number of serum creatinine measurements and duration
of follow-up.

KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
International 2013.
 Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage Description GFR Evaluation Management
At increased
Test for CKD Risk factor management
risk
Diagnosis
Kidney
Comorbid Specific therapy, based on diagnosis
damage with
1 >90 conditions Management of comorbid conditions
normal or 
CVD and CVD Treatment of CVD and CVD risk factors
GFR
risk factors
Kidney
Rate of
2 damage with 60-89 Slowing rate of loss of kidney function 1
progression
mild  GFR
Moderate 
3 30-59 Complications Prevention and treatment of complications
GFR
Preparation for kidney replacement therapy
4 Severe  GFR 15-29
Referral to Nephrologist
5 Kidney Failure <15 Kidney replacement therapy
1
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
Definition of ESRD vs Kidney Failure
• ESRD is a federal government defined term that indicates
chronic treatment by dialysis or transplantation

• Kidney Failure: GFR < 15 ml/min/1.73 m2 or on dialysis.

Classification of CKD by Diagnosis

• Diabetic Kidney Disease

• Glomerular diseases (autoimmune diseases, systemic
infections, drugs, neoplasia)
• Vascular diseases (renal artery disease, hypertension,
microangiopathy)
• Tubulointerstitial diseases (urinary tract infection,
stones, obstruction, drug toxicity)
• Cystic diseases (polycystic kidney disease)
• Diseases in the transplant (Allograft nephropathy, drug
toxicity, recurrent diseases, transplant glomerulopathy)
Importance of Proteinuria in CKD
Interpretation Explanation

Marker of kidney Spot urine albumin-to-creatinine ratio >30 mg/g or

damage spot urine total protein-to-creatinine ratio >200 mg/g
for >3 months defines CKD
Clue to the type Spot urine total protein-to-creatinine ratio >500-
(diagnosis) of CKD 1000 mg/g suggests diabetic kidney disease,
glomerular diseases, or transplant glomerulopathy.

Risk factor for adverse Higher proteinuria predicts faster progression of

outcomes kidney disease and increased risk of CVD.
Effect modifier for Strict blood pressure control and ACE inhibitors are
interventions more effective in slowing kidney disease
progression in patients with higher baseline
proteinuria.

Hypothesized If validated, then lowering proteinuria would be a

surrogate outcomes goal of therapy.
and target for
interventions
 Screening
target

Floege et al. Comprehensive

Nephrology, 2010.
CKD Screening and Evaluation
Screening Tools: ACR
• Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing
albumin concentration in milligrams by creatinine concentration in
grams.
• Creatinine assists in adjusting albumin levels for varying urine
concentrations, which allows for more accurate results versus
albumin alone.
• Spot urine albumin-to-creatinine ratio for quantification of
proteinuria
• New guidelines classify albuminuria as mild, moderately or
severely increased
• First morning void preferable
• 24hr urine test rarely necessary
Criteria for CKD
• Abnormalities of kidney structure or function,
present for >3 months, with implications for health
• Either of the following must be present for >3
months:
• ACR >30 mg/g
• Markers of kidney damage (one or more*)
• GFR <60 mL/min/1.73 m2

*Markers of kidney damage can include nephrotic syndrome, nephritic syndrome, tubular
syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic
radiologic abnormalities, hypertension due to kidney disease.m²
Old Classification of CKD as Defined by Kidney Disease Outcomes
Quality Initiative (KDOQI) Modified and Endorsed by KDIGO

Stage Description Classificatio Classification

n by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.73 2 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
Classification of CKD Based on GFR and
Albuminuria Categories: “Heat Map”

Kidney Disease: Improving Global Outcomes

(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
CKD Management and the PCP
 Stages in Progression of Chronic Kidney
Disease and Therapeutic Strategies
Complications
Complications

Increased
Increased Kidney
Kidney CKD
CKD
Normal
Normal Damage
Damage  GFR
GFR
risk
risk failure
failure death
death

Screening CKD risk Diagnosis Estimate Replacement

for CKD reduction; & treatment; progression; by dialysis
risk factors Screening for Treat Treat & transplant
CKD comorbid complications;
conditions; Prepare for
Slow replacement
progression
Goals of Care in CKD
• Slow decline in kidney function
• Blood pressure control1
• ACR <30 mg/g: ≤140/90 mm Hg
• ACR 30-300 mg/g: ≤130/80 mm Hg*
• ACR >300 mg/g: ≤130/80 mm Hg
• Individualize targets and agents according to age,
coexistent CVD, and other comorbidities
• ACE or ARB

*Reasonable to select a goal of 140/90 mm Hg, especially for moderate albuminuria (ACR 30-300
mg/g.)2
1) Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. Kidney Int
Suppl. (2012);2:341-342.
Goals of Care in CKD: Glucose Control
• Target HbA1c ~7.0%
• Can be extended above 7.0% with comorbidities or
limited life expectancy, and risk of hypoglycemia
• Risk of hypoglycemia increases as kidney function
becomes impaired
• Declining kidney function may necessitate changes to
diabetes medications and renally-cleared drugs

NKF KDOQI. Diabetes and CKD: 2012 Update.

Am J Kidney Dis. 2012 60:850-856.
Modification of Other CVD Risk
Factors in CKD
• Smoking cessation
• Exercise
• Weight reduction to optimal targets
• Lipid lowering therapy
• In adults >50 yrs, statin when eGFR ≥ 60
ml/min/1.73m2; statin or statin/ezetimibe combination
when eGFR < 60 ml/min/1.73m2
• In adults < 50 yrs, statin if history of known CAD, MI,
DM, stroke
• Aspirin is indicated for secondary but not primary
prevention
Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int
Suppls. 2013;3:1-150.
Detect and Manage CKD Complications
• Anemia
• Initiate iron therapy if TSAT ≤ 30% and ferritin ≤ 500 ng/mL (IV
iron for dialysis, Oral for non-dialysis CKD)
• Individualize erythropoiesis stimulating agent (ESA) therapy:
Start ESA if Hb <10 g/dl, and maintain Hb <11.5 g/dl. Ensure
adequate Fe stores.
• Appropriate iron supplementation is needed for ESA to be
effective
• CKD-Mineral and Bone Disorder (CKD-MBD)
• Treat with D3 as indicated to achieve normal serum levels
• 2000 IU po qd is cheaper and better absorbed than 50,000 IU
monthly dose.
• Limit phosphorus in diet (CKD stage 4/5), with emphasis on
decreasing packaged products - Refer to renal RD
• May need phosphate binders
Detect and Manage CKD Complications
• Metabolic acidosis
o Usually occurs later in CKD
o Serum bicarb >22mEq/L
o Correction of metabolic acidosis may slow CKD progression
and improve patients functional status1,2
• Hyperkalemia
o Reduce dietary potassium
o Stop NSAIDs, COX-2 inhibitors, potassium sparing diuretics
(aldactone)
o Stop or reduce beta blockers, ACEi/ARBs
o Avoid salt substitutes that contain potassium

1) Mahajan, et al. Kidney Int. 2010;78:303-309.

2) de Brito-Ashurst I, et al. J Am Soc Nephrol.
2009;20:2075-2084.
 A Balanced Approach to Nutrition in CKD:
Macronutrient Composition and Mineral Content*

Adapted from DASH (dietary approaches to stop hypertension) diet.

*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.

*(CKD Stages 1-4)

NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-
S179.
Nutrition for CKD
• Water balance
• Calorie (1700-1900 kcal/day)
• Protein restriction
• Low protein intake 0,3-0,5 gram/KgBB/day (non HD)
• Protein 1 gram/KgBB/day (HD)
• No carbohydrate restriction
• Electrolite
• Keto acid
• Medication for CKD patients
Common Medications Requiring Dose
Reduction in CKD
• Allopurinol • Renally cleared beta blockers
• Gabapentin o Atenolol, bisoprolol, nadolol

• CKD 4- Max dose 300mg qd • Digoxin

• CKD 5- Max dose 300mg qod
• Reglan
• Some Statins
o Lovastatin, pravastatin,
• Reduce 50% for eGFR< 40
simvastatin. Fluvastatin,
• Can cause irreversible EPS rosuvastatin
with chronic use
• Narcotics • Antimicrobials
o Antifungals, aminoglycosides,
• Methadone and fentanyl best
Bactrim, Macrobid
for ESRD patients
• Lowest risk of toxic • Enoxaparin
metabolites
• Methotrexate
• Colchicine
Timing the initiation of RRT
• We suggest that dialysis be initiated when one or more of
the following are present: symptoms or signs attributable to
kidney failure (serositis, acid-base or electrolyte
abnormalities, pruritus); inability to control volume status or
blood pressure; a progressive deterioration in nutritional
status refractory to dietary intervention; or cognitive
impairment.
• This often but not invariably occurs in the GFR range
between 5 and 10.
• Living donor preemptive renal transplantation in adults
should be considered when the GFR is < 20, and there is
evidence of progressive and irreversible CKD over the
KDIGO 2012 Clinical Practice Guideline for Chronic Kidney Disease. Kidney
preceding 6–12 months.
International 2013.
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