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CHRONIC KIDNEY DISEASE
CLINICAL PRACTICE GUIDELINES
PGI Horacio, Mel Patrick A.
Objectives
Topic
1. To define and classify Chronic Kidney disease
2. To identify and predict CKD progression
3. To discuss management of CKD based on CPG
Definition and Classification of CKD
topic
CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health
Criteria for CKD (either of the following present for >3 months)
criteria
Markers of kidney damage (one or more)
- Albuminuria (AER >/=30mg/24hrs)
- Urine sediment abnormalities
- Electrolyte and other abnormalities due to tubular disorders
- Pathologic abnormalities
- Structural abnormalities detected by imaging
- History of kidney transplant
Decreased GFR
- GFR <60ml/min/1.73m2
Staging of CKD
- Classified based on cause, GFR category, and albuminuria category (CGA)
- Assign cause of CKD based on presence or absence of systemic disease and the location within the kidney
- Assign
GFR categories
GFR categories
Albuminuria categories
Prognosis
Pathophysiology of CKD
Pathophysio
of CKD
Mechanisms of kidney damage:
1. Initiating mechanism specific to an underlying etiology
- Abnormalities in kidney development
- Immune complex deposition
- Glomerulonephritis
- Toxin exposure
2. Set of progressive mechanism
- Hyperfiltration and hypertrophy of viable nephrons
Topic
Topic
Topic
Cockcroft-Gault Formula (Creatinine Clearance)
CrCl (male)= [(140-age) x weight in kg]/ (serum creatine x 72)
CrCl (female)= CrCl (male) x 0.85
Topic
Management of progression and complications of CKD
Topic
Prevention of CKD progression
- BP and RAAS interruption
- CKD and risk of AKI
- Protein intake
- Glycemic control
- Salt intake
- Hyperuricemea
- lifestyle
- diet
BP and RAAS interruption
Topic
1. Individualize BP targets and agents according to age, coexistent cardiovascular disease and other comorbidities,
risk of progression of CKD.
2. Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs.
3. Tailor BP treatment regimens in elderly patients with CKD by carefully considering age, comorbidities and
other therapies, with gradual escalation of treatment and close attention
- electrolyte disorders,
- acute deterioration in kidney function
- orthostatic hypotension and
- drug side effects.
4. both diabetic and non-diabetic adults with CKD and with urine albumin excretion of
>/=30 mg/24 hours whose BP is consistently
>140 mm Hg systolic or >90 mm Hg
- maintain a BP that is consistently <140 mm Hg systolic and <90 mm Hg diastolic.
5. both diabetic and non-diabetic adults with CKD and with urine albumin excretion of
>/=30 mg/24 hours (or equivalent*) whose office BP is consistently
- >130 mm Hg systolic or >80 mm Hg
diastolic maintain
- <130 mm Hg systolic and <80 mm Hg diastolic.
6. ARB or ACE-I be used in diabetic adults with CKD and urine albumin excretion 30–300 mg/
24 hours.
7. recommended that an ARB or ACE-I be used in both diabetic and non-diabetic adults with CKD and urine
albumin excretion >/=300 mg/24 hours
8. There is insufficient evidence to recommend combining an ACE-I with ARBs to prevent progression of CKD.
Protein intake
Topic
1. lowering protein intake to 0.8 g/kg/day in adults with diabetes or without diabetes and
GFR <30 ml/min/1.73 m2 (G4-G5), with appropriate education.
2. avoiding high protein intake (41.3 g/kg/day) in adults with CKD at risk of progression.
Topic
Glycemic control
1. a target hemoglobin A1c (HbA1c) of 7.0% (53 mmol/mol) to prevent or delay progression of the microvascular complications of diabetes, including diabetic kidney disease.
2. not to treat an HbA1c target of <7.0% (<53 mmol/mol) in patients at risk of hypoglycemia.
4. In people with CKD and diabetes, glycemic control should be part of a multifactorial intervention strategy
- addressing blood pressure control
- cardiovascular risk
promoting the use of ACEi or ARBs, statins, and antiplatelet therapy.
Salt intake
lowering salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5g of sodium chloride) in adults, unless contraindicated.
Topic
1. restriction of sodium intake for children with CKD who have hypertension or prehypertension
2. supplemental free water and sodium supplements for children with CKD and polyuria to avoid chronic intravascular depletion and to promote optimal growth.
Hyperuricemia
Topic
There is insufficient evidence to support or refute the use of agents to lower serum uric acid concentrations in people with CKD and either symptomatic or asymptomatic hyperuricemia in order to delay progression of CKD.
Lifestyle
Topic
people with CKD be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30 minutes 5 times per week), achieve a healthy weight (BMI 20 to 25), and stop smoking.
Additional dietary advice
Topic
individuals with CKD
- receive expert dietary advice
- education program, tailored to severity of CKD
- the need to intervene on salt, phosphate, potassium, and protein intake.
COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION
- Identification of anemia in CKD
- Evaluation of anemia in people with CKD
Topic
Identification of anemia in CKD
Topic
1. Diagnose anemia in adults and children >15 years with CKD when the Hb concentration is <13.0 g/dl in males and <12.0 g/dl in females.
2. Diagnose anemia in children with CKD if Hb concentration is
- <11.0 g/dl in children 0.5–5 years,
- <11.5 g/dl in children 5–12 years,
- <12.0 g/dl in children 12-15 years.
Evaluation of anemia in people with CKD
Topic
To identify anemia in people with CKD measure Hb concentration
- when clinically indicated in people with GFR >/=60 (G1-G2)
- at least annually in people with GFR 30–59 (G3a-G3b)
- at least twice per year in people with GFR <30 (G4-G5).
CKD METABOLIC BONE DISEASE INCLUDING LABORATORY ABNORMALITIES
Topic
1. measure serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity at least
once in adults with GFR <45 (G3b-G5) to determine
- baseline values
- inform prediction equations
2. not to perform bone mineral density testing routinely in those with eGFR <45
(G3b-G5), as information may be misleading or unhelpful.
3. In people with GFR <45 (G3b-G5), we suggest maintaining serum phosphate
concentrations in the normal range.
4. In people with GFR <45 (G3b-G5) the optimal PTH level is not known.
- first evaluated for hyperphosphatemia, hypocalcemia, and vitamin D deficiency.
Topic
Vitamin D supplementation and bisphosphonates in people with CKD
1. not to routinely prescribe vitamin D supplements or vitamin D analogs, in the absence of suspected or
documented deficiency, to suppress elevated PTH concentrations in people with CKD not on dialysis.
2. not to prescribe bisphosphonate treatment in people with GFR <30 (G4-G5) without a strong clinical rationale.
ACIDOSIS
people with CKD and serum bicarbonate concentrations <22 mmol/l treatment with oral
bicarbonate supplementation be given to maintain within the normal range, unless contraindicated.