Chronic kidney diseases (CKD)
Introduction
It is structural or functional kidney damage present for > 3 months, with or without a decreased glomerular filtration rate (GFR).
Note: A history of diabetes, hypertension or cardiovascular disease confers the highest risk for developing CKD and individuals who have such a history should be screened
Note:
•Chronic kidney disease can be entirely asymptomatic BUT early detection and management can improve the outcome of this condition
•Adults with early CKD i.e. stages 0–3 can all be managed at primary care level once the cause and plan for care has been established. All children should be referred for investigation and initial management
Risk factors
Common causes of chronic kidney disease include:
• Hypertension
• Diabetes mellitus
• Glomerular diseases
Signs and Symptoms
Clinical features depend on the stage of renal disease. In advance stage includes:
• Anorexia
• Malaise
• Vomiting
• Oliguria/Anuria
Diagnostic criteria
• Anorexia
• Malaise
• Vomiting
• Oliguria/Anuria
Investigation
• Renal function tests (serum creatinine and urea)
• FBC (HB)
• Urinalysis (Protein, red blood cells and cast cells)
• Renal ultrasound
Management
The general management of the patient with chronic kidney disease involves the following issues
• Treatment of reversible causes of renal dysfunction
• Preventing or slowing the progression of renal disease
• Treatment of the complications of renal dysfunction
• Identification and adequate preparation of the patient in whom renal replacement therapy will be required
-
Pharmacological
- Adults
• Enalapril 10–20 mg (PO) 12 hourly.
Hyperlipidaemia
If hyperlipidaemia is a co-existent risk factor manage according to section
Diabetes mellitus
• In diabetics, optimise control according to section 9.6: Diabetes mellitus type 2, in adults
• Avoid oral hypoglycaemics if GFR is < 60 because of the risk of lactic acidosis with metformin and prolonged hypoglycaemia with long acting sulphonylureas.
Hypertension
Treat if present as per Hypertension managemenr guideline
Current evidence does not support stricter blood pressure control targets for the majority of patients with CKD [IA]. CKD patients with albuminuria may benefit from tighter control with a target of < 130/80 [IIA].
Fluid overload
Treat fluid overload if present and refer.
Adults
• Furosemide 40–80mg slow I.V or oral, 12 hourly.
If poor response, repeat after 1 hour.
Do not give I.V fluids – use heparin lock or similar I.V access.
Note: Exclude heart failure in patients with persistent pedal oedema.
Referral to nephrologist
• All cases of suspected chronic kidney disease stages 3–5 for assessment and planning
• All children
• All cases of CKD with:
oHaematuria,
oProteinuria
oRaised blood urea or creatinine initially for assessment and planning
• Uncontrolled hypertension/fluid overload
• CKD associated with hyperlipidaemia
• No resolution of proteinuria with ACE-I therapy
Note: Patients who might qualify for dialysis and transplantation or who have complications should be referred early to ensure improved outcome and survival on dialysis, i.e. as soon as GFR drops below 30 mL/min/1.73 m2, or as soon as diagnosis is made/suspected
-
Non-pharmacological
- • Reduce salt intake.
• Low protein diet (not exceed 1g/kg per day) is indicated in the presence of CKD stage 4 and 5. (Evidence)
• Reduce cardiovascular disease risk factors – See section: Prevention of ischaemic heart disease and atherosclerosis.
• Treat underlying conditions.
• Decrease significant proteinuria, if present.
Significant proteinuria = spot urine protein creatinine ratio of > 0.1 g/mmol or ACR (albumin-creatinine ratio) > 100 g/mol, confirm as positive if raised on at least 2 of 3 occasions, in the absence of infection, cardiac failure and menstruation.
Proteinuria
• In established chronic kidney disease, decrease proteinuria, irrespective of presence or absence of systemic hypertension.
• Monitor renal function and potassium especially with impaired renal function.
• If volume depleted, first rehydrate before commencing ACE-inhibitor.
• ACE-inhibitor are contraindicated in:
Hyperkalaemia
known allergy to ACE-inhibitor
Begin with low dosage of ACE-inhibitor and titrate up ensuring blood pressure remains in normal range and no side effects are present, up to the maximum dose or until the proteinuria disappears – whichever comes first.
Prevention
Updated on,
23 Novemba 2020 11:43:15
References
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