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21.1 Chronic Kidney Diseases (CKD)

Table of Contents

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

Diagnostic Criteria

Clinical features depend on the stage of renal disease. In advance stage includes:

  • Anorexia
  • Malaise
  • Vomiting
  • Oliguria/Anuria

Investigations

  • Renal function tests (serum creatinine and urea)
  • FBC (HB)
  • Urinalysis (Protein, red blood cells and cast cells)
  • Renal ultrasound

Common causes of chronic kidney disease include:

  • Hypertension
  • Diabetes mellitus
  • Glomerular diseases
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

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

Table 21.1: Staging of kidney disease for adequate management of CKD stage/glomerular filtration rate (ml/minute/1.73)

Description Action Includes actions from preceding stages
Stage 0 or GFR > 90 Increased risks for CKD e.g
– Diabetes mellitus
– Hypertension
– Glomerular disease
– and HIV
– Screening for advanced CKD and CVD disease

– CKD risk reduction i.e. treat hypertension, diabetes and HIV

Stage 1 or GFR >90 Kidney damage with normal GFR – Diagnose and treat comorbid conditions. See for Stage 0
Stage 2 or GFR 60-89 Kidney damage with mild GFR – Refer to determine cause and develop care plan

– While on the care plan, monitor the GFR in these patients and make sure kidney function is not worsening rapidly and watch for stage 3

Stage 3 or GFR 30-59 Moderate GFR Refer
Stage 4 or GFR 15-9 Severe GFR Refer
Stage 5 or GFR < 15 Kidney failure requiring renal replacement therapy

End stage renal disease

Refer

Non-Pharmacological Treatment

  • 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.

Pharmacological Treatment

Adults

C: 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. See Section 20.7: Hypertension

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

B: 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:
    • haematuria,
    • proteinuria
    • raised 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

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