Chronic Kidney Disease

CLINICAL DESCRIPTION

Chronic Kidney Disease (CKD) refers to kidney damage of more than 3 months duration. The early stage of CKD is usually asymptomatic but can be detected through laboratory tests of serum creatinine and estimation of Glomerular Filtration Rate (eGFR), measurement of urine albumin creatinine ratio and screening of individuals at increased risk such as those with hypertension, diabetes mellitus or a past history of glomerulonephritis.

Causes:

Chronic hypertension, Chronic glomerulonephritis, Diabetes mellitus, Obstructive uropathy, Renal calculi, Polycystic kidney disease, Toxins (drugs, herbs, heavy metals, etc.), Connective tissue disease

Stages of Chronic Kidney Disease

Stage	Description	eGFR (ml/min/1.73 m²)
1	Kidney damage with normal or increased eGFR	>90
2	Kidney damage with mildly reduced eGFR	60 – 89
3	Moderately reduction in eGFR	30 – 59
4	Severe reduction in eGFR	15 – 29
5	Kidney failure (End-stage kidney disease)	<15

**eGFR – estimated glomerular filtration rate

SIGNS AND SYMPTOMS

None in the early stages, Reduced attention and concentration, Anorexia, nausea, vomiting, Gastrointestinal bleeding, Hiccups, Breathlessness on exertion, Thirst, Nocturia, polyuria, Muscle Cramps, Paraesthesia, Pruritus, Insomnia
Lethargy, Bleeding tendency, Pallor, Hypertension, Pericarditis, Peripheral neuropathy, Peripheral oedema, asterixis (flapping tremor), Increased skin pigmentation and/or excoriation

INVESTIGATIONS

FBC, Sickling, Blood film comment, Urinalysis, Blood Urea, Electrolytes, Serum Creatinine, Calcium, Phosphate, Fasting blood glucose, Lipids, Chest X-ray, Ultrasound of kidney

TREATMENT

To detect chronic kidney disease early in susceptible individuals, To control hypertension, To control blood glucose, To manage underlying causes, To prevent complications and further worsening of kidney function.

NON-PHARMACOLOGICAL TREATMENT:

Avoid nephrotoxins e.g. NSAIDs, herbal medication, Restrict salt intake, Restrict dietary protein to 1 gram/kg/day, Avoid potassium containing foods e.g. bananas, Dialysis (refer to a nephrologist).

PHARMACOLOGICAL TREATMENT:

To control fluid overload
- Furosemide, oral or IV, 40-120 mg 24 hourly
Treatment of hypertension (See section on ‘Hypertension’)
Treatment of renal anaemia (See section on ‘Anaemia in Chronic Kidney Disease’)
Control of hyperkalemia Adult
- Calcium gluconate 10%, IV, 10-20 ml, slow IV, over 2-5 minutes. And then Soluble Insulin, IV, 10 units in 50-100 ml Dextrose 50%, Sodium bicarbonate IV 8.4% (50 mEq in 50ml) 1-2 ml/kg over 5 minutes can be given to control acidosis.

Note: Do not mix calcium gluconate and sodium bicarbonate

Referral Criteria: Refer all patients with predisposing factors and complications to a physician specialist or nephrologist for further definitive management of chronic kidney disease. Refer all patients requiring dialysis to a nephrologist.

CKD Stage	Description	Action
Stage 1	Kidney damage with normal or reduced GFR	Slow progression by meticulous BP control, annual follow up, Urinalysis, and UPCR measurement
Stage 2	Kidney damage with mildly decreased GFR	Estimate progression and manage as Stage 1
Stage 3	Moderately decreased GFR	Estimate and treat complications: If Hb<11, check ferritin, B12 and folate. Annual check of calcium, phosphate and PTH.
Stage 4	Severely decreased GFR	Prepare for kidney replacement therapy
Stage 5	Kidney failure	Kidney replacement therapy: Dialysis or kidney transplant