CHRONIC KIDNEY DISEASE

Chronic impairment of kidney function

Causes/risk factors

  • Diabetes mellitus
  • Hypertension/cardiovascular disease
  • Age >50 years
  • Kidney stones
  • Drugs especially pain killers like diclofenac, ibuprofen and
    other NSAIDs
  • Family history of kidney disease
  • HIV/AIDS

Clinical features

  • Most patients with CKD have no symptoms until the disease is advanced
  • May present with features of predisposing risk factor
  • Anaemia, lethargy, easy fatigue, appetite loss, nausea, vomiting, skin itching, bone pains
  • May have body swelling
  • May have loin pain

Differential diagnosis

  • Other causes of chronic anaemia
  • Heart failure
  • Protein-energy malnutrition
  • Chronic liver disease

Investigations

  • Creatinine/Urea/electrolytes
  • Urine dip stick for protein and blood
  • Kidney ultrasound

How to screen for CKD in patient at risk

  • Urine dipsticks (for protein and blood) and blood pressure measurement at least once a year in high risk patients
  • In diabetics, urine microalbumin where possible or a spot  urine for protein: creatinine ratio at least once a year
  • Patients with detected abnormalities should have a serum creatinine test performed and GFR calculated as suggested above

Refer the following patients for specialist attention:

  • Children
  • Persistent proteinuria or haematuria beyond 3 months
  • GFR <60 ml/min or creatinine >1.9 mg/dl
  • Familial kidney disease, e.g. polycystic kidney disease

Management

Treatment of end stage renal disease is complex and expensive, and available only at national referral hospital.

Goals

  • Establish diagnosis and treat reversible diseases
  • Identify co-morbid conditions and manage further complications of CKD
  • Slow progression of CKD by optimizing treatment
  • Plan renal replacement therapy well before end stage kidney disease is reached

Treatment to preserve kidney function in patients with CKD

  • Lifestyle modifications: Weight loss, stop smoking, exercise, healthy balanced diet, lipid
    control, salt restriction
  • Blood pressure control: Target 130/80 mmHg (lower in children). Use ACE inhibitors as first
    line antihypertensives for diabetics and patients with proteinuria, plus low salt diet
  • In diabetics: BP control is paramount
  • Optimal blood sugar control (HbA1C <7%)
  • Proteinuria: Reduce using ACE inhibitors and/or ARBs; target < 1 g/day
  • Avoid nephrotoxic medicines, e.g. NSAIDs, celecoxibs, aminoglycosides, contrast agents

Prevention of complications

  • Anaemia: due to multiple causes. Consider iron and folic supplements. Target Hb 11-12 gr/dL
  • Bone mineral disease: consider adding calcium lactate or other calcium/vitamin D supplements

Treatment of symptoms

  • If fluid retention/oliguria, furosemide tablet according to response (high doses may be necessary)
  • Dialysis for end stage cases
Caution
  • Start ACE inhibitors at low doses and monitor renal function carefully. DO NOT use in advanced chronic
    disease

Prevention

  • Screening of high risk patients
  • Optimal treatment of risk factors
  • Treatments to slow progression in initial phases
  • Avoidance of nephrotoxic drugs