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1. CHRONIC KIDNEY DISEASE 29 TH JULY 2022 BY: DR. LUCY MURUGARA

2. SCOPE Epidemiology Definition Classification Causes Risk factors Complications Prevention diagnosis Management of CKD Progression & Complications

3. EPIDEMILOGY Chronic kidney disease (CKD) has been recognized as a leading public health problem worldwide . The global estimated prevalence of CKD is 13.4% (11.7-15.1%), and patients with end-stage kidney disease (ESKD) needing renal replacement therapy is estimated between 4.902 and 7.083 million. Through its effect on cardiovascular risk and ESKD, CKD directly affects the global burden of morbidity and mortality worldwide . The global increase in this disease is mainly driven by the increase in the prevalence of diabetes mellitus, hypertension, obesity, and aging. But in some regions, other causes such as infection, herbal and environmental toxins are still common. In US, More than 1 in 7, that is 15% of US adults or 37 million people, are estimated to have CKD . As many as 9 in 10 adults with CKD do not know they have CKD. About 2 in 5 adults with severe CKD do not know they have CKD. The large number of deaths is due to poor access to renal replacement therapy in developing countries

4. D efinition C hronic kidney disease is defined as the presence of kidney damage (usually detected as urinary albumin excretion of ≥30 mg/day or equivalent) or decreased kidney function (defined as estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) for three or more months, irrespective of the cause.

5. staging The stages of CKD are classified as follows : Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m 2) Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m 2) Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m 2) Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m 2) Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m 2) Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m 2 or dialysis)

6. Albuminuria categories

7. GFR and albuminuria levels are also used when evaluating risks for overall mortality, cardiovascular disease, end-stage kidney failure, acute kidney injury, and the progression of CKD. Patients with CKD should be referred to a nephrologist when the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m2 in order to discuss and potentially plan for kidney replacement therapy

8. Assess GFR and albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression, and/ or where measurement will impact therapeutic decisions. (Not Graded Define CKD progression based on one or more of the following: Decline in GFR category (≥90 [G1], 60-89 [G2], 45-59 [G3a], 30-44 [G3b], 15-29 [G4], <15 [G5] ml/min/1.73m2). A certain drop in eGFR is defined as a drop in GFR category accompanied by a 25% or greater drop in eGFR from baseline. Rapid progression is defined as a sustained decline in eGFR of more than 5 mL/1.73m2/year. The confidence in assessing progression is increased with increasing number of serum creatinine measurements and duration of follow-up.

9. causes Diseases and conditions that cause chronic kidney disease include: Type 1 or type 2 diabetes High blood pressure Glomerulonephritis , an inflammation of the kidney's filtering units (glomeruli) Interstitial nephritis, an inflammation of the kidney's tubules and surrounding structures Polycystic kidney disease or other inherited kidney diseases Prolonged obstruction of the urinary tract e.g. in enlarged prostate, kidney stones and some cancers Vesicoureteral reflux, a condition that causes urine to back up into your kidneys pyelonephritis

10. Risk factors Factors that can increase your risk of chronic kidney disease include: Diabetes High blood pressure Heart (cardiovascular) disease Smoking Obesity Being Black, Native American or Asian American Family history of kidney disease Abnormal kidney structure Older age Frequent use of medications that can damage the kidneys

11. complications Fluid retention (Anarsaca, high blood pressure, pulmonary edema) hyperkalemia Anemia Heart disease Weak bones and an increased risk of bone fractures Low libido, erectile dysfunction or reduced fertility CNS - difficulty concentrating, personality changes or seizures Decreased immune response, which makes you more vulnerable to infection, malignancy Pericarditis Pregnancy complications end-stage kidney disease D eath

12. prevention To reduce the risk of developing kidney disease: Follow instructions on over-the-counter medications or a prescribed by doctor Maintain a healthy weight. Don't smoke. Manage your medical conditions with your doctor's help, If you have diseases or conditions that increase your risk of kidney disease,

13. Signs and symptoms Patients with CKD stages 1-3 are generally asymptomatic, if symptomatic, they are often non-specific Nausea Vomiting Loss of appetite Fatigue and weakness Sleep problems Urinating more or less Decreased mental sharpness Muscle cramps Swelling of feet and ankles Dry, itchy skin High blood pressure (hypertension) that's difficult to control Shortness of breath, if fluid builds up in the lungs Chest pain, if fluid builds up around the lining of the heart

14. Signs and symptoms Signs of metabolic acidosis in stage 5 CKD include the following: Protein-energy malnutrition Loss of lean body mass Muscle weakness Signs of alterations in the way the kidneys are handling salt and water in stage 5 include the following: Peripheral edema Pulmonary edema Hypertension

15. Anemia in CKD is associated with the following : Fatigue Reduced exercise capacity Impaired cognitive and immune function Reduced quality of life Development of cardiovascular disease New onset of heart failure or the development of more severe heart failure Increased cardiovascular mortality

16. Other manifestations of uremia in ESRD : Pericarditis Encephalopathy: Peripheral neuropathy, usually asymptomatic Restless leg syndrome Gastrointestinal symptoms: Anorexia, nausea, vomiting, diarrhea Skin manifestations: Dry skin, pruritus, ecchymosis Fatigue, increased somnolence, failure to thrive Malnutrition Erectile dysfunction, decreased libido, amenorrhea Platelet dysfunction with tendency to bleeding

17. Diagnosis History and physical examination Complete blood count (CBC) Basic metabolic panel – U/E/Cs, eGFR Urinalysis Serum albumin levels Lipid profile Serum calcium and phosphate 25-hydroxyvitamin D Alkaline phosphatase Intact parathyroid hormone (PTH) levels

18. Others Serum and urine protein electrophoresis and free light chains: Screen for a monoclonal protein possibly representing multiple myeloma Antinuclear antibodies (ANA), double-stranded DNA antibody levels: Screen for systemic lupus erythematosus Serum complement levels: Results may be depressed with some glomerulonephritides Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody (C-ANCA and P-ANCA) levels: Positive findings are helpful in the diagnosis of granulomatosis with polyangiitis (Wegener granulomatosis); P-ANCA is also helpful in the diagnosis of microscopic polyangiitis Anti–glomerular basement membrane (anti-GBM) antibodies: Presence is highly suggestive of underlying Goodpasture syndrome Hepatitis B and C, human immunodeficiency virus (HIV), Venereal Disease Research Laboratory (VDRL) serology: Conditions associated with some glomerulonephritides

19. Imaging studies Renal U/S: Useful to screen for hydronephrosis, which may not be observed in early obstruction or dehydrated patients; or for involvement of the retroperitoneum with fibrosis, tumor, or diffuse adenopathy; small, echogenic kidneys are observed in advanced kidney failure pyelography: useful in cases with high suspicion for obstruction despite negative renal ultrasonograms, for diagnosing renal stones CT scan: Useful to better define renal masses and cysts usually noted on ultrasonograms; also the most sensitive test for identifying kidney stones MRI: Useful in patients who require a CT scan but who cannot receive intravenous contrast; reliable in the diagnosis of renal vein thrombosis Renal radionuclide scanning: Useful to screen for renal artery stenosis when performed with captopril administration; also quantitates the renal contribution to the GFR

20. Biopsy indications kidney impairment and/or proteinuria approaching the nephrotic range diagnosis is unclear after appropriate workup

21. management General management of the patient with CKD involves the following issues Treatment of reversible causes of kidney failure Preventing or slowing the progression of kidney disease Treatment of the complications of kidney failure Adjusting drug doses when appropriate for the level of estimated glomerular filtration rate (eGFR) Identification and adequate preparation of the patient in whom kidney replacement therapy will be required Management of CKD requires a multidisciplinary approach.

22. Management of CKD complications Anemia : When the hemoglobin level is below 10 g/dl, treat with erythropoiesis-stimulating agents (ESAs), which include epoetin alfa and darbepoetin alfa after iron saturation and ferritin levels are at acceptable levels Hyperphosphatemia: Treat with dietary phosphate binders and dietary phosphate restriction Hypocalcemia : Treat with calcium supplements with or without calcitriol Hyperparathyroidism : Treat with calcitriol or vitamin D analogues or calcimimetics Hypertension i s present in approximately 80 to 85% of patients with CKD. ACEIs & ARBs are recommended

23. H yperlipidemia - Use statins Fluid overload : Treat with loop diuretics or ultrafiltration Metabolic acidosis : Treat with oral alkali supplementation e.g. sodium bicarbonate Uremic manifestations : Treat with long-term renal replacement therapy (hemodialysis, peritoneal dialysis, or renal transplantation

24. Infection and vaccination — Patients with CKD are at increased risk for infection that increases with the decline in kidney function( P ul’ &GUT). Vaccination is important 2012 KDIGO guidelines Adults with all stages of CKD should be offered annual vaccination with influenza virus unless contraindicated. Adults with stage 4 and 5 CKD who are at high risk of progression of CKD should be immunized against hepatitis B and the response confirmed by immunologic testing. Adults with CKD stages 4 and 5 should be vaccinated with polyvalent pneumococcal vaccine unless contraindicated. Patients who have received pneumococcal vaccination should be offered revaccination within five years. REFERRAL TO A NEPHROLOGISTS Patients with CKD should be referred to a nephrologist when the estimated glomerular filtration rate ( eGFR ) is <30 mL/min/1.73 m2 in order to discuss and potentially plan for kidney replacement therapy

25. Indications for renal replacement therapy include the following : Severe metabolic acidosis Hyperkalemia Pericarditis/ Pleuritis (URGENT) Encephalopathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe, cases, seizures(URGENT) Intractable volume overload Hypertension poorly responsive to antihypertensive medications

26. Failure to thrive and malnutrition Persistent nausea and vomiting Peripheral neuropathy A clinically significant bleeding diathesis attributable to uremia (urgent indication). In asymptomatic patients, a GFR of 5-9 mL/min/1.73 m², irrespective of the cause of the CKD or the presence or absence of other comorbidities Relative indications for the initiation of dialysis include decreased attentiveness and cognitive tasking, depression, persistent pruritus, or the restless leg syndrome

27. Dialysis should be initiated in the patient with symptoms and/or signs due to uremia. To help avoid the onset of possible life-threatening complications of uremia, dialysis should be initiated in the asymptomatic patient with an extremely low eGFR, such as an eGFR of approximately 8 to 10 mL/min/1.73 m2

28. Replacement therapy The 2015, KDOQI guidelines recommend that patients with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 should be educated on replacement therapy Replacement therapy: hemodialysis, peritoneal dialysis and renal transplant Kidney transplantation is the treatment of choice for ESKD . Patient declining replacement therapy should be offered conservative management ( KDIGO, 2012 ). Conservative care includes the management of symptoms, advance-care planning, and provision of appropriate palliative care There are three major types of vascular access for maintenance hemodialysis: primary arteriovenous (AV) fistulas, AV grafts, and tunneled hemodialysis catheters

29. Arteriovenous fistulas AVFs are the preferred form of vascular access given their significantly higher long-term patency rates and lower rate of complications (infections). A well-constructed radial cephalic fistula that functions for the first six months can be expected to function for up to 20 years. routinely The patient should be instructed on the care of the fistula e.g. checking for a thrill and notifying the nephrologist if this is not present. The arm that has the fistula should not be used for blood drawing or for blood pressure checks. Patients should avoid sleeping on the access arm, avoid tight clothing on the access, and not carry anything that weighs more than 5 pounds with that arm . The fistula should be regularly examined by a clinician

30. Arteriovenous grafts AV grafts are constructed by interposing a graft between an artery and vein, most commonly polytetrafluoroethylene (PTFE). provide excellent vascular access in patients who have inadequate vascular anatomy to support an AV fistula . AV grafts have a higher long-term complication rate ( eg , infection, thrombosis) compared with primary fistulas. patient should be instructed in the care of the AV graft The graft should be regularly examined by a clinician.

31. Tunneled hemodialysis catheters This can be used immediately after placement (in the right internal jugular vein). A re primarily used as intermediate-duration vascular access during maturation of AV fistulas. They can also provide acceptable long-term access in patients with contraindications to AV access or those who have exhausted all available sites. A re inferior to AV access, they provide lower flows and have higher rates of infection and other complications.

32. P eritoneal dialysis Catheters are placed into the abdominal cavity can be used immediately after placement . However, to minimize the risk of fluid leak, it is preferable to wait at least 10 to 14 days before beginning dialysis . If dialysis is required less than 10 days following catheter placement, small volume exchanges performed in the recumbent position can be performed with little risk of leak

33. Dietary recommendations in CKD CARBOHYDRATES If your provider has recommended a low-protein diet, you may replace the calories from protein by eating carbohydrates PROTEINS - a low-protein is recommended FATS -Fats can be a good source of calories. Use monounsaturated and polyunsaturated fats (olive oil, canola oil, sunflower oil)

34. CALCIUM AND PHOSPHOROUS Hyperphosphatemia in CKD leads to hypocalcemia Patient is advised to limit phosphorus intake by limiting dairy foods e.g. yogurt, and cheese. calcium supplements may be require to prevent bone disease, and vitamin D to control the balance of calcium and phosphorous in your body. "phosphorous binders" may be recommended if diet changes alone do not work to control the balance of this mineral in your body.

35. FLUIDS No fluid limitation is required in the early stages of CKD. In advanced stages and when on dialysis, patient needs to watch the amount of liquid he/she takes in. Take fluids as recommended Patient should Keep a count of foods that contain a lot of water, such as soups, fruit-flavored gelatin, fruit-flavored ice pops, ice cream, grapes, melons, lettuce, tomatoes, and celery. Use smaller cups or glasses and turn over your cup after you have finished it. Tips to keep from becoming thirsty include: Avoid salty foods Freeze some juice in an ice cube tray and eat it like a fruit-flavored ice pop (you must count these ice cubes in your daily amount of fluids) Stay cool on hot days

36. SALT OR SODIUM Sodium intake reduction helps control high blood pressure. It also keeps you from being thirsty, and prevents your body from holding onto extra fluid. When buying foods look for these words on food labels: Low-sodium, No salt added, Sodium-free, Sodium-reduced, Unsalted Check all labels to see how much salt or sodium foods contain per serving. Also, avoid foods that list salt near the beginning of the ingredients. Look for products with less than 100 milligrams (mg) of salt per serving. DO NOT use salt when cooking and take the salt shaker away from the table. Most other herbs are safe, and you can use them to flavor your food instead of salt. DO NOT use salt substitutes because they contain potassium. People with CKD also need to limit their potassium .

37. POTASSIUM Hyperkalemia is associated with arrhythmias – death. Fruits and vegetables contain large amounts of potassium, and for that reason should be avoided or chosen carefully to maintain a healthy heart. Fruits: Choose peaches, grapes, pears, apples, berries, pineapple, plums, tangerines, and watermelon Limit or avoid oranges and orange juice, nectarines, kiwis, raisins or other dried fruit, bananas, cantaloupe, honeydew, prunes, and nectarines Vegetables: Choose broccoli, cabbage, carrots, cauliflower, celery, cucumber, eggplant, green and wax beans, lettuce, onion, peppers, watercress, zucchini, and yellow squash Limit or avoid asparagus, avocado, potatoes, tomatoes or tomato sauce, winter squash, pumpkin, and cooked spinach

38. IRON anemia in KF requires extra iron. Sources of iron - liver, beef, pork, chicken, lima and kidney beans, iron-fortified cereals.

39. DIETARY RECOMMENDATIONS FOR ADULT PATIENTS WITH CHRONIC RENAL FAILURE WHO ARE NOT ON DIALYSIS Nutrient Recommendation Protein 0.6–0.8 g/kg/day Calories 35 kcal/kg/day Phosphorus 0.8–1.2 g/day Calcium 1.2–1.6 g/day Sodium 1–3 g/day Potassium < 60 mEq/day (restricted if serum potassium level is elevated or urinary output is <1 L/day)

40. DIETARY RECOMMENDATIONS FOR ADULTS WITH END-STAGE RENAL DISEASE ON DIALYSIS Nutrient Recommendation for Hemodialysis Recommendation for Peritoneal Dialysis Protein 1.1–1.4 g/kg/day 1.2–1.5 g/kg/day Calories 30–35 kcal/kg/day 25–35 kcal/kg/day Phosphorus < 17 mg/kg/day < 17 mg/kg/day Calcium 1.0–1.8 g/day 1.0–1.8 g/day Fluid Daily urinary output + 500–750 mL/day 2–3 L/day based on weight and blood pressure Sodium 2–3 g/day 3–4 g/day based on weight Potassium 40 mg/kg Unrestricted unless elevated

41. REFERENCES Uptodate, overview of chronic kidney disease https :// www.uptodate.com/contents/overview-of-chronic-kidney-disease- https:// www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521 KDIGO CKD GUIDELINES, 2014. American Dietetic Association. Manual of Clinical Dietetics. 6th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2000.