CKD Introduction

1. Background/Introduction a. Introduction • CKD is defined as abnormalities of kidney structure or function lasting >3 months. b. Epidemiology • • • Diabetes and hypertension are leading causes of CKD, especially in developed countries. Aging populations are expected to greatly increase Stage 5 CKD cases by 2030. CKD is most prevalent in individuals over 60 years old, mainly due to reduced eGFR. c. Different types/classifications of the disease • CKD Classifications: o Cause of Kidney Disease CKD is categorized by the underlying cause (e.g., diabetic kidney disease, hypertensive nephrosclerosis, polycystic kidney disease). o Glomerular Filtration Rate (GFR) Categories  G1: ≥90 mL/min/1.73 m² (normal or high)  G2: 60–89 mL/min/1.73 m² (mildly decreased)  G3a: 45–59 mL/min/1.73 m² (mild to moderately decreased)  G3b: 30–44 mL/min/1.73 m² (moderately to severely decreased)  G4: 15–29 mL/min/1.73 m² (severely decreased)  G5: <15 mL/min/1.73 m² (kidney failure or End-Stage Renal Disease) o Albuminuria Categories (based on urinary Albumin-to-Creatinine Ratio, ACR)  A1: <30 mg/g (normal to mildly increased albuminurea)  A2: 30–300 mg/g (moderately increased)  A3: >300 mg/g (severely increased) These classifications (cause, GFR, and albuminuria) guide prognosis, management, and treatment decisions in CKD patients. d. Risk Factors • • • • • Diabetes Hypertension Obesity Smoking Autoimmune diseases 2. Pathophysiology/Etiology Causes: Diabetes mellitus and hypertension Pathophysiology: • • • • • • CKD begins with damage to kidney cells (nephrons) from various causes (like diabetes or high blood pressure). When nephrons are damaged, remaining healthy nephrons have to work harder, causing higher pressure inside the kidneys. This increased pressure (glomerular hypertension) eventually damages more nephrons. Damaged kidneys leak proteins (albumin) into the urine (called proteinuria or albuminuria). These leaked proteins cause inflammation and scarring inside the kidney, further reducing kidney function. Over time, ongoing damage leads to gradual loss of kidney function, eventually progressing toward kidney failure. 3. Signs and Symptoms a. Pertinent labs • Decreased GFR, increased serum creatinine, albuminuria, electrolyte abnormalities, anemia, metabolic acidosis. b. Presenting symptoms • • • Early stages: usually asymptomatic. Stage 3: possible anemia, hypertension. Stages 4–5: edema, fatigue, uremic symptoms, nausea, itching. c. Assessment/diagnostic criteria/tools • • • • Estimated Glomerular Filtration Rate (eGFR): Calculated from serum creatinine. Urine Albumin-to-Creatinine Ratio (ACR): Measures severity of albuminuria. Kidney Failure Risk Equation (KFRE): Predicts progression to kidney failure within 2–5 years based on age, sex, eGFR, and urine tests. Lab Monitoring: CBC, electrolytes (Na, K, bicarbonate), calcium, phosphorus, iron studies, HbA1c, lipid profile. 4. Treatment Pharmacological 1. Blood Pressure Control: • • Goal: Target BP <120 /80 mmHg (KDIGO 2021) First-line treatment: o ACE inhibitors (ACE-I) or Angiotensin Receptor Blockers (ARB)  Indicated if urinary albumin excretion >30 mg/day  Initiate low, titrate to max tolerated dose (target albuminuria reduction by 30– 50%)  Monitor serum creatinine and potassium closely (within 2-4 weeks) o Avoid combinations of ACE-I, ARB, and direct renin inhibitors due to risks. 2. Glycemic Control: • • Target HbA1c individualized (range <6.5–8%) SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) recommended: o For diabetic CKD patients after ACE-I/ARB o Continue until dialysis or transplantation Anemia: • • Iron supplementation, ESA (epoetin alfa, darbepoetin alfa) Target hemoglobin: 9–11.5 g/dL. ii. Non-pharmacological • • • • • • Dietary sodium/phosphate restriction. Physical activity: ≥150 min/week. Smoking cessation, weight loss. Blood pressure and glucose control. Vaccinations: influenza, pneumococcal, hepatitis B. Dialysis or transplant in ESRD. Guideline: - KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease - National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines