Chapter 61: Chronic Kidney Disease

KEY CONCEPTS

• Chronic kidney disease (CKD) is classified based on the cause of kidney disease, assessment of glomerular filtration rate, and extent of albuminuria over at least a 3-month period.

• The most common causes of CKD 5D (requiring dialysis or kidney transplantation), often called end-stage renal disease (ESRD), are diabetes mellitus and hypertension.

• Anemia of CKD is multifactorial with loss of erythropoietin synthesis by the kidney, iron deficiency, and chronic inflammation all implicated.

• CKD-mineral and bone disorder (CKD-MBD) includes abnormalities in parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), phosphorus, calcium, vitamin D, and bone turnover, and contributes to soft-tissue and extravascular calcifications.

• Guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) provide information to assist healthcare providers in clinical decision making and the design of appropriate therapy to manage CKD progression and the associated complications.

• Patient education and shared decision making play a critical role in the appropriate management of patients with CKD and its associated complications. A high functioning multidisciplinary team structure for patients at high risk of progression to ESRD is preferred to effectively design and implement the recommended nonpharmacologic and pharmacologic interventions.

• Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are primary pharmacologic treatments to delay progression of CKD because of their effects on renal hemodynamics to reduce intraglomerular pressure and proteinuria.

• Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are emerging as potential agents to prevent progression to later stages of CKD and ESRD and these effects seem to be independent of glucose lowering.

• Management of anemia includes administration of erythropoiesis-stimulating agents (ESAs) (eg, epoetin alfa, epoetin alfa-epbx, darbepoetin alfa, methoxy polyethylene glycol-epoetin beta) and regular iron supplementation to maintain hemoglobin concentration and prevent the need for blood transfusions. There is a higher risk of cardiovascular events when hemoglobin is targeted to a value of greater than 11 g/dL (110 g/L; 6.83 mmol/L).

• Management of CKD-MBD includes dietary phosphorus restriction, phosphate-binding agents, activated vitamin D supplementation, and calcimimetic therapy to achieve KDIGO targets.

• Although statins are not recommended for primary prevention of hyperlipidemia in patients receiving dialysis, they are indicated for primary prevention in those with nondialysis dependent CKD.

Patient Care Process for Chronic Kidney Disease (CKD)

Collect

• Patient characteristics (eg, age, sex, CKD stage [see Fig. 61-1] and cause of CKD, medication allergies)

• Past medical history

• Social history (eg, smoking), family/friend supports

• Current medications including OTC (eg, NSAID use), herbals, dietary supplements

• Objective data:

  • Blood pressure, heart rate, weight

  • Labs as outlined in ‘Clinical Presentation’.

Assess

• Serum creatinine, glomerular filtration rate (GFR), or creatinine clearance

• Presence of albuminuria (see Fig 61-1 and )

• Serum potassium concentration—assess frequently in patients with CKD and heart failure requiring adjustment of diuretics and/or ACE inhibitors

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