Chapter 63: Chronic Kidney Disease: Management of Secondary Complications

KEY CONCEPTS

• Chronic kidney disease (CKD) affects many other organ systems leading to secondary complications. The most common complications include fluid and electrolyte disorders, anemia, mineral and bone disorder, metabolic acidosis, and increased incidence of cardiovascular disease.

• 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 complications of CKD.

• Patient education, an interdisciplinary team, and shared decision making play critical roles in the appropriate management of complications of CKD.

• Management of anemia includes administration of erythropoiesis-stimulating agents (ESAs) and regular iron supplementation to maintain the target hemoglobin concentration and prevent the need for blood transfusions. There is a higher risk of cardiovascular events when ESAs are used to target hemoglobin values 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.

• Initiation of statins for primary prevention of hyperlipidemia in patients receiving dialysis is not recommended due to a lack of benefit from randomized controlled trials and meta-analyses, while benefit still may exist in those with non-dialysis dependent CKD.

• CKD-associated pruritus is a secondary complication that significantly affects patients’ quality of life and has limited treatment options. Difelikefalin is a selective kappa opioid receptor agonist with antipruritic effects approved for pruritus in hemodialysis patients and is the only approved treatment option.

Patient Care Process for Secondary Complications of Chronic Kidney Disease (CKD)

Collect

• Patient characteristics (eg, age, sex, CKD stage [see Chapter 62], medication allergies)

• Past medical history

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

• Dietary intake (eg, phosphate-containing foods/sources, iron sources, sodium intake)

• Current medications including OTC medications, herbals, dietary supplements

• Objective data:

  • Blood pressure, heart rate, weight

  • Labs as defined under “Assess”

Assess

• CKD stage (see Chapter 62 for staging criteria)

• Reported symptoms: see Clinical Presentation for signs and symptoms of secondary complications

• Serum potassium concentration—assess frequently in CKD stage 4, 5, and end-stage kidney disease (ESKD)

• Volume status—peripheral and pulmonary edema versus hypovolemia (may need to alter diuretic regimen)

• Hemoglobin concentration (see Table 63-2 for ESA initiation)

• Iron indices (transferrin saturation and ferritin) for patients on an ESA, assess transferrin saturation (TSAT) and ferritin at least every 3 months and assess when clinically indicated (eg, following blood loss)

• Concentrations of calcium, albumin (to calculate corrected calcium), phosphorus, and parathyroid hormone (PTH) (see Table 63-6)

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