CKD staging - GFR
- mL/min/1.73m^2
- G1: normal/increased: > 90
- G2: mildly decreased: 60-89
- G3a: mild-mod decrease: 45-59
- G3b: mod-severe decrease: 30-44
- G4: severe decrease: 15-29
- G5 kidney failure: < 15
CKD staging - Albuminuria
- A1: normal/slightly increased: < 30 mg/g
- A2: moderate increase: 30-300 mg/g
- A3: severe increase: > 300mg/g
- mg/mmol X 10 = mg/g
CKD staging - categories w GFR + Albuminuria
- low risk: G1A1, G2A1
- moderate risk: G1A2, G2A2, G3aA1
- high risk: G1A3, G2A3, G3aA2, G3bA1
- the rest very high risk
causes of CKD
- common: DM, glomerulonephritis (kidney inflammation), HTN
- others: urinary obstruction (stone), chronic infection (pyelonephritis), immune/vascular disease, genetic disorder (polycystic kidney disease), drug, HIV-associated nephropathy (HIVAN)
clinical presentation of CKD
. uremic signs
- fatigue, weakness, SOB, mental confusion, N/V, bleeding, loss of appetite, itching, cold intolerance, weight loss, nephropathy, uremic breath (smell like pee)
. signs
- oedema, change in urine output, abdominal distention, pericardial rub (abnormal sound produced from friction between heart and pericardium), asterixis (flapping tremor)
. lab values
- increase in: SCr, urea, K, P, PTH, BP, glucose, lipid, Ca (if on Vit D therapy)
- decrease in GFR, CrCl, CO2 (metabolic acidosis), Hgb (Anaemia), Iron store (Deficiency), Vit D, Ca (Early stage), HDL, albumin (malnutrition)
CKD complications - CVS - risk factors
traditional: age, gender, smoking, DM, HTN, dyslipidemia
non-traditional: malnutrition, uremic toxin, inflammation (increase CRP, IL-6), oxidative stress (increased oxidised LDL), vascular calcification (increase Ca, P, PTH, Ca x P, homocysteine, lipoprotein, fibrinogen)
CKD complication - CVS - HTN - treatment goals
1) X/mild albuminuria (< 30mg/g): </= 140/90
2) mod/severe albuminuria (> 30mg/g): </= 130/80
CKD complication - CVS - HTN - management
1) ACEi/ARB
- titrate to highest possible dose
- SE: hypotension, renal function, hyperkalemia, dry cough, angioodema
- STOP if SCr increase > 30% within 4 wks of initiating/change dose or Serum K > 5.5 mmol/L (X absolute clearance so monitor diet)
- X use if pregnant, allergic, dry cough, history of angioedema
2) diuretics
- useful for: decrease extracellular volume, decrease BP, decrease hyperkalemia effect of ACEi/ARB
- over diuresis worsen renal function
- thiazide (mild, need renal func), loop (Advanced, more potent)
3) BB
- atenolol, bisoprolol renally eliminated, need adjust dose
- carvedilol, metoprolol more cardio selective
4) CCB
- DHP CCB SE: peripheral oedema, flushing, HA
- non DHP SE: less potent BP reduction, reduce angioedema
5) direct acting vasodilators
- SE: tachycardia, fluid retention
6) alpha blockers
- good for patient w BPH
- SE: postural hypotension
CKD complication - CVS - Dyslipidemia
- especially for patient w nephrotic syndrome (protein excretion > 3.5 mg/day): body compensate by producing more lipoprotein = increase LDL
- statin therapy
1) adult > 50 yo + eGFR < 60: Statin +/- ezetimibe
2) adult > 50 yo + eGFR > 60: statin
3) adult dialysis: no statin +/- ezetimibe
4) Adult CKD + high TG: TLC, no fibrate - DI: macrolide antibiotics (clarithromycin), cyclosporin, colchine (gout), amlodipine (w simvastatin)
- no fibrate unless TG > 11.3 mmol/L, fenofibrate associated w increase SCr
CKD complications - CVS - others
- atherosclerosis
- vascular calcification: increase Ca, P, PTH, Ca X P, homocysteine, lipoprotein, fibrinogen
- HF: underlying disease, fluid overload
- pericarditis: secondary to uremia/fluid overload, emergency dialysis
slowing down CKD complication progression - SGLT2i - MOA
- reduce glucose reabsorption in proximal tubule through SGLT2
- reduce renal glucose threshold = glycosuria
slowing down CKD complication progression - SGLT2i - requirements
. CKD (eGFR < 20) with
- type 2 DM
- non DM w albuminuria >/= 200-300mg/day
. eGFR > 20, continue if albuminuria drop below 20, stop if intolerant/start dialysis
slowing down CKD complication progression - SGLT2i - efficacies
- more effective if albumin-Cr ration >/= 200mg/day
- less effective in less severe albuminuria
slowing down CKD complication progression - SGLT2i - benefits
- kidney & CV protection (DM/non DM)
- calories lost cuz of glycosuria = weight loss
- osmotic diuresis & modest direct natriuretic effect
- reduced glomerular hyperfiltration (tubuloglomerular feedback)
- reduction in development/worsening albuminuria
- potential role in eGFR lower than expectations to achieve relevant HbA1c reduction
slowing down progression of CKD - SGLT2i - potential CI
- genital infection risk, diabetic ketoacidosis, foot ulcer, immunosuppression
- reversible drop in eGFR after initiation but doesn’t mean discontinuation
- don’t apply to kidney transplantation (txp) patient
