Pathogenesis
Causes of Chronic Kidney Disease
- Diabetic nephropathy
- Hypertensive nephropathy
- Glomerulonephritis
- Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
- Congenital disease - polycystic kidney disease
Manifestations
Complications of Chronic Kidney Disease
Disease-Related
- Acidosis (poor clearance of hydrogen ions)
- Fluid overload
- Electrolyte derangements - hyperkalaemia, hyperphosphataemia
- Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
- Anaemia (EPO deficiency)
- Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
- Uraemia - encephalopathy, uraemic pericarditis
- Malnutrition
Treatment-Related
- Lethargy
- Muscle cramps
- Restless legs syndrome
- Access-related complications - thrombosis, infection
Diagnosis
Signs of Chronic Kidney Disease
General Signs
- Sallow complexion
- Leukonychia
- Sarcopaenia
Signs Suggesting a Cause
- Finger prick markings (diabetes)
- Palpable polycystic kidneys
Signs of Complications
- Acidosis - tachypnoea
- Fluid overload - hypertension, raised JVP, sacral / pedal oedema, pulmonary crepitations
- Anaemia - palmar crease pallor, conjunctival pallor
- Uraemia - scratch marks, confusion, asterixis, pericardial rub
Signs of Management
- Haemodialysis - VasCath, arteriovenous fistula, graft
- Peritoneal dialysis - Tenkhoff catheter
- Scars - nephrectomy, renal transplant, parathyroidectomy
- Palpable renal transplant (usually right lower quadrant)
Stages of Chronic Kidney Disease
GFR Categories (mL/min/1.73m²)
- G1 - ⩾90
- G2 - 60-89
- G3a - 45-59
- G3b - 30-44
- G4 - 15-29
- G5 - <15
Albuminuria Categories
- A1 - <30mg/g / <3mg/mmol
- A2 - 30-300mg/g / 3-30mg/mmol
- A3 - >300mg/mg / >30mg/mmol
Management
Management Strategies
Slow Progression
- Treat the cause of CKD - e.g. diabetes, hypertension
- ACE inhibitors - captopril, perindopril, ramipril
- Angiotensin II receptor blockers - candesartan, irbesartan, telmisartan
Treat Complications
- Acidosis - consider sodium bicarbonate
- Fluid overload - fluid restriction, salt restriction
- Anaemia - iron replacement if required, consider EPO
- Cardiovascular disease - control hypertension, statin, consider aspirin
- Mineral bone disease - dietary phosphate restriction, phosphate binders (calcium / non-calcium-based), calcitriol, parathyroidectomy
- Malnutrition - high protein intake
Other
- Dialysis - consider when to start and what modality
- Renal transplant - consider suitability
Most patients with chronic kidney disease will die due to cardiovascular disease, so it is important to manage the risk factors of this.
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