Chronic kidney disease (CKD) is a medical condition characterized by the gradual loss of kidney function over time. It is a progressive disease that can lead to end-stage kidney disease if left untreated. The kidneys play a vital role in filtering waste products from the blood, regulating fluid and electrolyte balance, and producing hormones that regulate blood pressure and red blood cell production. CKD is associated with a range of risk factors, including diabetes, hypertension, and obesity, and it can have a significant impact on a person’s quality of life. Management of CKD typically involves a combination of lifestyle modifications, medication, and medical interventions.
Epidemiology
Prevalence: CKD affects approximately 10% of the global population. The prevalence of CKD varies by country and by population subgroup, but it tends to be higher in older individuals and those with comorbidities like hypertension and diabetes.
Incidence: The incidence of CKD is increasing, and it is estimated that CKD will be one of the leading causes of death worldwide by 2040. The incidence of CKD is higher in certain ethnic groups, such as African Americans, Native Americans, and Hispanic Americans.
Mortality: The mortality rate in CKD patients is high, with an increased risk of cardiovascular disease, infection, and malignancy. Mortality rates increase with advancing stages of CKD.
Economic burden: The economic burden of CKD is significant, with costs related to medical care, dialysis, transplantation, and loss of productivity. The cost of CKD is highest in the advanced stages of the disease.
Risk factors: Risk factors for CKD include diabetes, hypertension, obesity, smoking, and family history of kidney disease.
Anatomy
Pathophysiology
The pathophysiology of CKD involves a complex interplay of various factors that contribute to the development and progression of the disease.
Renal Blood Flow and Glomerular Filtration Rate (GFR): In CKD, there is a decrease in renal blood flow due to the progressive loss of nephrons. This results in a decrease in GFR, which is the primary measure of kidney function. As the GFR declines, there is a reduction in the ability of the kidneys to excrete waste products and maintain fluid and electrolyte balance.
Inflammation: Inflammation plays a significant role in the pathophysiology of CKD. The initial insult to the kidneys, such as diabetes or hypertension, triggers an inflammatory response that leads to the destruction of renal tissue. The immune system also contributes to the inflammatory process by releasing cytokines and chemokines that further damage the kidneys.
Fibrosis: In response to injury, the kidneys undergo a process of fibrosis, which involves the accumulation of extracellular matrix (ECM) proteins such as collagen. This results in the formation of scar tissue, which impairs the function of the kidneys.
Oxidative Stress: CKD is associated with increased oxidative stress, which is caused by an imbalance between reactive oxygen species (ROS) and antioxidant defenses. ROS can damage cellular structures and impair renal function.
Endothelial Dysfunction: Endothelial dysfunction is a common feature of CKD, characterized by impaired vasodilation and increased vascular resistance. This contributes to the reduction in renal blood flow and the progression of the disease.
Electrolyte Imbalances: As the GFR declines, there is a reduced ability of the kidneys to maintain electrolyte balance. This can result in the development of hyperkalemia, hyponatremia, and other electrolyte imbalances, which can have significant clinical consequences.
Etiology
Diabetes: Diabetes is the most common cause of CKD. Uncontrolled high blood sugar levels can damage the blood vessels in the kidneys, leading to CKD.
Hypertension: High blood pressure can damage the blood vessels in the kidneys, leading to CKD.
Glomerulonephritis: This is a type of kidney disease that affects the glomeruli, which are the tiny blood vessels in the kidneys that filter waste from the blood.
Polycystic kidney disease: This is an inherited disorder in which numerous cysts grow in the kidneys, eventually leading to CKD.
Obstructive nephropathy: This occurs when there is a blockage in the urinary tract, such as from an enlarged prostate or kidney stones, that prevents urine from draining properly from the kidneys.
Interstitial nephritis: This is a condition in which the spaces between the kidney tubules become inflamed and scarred, leading to CKD.
Lupus nephritis: This is a type of kidney disease that occurs in people with systemic lupus erythematosus (SLE), an autoimmune disease.
Congenital abnormalities: Some people are born with structural abnormalities in their kidneys that can lead to CKD.
Nephrotic syndrome: This is a condition in which the kidneys leak large amounts of protein into the urine, leading to CKD.
Exposure to toxins: Certain drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and environmental toxins, such as lead, can damage the kidneys and lead to CKD.
Genetics
Prognostic Factors
Prognostic factors for chronic kidney disease (CKD) include the stage of the disease, the presence of proteinuria or albuminuria, blood pressure control, the degree of kidney function impairment, and the presence of comorbidities such as diabetes and cardiovascular disease.
Stage of CKD: The stage of CKD is determined based on the estimated glomerular filtration rate (eGFR) and the presence of proteinuria. The higher the stage, the greater the risk of progression to end-stage renal disease (ESRD).
Proteinuria or albuminuria: Proteinuria or albuminuria is an important prognostic factor for CKD. It is a marker of kidney damage and is associated with an increased risk of progression to ESRD.
Blood pressure control: Hypertension is a common comorbidity in CKD and is associated with an increased risk of progression to ESRD. Blood pressure control is important in slowing the progression of CKD.
Degree of kidney function impairment: The degree of kidney function impairment, as measured by eGFR, is also an important prognostic factor for CKD. The lower the eGFR, the greater the risk of progression to ESRD.
Comorbidities: The presence of comorbidities such as diabetes and cardiovascular disease can also impact the prognosis of CKD. These conditions can accelerate the progression of CKD and increase the risk of cardiovascular events.
Clinical History
Chronic kidney disease (CKD) is often asymptomatic in its early stages, and symptoms may not appear until significant damage has been done to the kidneys. The clinical presentation of CKD can vary widely depending on the stage of the disease and the underlying cause.
Age group: CKD can occur at any age, but it is more common in older adults, particularly those over the age of 65.
Associated comorbidity or activity: CKD is often associated with other chronic conditions such as diabetes, hypertension, and cardiovascular disease. It can also be associated with lifestyle factors such as smoking, obesity, and a sedentary lifestyle.
Acuity of presentation: The presentation of CKD can range from mild to severe, depending on the stage of the disease. In the early stages, CKD may not present with any symptoms. As the disease progresses, symptoms may include fatigue, nausea, vomiting, loss of appetite, muscle cramps, itching, swelling in the legs and feet, and changes in urination, including increased frequency or decreased output. In the later stages of CKD, patients may develop complications such as anemia, bone disease, and cardiovascular disease.
Physical Examination
Physical examination of a patient with chronic kidney disease (CKD) may reveal signs and symptoms related to the underlying cause of CKD, as well as complications associated with kidney dysfunction.
Some of the physical findings that may be observed in patients with CKD include:
Edema: swelling in the legs, feet, and sometimes face and hands
Hypertension: elevated blood pressure
Anemia: pale appearance, fatigue, and weakness
Uremic frost: white crystals of urea on the skin, which may be observed in advanced cases of CKD
Changes in skin color and texture: dry, itchy skin and darkening of the skin due to accumulation of waste products
Oral changes: metallic taste in the mouth, bad breath, and uremic stomatitis (inflammation of the mouth)
Abdominal examination: enlargement of the kidneys due to polycystic kidney disease or hydronephrosis, a condition in which urine is backed up into the kidneys
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Chronic kidney disease (CKD) can have a variety of differential diagnoses, depending on the underlying cause and presentation of the disease. Some of the possible differential diagnoses of CKD include:
Acute kidney injury (AKI)
Glomerulonephritis
Polycystic kidney disease (PKD)
Nephrotic syndrome
Diabetes mellitus
Hypertension
Lupus nephritis
Obstructive uropathy
Pyelonephritis
Drug-induced nephrotoxicity
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Depending on the disease’s stage and underlying cause, chronic kidney disease (CKD) can occur at any time. The main goals of CKD treatment are to slow down or halt the progression of kidney damage, manage symptoms, and reduce the risk of complications.
Modification of Environment:
Lifestyle changes: Patients with CKD should follow a healthy lifestyle, which includes regular exercise, maintaining a healthy weight, quitting smoking, and limiting alcohol consumption.
Diet modification: Patients with CKD are advised to follow a kidney-friendly diet, which includes limited protein, sodium, and phosphorus intake. The diet should also include foods rich in vitamins and minerals, such as fruits and vegetables.
Blood pressure control: Hypertension is a common complication of CKD, and controlling blood pressure is important to slow down the progression of the disease. Blood pressure should be maintained at a level below 130/80 mmHg.
Administration of a Pharmaceutical Agent:
Medications to control blood pressure: Patients with CKD are often prescribed medications to control blood pressure, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).
Medications to lower cholesterol: High cholesterol levels can increase the risk of cardiovascular disease in patients with CKD. Statins are often prescribed to lower cholesterol levels.
Medications to manage anemia: CKD can cause anemia, and medications such as erythropoietin-stimulating agents (ESAs) may be prescribed to manage this condition.
Medications to manage bone disorders: CKD can cause bone disorders, and medications such as phosphate binders and vitamin D supplements may be prescribed to manage these conditions.
Intervention with a procedure:
Dialysis: Patients with end-stage kidney disease require dialysis, which is a procedure that helps remove waste and excess fluid from the body when the kidneys are no longer able to perform this function.
There are 2 types of dialysis:
hemodialysis
peritoneal dialysis.
Kidney transplant: In some cases, a kidney transplant may be an option for patients with end-stage kidney disease. During this procedure, a healthy kidney from a donor is transplanted into the patient’s body.
Phase of management:
Early-stage management: In the early stages of CKD, the focus is on slowing down or halting the progression of kidney damage. This may involve lifestyle changes, medications to control blood pressure and lower cholesterol, and monitoring kidney function.
Advanced-stage management: In advanced stages of CKD, dialysis or kidney transplant may be necessary to manage the symptoms of the disease and prevent complications.
Indicated for Chronic kidney disease-associated anemia :
CKD on dialysis
Initial dose:0.45mcg/kg intravenous/ subcutaneous once every four weeks
or
0.75mcg/kg intravenous/ subcutaneous once every two weeks
CKD not on dialysis
Initial dose:0.45mcg/kg intravenous/ subcutaneous once every four weeks or
0.75mcg/kg intravenous/ subcutaneous once every two weeks
In the case of renal impairment when eGFR ≥45mL/min/1.73 m2 no dose adjustment is required
When eGFR ranges from 25 to 45 mL/min/1.732 m2 no dose adjustment is required
When eGFR <25mL/min/1.73 m2 the patients with heart failure or chronic kidney disease may continue the dose at 10 mg/day to minimize the risk of eGFR decline, cardiovascular death, and heart failure accompanying hospitalization
The drug is contraindicated during dia:
dapagliflozin is indicated in the patients with chronic kidney disease to reduce the risk of eGFR decline
10 mg orally each day
Procrit, Epogen, Retacrit
Red blood cell (RBC) transfusion needs are reduced in patients with CKD and are on dialysis and those who are not Dialysis patients with CKD
When hemoglobin (Hgb) levels fall below 10 g/dL, initiate the therapy
If the Hgb level approaches or is above 11 g/dL, reduce or discontinue the 50-100 unit/kg IV/SC dose initially, three times per week Patients with CKD and are not on dialysis
initiate therapy when the Hbg level is below 10 g/dL, and the following conditions are met
The rate at which Hgb declines indicates the likelihood of requiring an RBC transfusion
Another goal is to reduce the risk of alloimmunization and other RBC transfusion-related risks
If the Hgb level is greater than 10 g/dL, reduce or discontinue dosing and use the lowest dose of epoetin alfa necessary to reduce the requirement for RBC transfusions
50-100 units/kg intravenous three times weekly initially Zidovudine-Related Anemia Procrit, Epogen, Retacrit
Anemia treatment with zidovudine less than 4200 mg/week in HIV patients with endogenous serum erythropoietin levels of less than 500 milliunits/mL
100 units/kg intravenous/subcutaneous initially, three times per week
If Hgb does not increase after the 8 weeks, increase the dose by 50-100 units/kg every 4-8 weeks until hemoglobin is high enough to avoid RBC transfusions; administer 300 units/kg alternatively.
If Hgb is greater than 12 g/dL: Withhold the dose; begin therapy at a 25% lower dose when Hgb declines to 11 g/dL
If no Hgb increase is achieved after 8 weeks at a dose of 300 Units/kg, discontinue the medication
0.25 mcg orally once daily
Lower the dose to 0.25 mcg thrice weekly if required
May titrate the dose upwards by increasing 0.25 mcg each day every 2 months
Maximum dose- 1 mcg/day
Procrit, Epogen, Retacrit
Indicated to reduce the requirement for red blood cell (RBC) transfusions in chronic renal disease patients (CKD)
Below one month: Safety and efficacy were not established
Above one month: 50 units/kg IV/SC 3 times weekly initially; if the patient is on dialysis, the Intravenous route is recommended
Initiate when the hemoglobin level is less than 10 g/dL; if the hemoglobin level reaches or exceeds 11 g/dL, reduce or discontinue the dose Zidovudine-Related Anemia Procrit, Epogen, Retacrit
Below eight months: Safety and efficacy were not established
8 months to 17 years: 50-400 units/kg subcutaneous/intravenous 2-3 times a week
Chronic kidney disease (CKD) is a medical condition characterized by the gradual loss of kidney function over time. It is a progressive disease that can lead to end-stage kidney disease if left untreated. The kidneys play a vital role in filtering waste products from the blood, regulating fluid and electrolyte balance, and producing hormones that regulate blood pressure and red blood cell production. CKD is associated with a range of risk factors, including diabetes, hypertension, and obesity, and it can have a significant impact on a person’s quality of life. Management of CKD typically involves a combination of lifestyle modifications, medication, and medical interventions.
Prevalence: CKD affects approximately 10% of the global population. The prevalence of CKD varies by country and by population subgroup, but it tends to be higher in older individuals and those with comorbidities like hypertension and diabetes.
Incidence: The incidence of CKD is increasing, and it is estimated that CKD will be one of the leading causes of death worldwide by 2040. The incidence of CKD is higher in certain ethnic groups, such as African Americans, Native Americans, and Hispanic Americans.
Mortality: The mortality rate in CKD patients is high, with an increased risk of cardiovascular disease, infection, and malignancy. Mortality rates increase with advancing stages of CKD.
Economic burden: The economic burden of CKD is significant, with costs related to medical care, dialysis, transplantation, and loss of productivity. The cost of CKD is highest in the advanced stages of the disease.
Risk factors: Risk factors for CKD include diabetes, hypertension, obesity, smoking, and family history of kidney disease.
The pathophysiology of CKD involves a complex interplay of various factors that contribute to the development and progression of the disease.
Renal Blood Flow and Glomerular Filtration Rate (GFR): In CKD, there is a decrease in renal blood flow due to the progressive loss of nephrons. This results in a decrease in GFR, which is the primary measure of kidney function. As the GFR declines, there is a reduction in the ability of the kidneys to excrete waste products and maintain fluid and electrolyte balance.
Inflammation: Inflammation plays a significant role in the pathophysiology of CKD. The initial insult to the kidneys, such as diabetes or hypertension, triggers an inflammatory response that leads to the destruction of renal tissue. The immune system also contributes to the inflammatory process by releasing cytokines and chemokines that further damage the kidneys.
Fibrosis: In response to injury, the kidneys undergo a process of fibrosis, which involves the accumulation of extracellular matrix (ECM) proteins such as collagen. This results in the formation of scar tissue, which impairs the function of the kidneys.
Oxidative Stress: CKD is associated with increased oxidative stress, which is caused by an imbalance between reactive oxygen species (ROS) and antioxidant defenses. ROS can damage cellular structures and impair renal function.
Endothelial Dysfunction: Endothelial dysfunction is a common feature of CKD, characterized by impaired vasodilation and increased vascular resistance. This contributes to the reduction in renal blood flow and the progression of the disease.
Electrolyte Imbalances: As the GFR declines, there is a reduced ability of the kidneys to maintain electrolyte balance. This can result in the development of hyperkalemia, hyponatremia, and other electrolyte imbalances, which can have significant clinical consequences.
Diabetes: Diabetes is the most common cause of CKD. Uncontrolled high blood sugar levels can damage the blood vessels in the kidneys, leading to CKD.
Hypertension: High blood pressure can damage the blood vessels in the kidneys, leading to CKD.
Glomerulonephritis: This is a type of kidney disease that affects the glomeruli, which are the tiny blood vessels in the kidneys that filter waste from the blood.
Polycystic kidney disease: This is an inherited disorder in which numerous cysts grow in the kidneys, eventually leading to CKD.
Obstructive nephropathy: This occurs when there is a blockage in the urinary tract, such as from an enlarged prostate or kidney stones, that prevents urine from draining properly from the kidneys.
Interstitial nephritis: This is a condition in which the spaces between the kidney tubules become inflamed and scarred, leading to CKD.
Lupus nephritis: This is a type of kidney disease that occurs in people with systemic lupus erythematosus (SLE), an autoimmune disease.
Congenital abnormalities: Some people are born with structural abnormalities in their kidneys that can lead to CKD.
Nephrotic syndrome: This is a condition in which the kidneys leak large amounts of protein into the urine, leading to CKD.
Exposure to toxins: Certain drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and environmental toxins, such as lead, can damage the kidneys and lead to CKD.
Prognostic factors for chronic kidney disease (CKD) include the stage of the disease, the presence of proteinuria or albuminuria, blood pressure control, the degree of kidney function impairment, and the presence of comorbidities such as diabetes and cardiovascular disease.
Stage of CKD: The stage of CKD is determined based on the estimated glomerular filtration rate (eGFR) and the presence of proteinuria. The higher the stage, the greater the risk of progression to end-stage renal disease (ESRD).
Proteinuria or albuminuria: Proteinuria or albuminuria is an important prognostic factor for CKD. It is a marker of kidney damage and is associated with an increased risk of progression to ESRD.
Blood pressure control: Hypertension is a common comorbidity in CKD and is associated with an increased risk of progression to ESRD. Blood pressure control is important in slowing the progression of CKD.
Degree of kidney function impairment: The degree of kidney function impairment, as measured by eGFR, is also an important prognostic factor for CKD. The lower the eGFR, the greater the risk of progression to ESRD.
Comorbidities: The presence of comorbidities such as diabetes and cardiovascular disease can also impact the prognosis of CKD. These conditions can accelerate the progression of CKD and increase the risk of cardiovascular events.
Chronic kidney disease (CKD) is often asymptomatic in its early stages, and symptoms may not appear until significant damage has been done to the kidneys. The clinical presentation of CKD can vary widely depending on the stage of the disease and the underlying cause.
Age group: CKD can occur at any age, but it is more common in older adults, particularly those over the age of 65.
Associated comorbidity or activity: CKD is often associated with other chronic conditions such as diabetes, hypertension, and cardiovascular disease. It can also be associated with lifestyle factors such as smoking, obesity, and a sedentary lifestyle.
Acuity of presentation: The presentation of CKD can range from mild to severe, depending on the stage of the disease. In the early stages, CKD may not present with any symptoms. As the disease progresses, symptoms may include fatigue, nausea, vomiting, loss of appetite, muscle cramps, itching, swelling in the legs and feet, and changes in urination, including increased frequency or decreased output. In the later stages of CKD, patients may develop complications such as anemia, bone disease, and cardiovascular disease.
Physical examination of a patient with chronic kidney disease (CKD) may reveal signs and symptoms related to the underlying cause of CKD, as well as complications associated with kidney dysfunction.
Some of the physical findings that may be observed in patients with CKD include:
Edema: swelling in the legs, feet, and sometimes face and hands
Hypertension: elevated blood pressure
Anemia: pale appearance, fatigue, and weakness
Uremic frost: white crystals of urea on the skin, which may be observed in advanced cases of CKD
Changes in skin color and texture: dry, itchy skin and darkening of the skin due to accumulation of waste products
Oral changes: metallic taste in the mouth, bad breath, and uremic stomatitis (inflammation of the mouth)
Abdominal examination: enlargement of the kidneys due to polycystic kidney disease or hydronephrosis, a condition in which urine is backed up into the kidneys
Chronic kidney disease (CKD) can have a variety of differential diagnoses, depending on the underlying cause and presentation of the disease. Some of the possible differential diagnoses of CKD include:
Acute kidney injury (AKI)
Glomerulonephritis
Polycystic kidney disease (PKD)
Nephrotic syndrome
Diabetes mellitus
Hypertension
Lupus nephritis
Obstructive uropathy
Pyelonephritis
Drug-induced nephrotoxicity
Depending on the disease’s stage and underlying cause, chronic kidney disease (CKD) can occur at any time. The main goals of CKD treatment are to slow down or halt the progression of kidney damage, manage symptoms, and reduce the risk of complications.
Modification of Environment:
Lifestyle changes: Patients with CKD should follow a healthy lifestyle, which includes regular exercise, maintaining a healthy weight, quitting smoking, and limiting alcohol consumption.
Diet modification: Patients with CKD are advised to follow a kidney-friendly diet, which includes limited protein, sodium, and phosphorus intake. The diet should also include foods rich in vitamins and minerals, such as fruits and vegetables.
Blood pressure control: Hypertension is a common complication of CKD, and controlling blood pressure is important to slow down the progression of the disease. Blood pressure should be maintained at a level below 130/80 mmHg.
Administration of a Pharmaceutical Agent:
Medications to control blood pressure: Patients with CKD are often prescribed medications to control blood pressure, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).
Medications to lower cholesterol: High cholesterol levels can increase the risk of cardiovascular disease in patients with CKD. Statins are often prescribed to lower cholesterol levels.
Medications to manage anemia: CKD can cause anemia, and medications such as erythropoietin-stimulating agents (ESAs) may be prescribed to manage this condition.
Medications to manage bone disorders: CKD can cause bone disorders, and medications such as phosphate binders and vitamin D supplements may be prescribed to manage these conditions.
Intervention with a procedure:
Dialysis: Patients with end-stage kidney disease require dialysis, which is a procedure that helps remove waste and excess fluid from the body when the kidneys are no longer able to perform this function.
There are 2 types of dialysis:
hemodialysis
peritoneal dialysis.
Kidney transplant: In some cases, a kidney transplant may be an option for patients with end-stage kidney disease. During this procedure, a healthy kidney from a donor is transplanted into the patient’s body.
Phase of management:
Early-stage management: In the early stages of CKD, the focus is on slowing down or halting the progression of kidney damage. This may involve lifestyle changes, medications to control blood pressure and lower cholesterol, and monitoring kidney function.
Advanced-stage management: In advanced stages of CKD, dialysis or kidney transplant may be necessary to manage the symptoms of the disease and prevent complications.
Indicated for Chronic kidney disease-associated anemia :
CKD on dialysis
Initial dose:0.45mcg/kg intravenous/ subcutaneous once every four weeks
or
0.75mcg/kg intravenous/ subcutaneous once every two weeks
CKD not on dialysis
Initial dose:0.45mcg/kg intravenous/ subcutaneous once every four weeks or
0.75mcg/kg intravenous/ subcutaneous once every two weeks
In the case of renal impairment when eGFR ≥45mL/min/1.73 m2 no dose adjustment is required
When eGFR ranges from 25 to 45 mL/min/1.732 m2 no dose adjustment is required
When eGFR <25mL/min/1.73 m2 the patients with heart failure or chronic kidney disease may continue the dose at 10 mg/day to minimize the risk of eGFR decline, cardiovascular death, and heart failure accompanying hospitalization
The drug is contraindicated during dia:
dapagliflozin is indicated in the patients with chronic kidney disease to reduce the risk of eGFR decline
10 mg orally each day
Procrit, Epogen, Retacrit
Red blood cell (RBC) transfusion needs are reduced in patients with CKD and are on dialysis and those who are not Dialysis patients with CKD
When hemoglobin (Hgb) levels fall below 10 g/dL, initiate the therapy
If the Hgb level approaches or is above 11 g/dL, reduce or discontinue the 50-100 unit/kg IV/SC dose initially, three times per week Patients with CKD and are not on dialysis
initiate therapy when the Hbg level is below 10 g/dL, and the following conditions are met
The rate at which Hgb declines indicates the likelihood of requiring an RBC transfusion
Another goal is to reduce the risk of alloimmunization and other RBC transfusion-related risks
If the Hgb level is greater than 10 g/dL, reduce or discontinue dosing and use the lowest dose of epoetin alfa necessary to reduce the requirement for RBC transfusions
50-100 units/kg intravenous three times weekly initially Zidovudine-Related Anemia Procrit, Epogen, Retacrit
Anemia treatment with zidovudine less than 4200 mg/week in HIV patients with endogenous serum erythropoietin levels of less than 500 milliunits/mL
100 units/kg intravenous/subcutaneous initially, three times per week
If Hgb does not increase after the 8 weeks, increase the dose by 50-100 units/kg every 4-8 weeks until hemoglobin is high enough to avoid RBC transfusions; administer 300 units/kg alternatively.
If Hgb is greater than 12 g/dL: Withhold the dose; begin therapy at a 25% lower dose when Hgb declines to 11 g/dL
If no Hgb increase is achieved after 8 weeks at a dose of 300 Units/kg, discontinue the medication
0.25 mcg orally once daily
Lower the dose to 0.25 mcg thrice weekly if required
May titrate the dose upwards by increasing 0.25 mcg each day every 2 months
Maximum dose- 1 mcg/day
Procrit, Epogen, Retacrit
Indicated to reduce the requirement for red blood cell (RBC) transfusions in chronic renal disease patients (CKD)
Below one month: Safety and efficacy were not established
Above one month: 50 units/kg IV/SC 3 times weekly initially; if the patient is on dialysis, the Intravenous route is recommended
Initiate when the hemoglobin level is less than 10 g/dL; if the hemoglobin level reaches or exceeds 11 g/dL, reduce or discontinue the dose Zidovudine-Related Anemia Procrit, Epogen, Retacrit
Below eight months: Safety and efficacy were not established
8 months to 17 years: 50-400 units/kg subcutaneous/intravenous 2-3 times a week
Chronic kidney disease (CKD) is a medical condition characterized by the gradual loss of kidney function over time. It is a progressive disease that can lead to end-stage kidney disease if left untreated. The kidneys play a vital role in filtering waste products from the blood, regulating fluid and electrolyte balance, and producing hormones that regulate blood pressure and red blood cell production. CKD is associated with a range of risk factors, including diabetes, hypertension, and obesity, and it can have a significant impact on a person’s quality of life. Management of CKD typically involves a combination of lifestyle modifications, medication, and medical interventions.
Prevalence: CKD affects approximately 10% of the global population. The prevalence of CKD varies by country and by population subgroup, but it tends to be higher in older individuals and those with comorbidities like hypertension and diabetes.
Incidence: The incidence of CKD is increasing, and it is estimated that CKD will be one of the leading causes of death worldwide by 2040. The incidence of CKD is higher in certain ethnic groups, such as African Americans, Native Americans, and Hispanic Americans.
Mortality: The mortality rate in CKD patients is high, with an increased risk of cardiovascular disease, infection, and malignancy. Mortality rates increase with advancing stages of CKD.
Economic burden: The economic burden of CKD is significant, with costs related to medical care, dialysis, transplantation, and loss of productivity. The cost of CKD is highest in the advanced stages of the disease.
Risk factors: Risk factors for CKD include diabetes, hypertension, obesity, smoking, and family history of kidney disease.
The pathophysiology of CKD involves a complex interplay of various factors that contribute to the development and progression of the disease.
Renal Blood Flow and Glomerular Filtration Rate (GFR): In CKD, there is a decrease in renal blood flow due to the progressive loss of nephrons. This results in a decrease in GFR, which is the primary measure of kidney function. As the GFR declines, there is a reduction in the ability of the kidneys to excrete waste products and maintain fluid and electrolyte balance.
Inflammation: Inflammation plays a significant role in the pathophysiology of CKD. The initial insult to the kidneys, such as diabetes or hypertension, triggers an inflammatory response that leads to the destruction of renal tissue. The immune system also contributes to the inflammatory process by releasing cytokines and chemokines that further damage the kidneys.
Fibrosis: In response to injury, the kidneys undergo a process of fibrosis, which involves the accumulation of extracellular matrix (ECM) proteins such as collagen. This results in the formation of scar tissue, which impairs the function of the kidneys.
Oxidative Stress: CKD is associated with increased oxidative stress, which is caused by an imbalance between reactive oxygen species (ROS) and antioxidant defenses. ROS can damage cellular structures and impair renal function.
Endothelial Dysfunction: Endothelial dysfunction is a common feature of CKD, characterized by impaired vasodilation and increased vascular resistance. This contributes to the reduction in renal blood flow and the progression of the disease.
Electrolyte Imbalances: As the GFR declines, there is a reduced ability of the kidneys to maintain electrolyte balance. This can result in the development of hyperkalemia, hyponatremia, and other electrolyte imbalances, which can have significant clinical consequences.
Diabetes: Diabetes is the most common cause of CKD. Uncontrolled high blood sugar levels can damage the blood vessels in the kidneys, leading to CKD.
Hypertension: High blood pressure can damage the blood vessels in the kidneys, leading to CKD.
Glomerulonephritis: This is a type of kidney disease that affects the glomeruli, which are the tiny blood vessels in the kidneys that filter waste from the blood.
Polycystic kidney disease: This is an inherited disorder in which numerous cysts grow in the kidneys, eventually leading to CKD.
Obstructive nephropathy: This occurs when there is a blockage in the urinary tract, such as from an enlarged prostate or kidney stones, that prevents urine from draining properly from the kidneys.
Interstitial nephritis: This is a condition in which the spaces between the kidney tubules become inflamed and scarred, leading to CKD.
Lupus nephritis: This is a type of kidney disease that occurs in people with systemic lupus erythematosus (SLE), an autoimmune disease.
Congenital abnormalities: Some people are born with structural abnormalities in their kidneys that can lead to CKD.
Nephrotic syndrome: This is a condition in which the kidneys leak large amounts of protein into the urine, leading to CKD.
Exposure to toxins: Certain drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and environmental toxins, such as lead, can damage the kidneys and lead to CKD.
Prognostic factors for chronic kidney disease (CKD) include the stage of the disease, the presence of proteinuria or albuminuria, blood pressure control, the degree of kidney function impairment, and the presence of comorbidities such as diabetes and cardiovascular disease.
Stage of CKD: The stage of CKD is determined based on the estimated glomerular filtration rate (eGFR) and the presence of proteinuria. The higher the stage, the greater the risk of progression to end-stage renal disease (ESRD).
Proteinuria or albuminuria: Proteinuria or albuminuria is an important prognostic factor for CKD. It is a marker of kidney damage and is associated with an increased risk of progression to ESRD.
Blood pressure control: Hypertension is a common comorbidity in CKD and is associated with an increased risk of progression to ESRD. Blood pressure control is important in slowing the progression of CKD.
Degree of kidney function impairment: The degree of kidney function impairment, as measured by eGFR, is also an important prognostic factor for CKD. The lower the eGFR, the greater the risk of progression to ESRD.
Comorbidities: The presence of comorbidities such as diabetes and cardiovascular disease can also impact the prognosis of CKD. These conditions can accelerate the progression of CKD and increase the risk of cardiovascular events.
Chronic kidney disease (CKD) is often asymptomatic in its early stages, and symptoms may not appear until significant damage has been done to the kidneys. The clinical presentation of CKD can vary widely depending on the stage of the disease and the underlying cause.
Age group: CKD can occur at any age, but it is more common in older adults, particularly those over the age of 65.
Associated comorbidity or activity: CKD is often associated with other chronic conditions such as diabetes, hypertension, and cardiovascular disease. It can also be associated with lifestyle factors such as smoking, obesity, and a sedentary lifestyle.
Acuity of presentation: The presentation of CKD can range from mild to severe, depending on the stage of the disease. In the early stages, CKD may not present with any symptoms. As the disease progresses, symptoms may include fatigue, nausea, vomiting, loss of appetite, muscle cramps, itching, swelling in the legs and feet, and changes in urination, including increased frequency or decreased output. In the later stages of CKD, patients may develop complications such as anemia, bone disease, and cardiovascular disease.
Physical examination of a patient with chronic kidney disease (CKD) may reveal signs and symptoms related to the underlying cause of CKD, as well as complications associated with kidney dysfunction.
Some of the physical findings that may be observed in patients with CKD include:
Edema: swelling in the legs, feet, and sometimes face and hands
Hypertension: elevated blood pressure
Anemia: pale appearance, fatigue, and weakness
Uremic frost: white crystals of urea on the skin, which may be observed in advanced cases of CKD
Changes in skin color and texture: dry, itchy skin and darkening of the skin due to accumulation of waste products
Oral changes: metallic taste in the mouth, bad breath, and uremic stomatitis (inflammation of the mouth)
Abdominal examination: enlargement of the kidneys due to polycystic kidney disease or hydronephrosis, a condition in which urine is backed up into the kidneys
Chronic kidney disease (CKD) can have a variety of differential diagnoses, depending on the underlying cause and presentation of the disease. Some of the possible differential diagnoses of CKD include:
Acute kidney injury (AKI)
Glomerulonephritis
Polycystic kidney disease (PKD)
Nephrotic syndrome
Diabetes mellitus
Hypertension
Lupus nephritis
Obstructive uropathy
Pyelonephritis
Drug-induced nephrotoxicity
Depending on the disease’s stage and underlying cause, chronic kidney disease (CKD) can occur at any time. The main goals of CKD treatment are to slow down or halt the progression of kidney damage, manage symptoms, and reduce the risk of complications.
Modification of Environment:
Lifestyle changes: Patients with CKD should follow a healthy lifestyle, which includes regular exercise, maintaining a healthy weight, quitting smoking, and limiting alcohol consumption.
Diet modification: Patients with CKD are advised to follow a kidney-friendly diet, which includes limited protein, sodium, and phosphorus intake. The diet should also include foods rich in vitamins and minerals, such as fruits and vegetables.
Blood pressure control: Hypertension is a common complication of CKD, and controlling blood pressure is important to slow down the progression of the disease. Blood pressure should be maintained at a level below 130/80 mmHg.
Administration of a Pharmaceutical Agent:
Medications to control blood pressure: Patients with CKD are often prescribed medications to control blood pressure, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).
Medications to lower cholesterol: High cholesterol levels can increase the risk of cardiovascular disease in patients with CKD. Statins are often prescribed to lower cholesterol levels.
Medications to manage anemia: CKD can cause anemia, and medications such as erythropoietin-stimulating agents (ESAs) may be prescribed to manage this condition.
Medications to manage bone disorders: CKD can cause bone disorders, and medications such as phosphate binders and vitamin D supplements may be prescribed to manage these conditions.
Intervention with a procedure:
Dialysis: Patients with end-stage kidney disease require dialysis, which is a procedure that helps remove waste and excess fluid from the body when the kidneys are no longer able to perform this function.
There are 2 types of dialysis:
hemodialysis
peritoneal dialysis.
Kidney transplant: In some cases, a kidney transplant may be an option for patients with end-stage kidney disease. During this procedure, a healthy kidney from a donor is transplanted into the patient’s body.
Phase of management:
Early-stage management: In the early stages of CKD, the focus is on slowing down or halting the progression of kidney damage. This may involve lifestyle changes, medications to control blood pressure and lower cholesterol, and monitoring kidney function.
Advanced-stage management: In advanced stages of CKD, dialysis or kidney transplant may be necessary to manage the symptoms of the disease and prevent complications.
Both our subscription plans include Free CME/CPD AMA PRA Category 1 credits.
Digital Certificate PDF
On course completion, you will receive a full-sized presentation quality digital certificate.
medtigo Simulation
A dynamic medical simulation platform designed to train healthcare professionals and students to effectively run code situations through an immersive hands-on experience in a live, interactive 3D environment.
medtigo Points
medtigo points is our unique point redemption system created to award users for interacting on our site. These points can be redeemed for special discounts on the medtigo marketplace as well as towards the membership cost itself.
Community Forum post/reply = 5 points
*Redemption of points can occur only through the medtigo marketplace, courses, or simulation system. Money will not be credited to your bank account. 10 points = $1.
All Your Certificates in One Place
When you have your licenses, certificates and CMEs in one place, it's easier to track your career growth. You can easily share these with hospitals as well, using your medtigo app.
