fbpx

Chronic Kidney Disease (CKD)

Updated : May 3, 2024





Background

The gradual decline or reduction in the kidneys function over a period is called chronic kidney disease which should be addressed immediately to avoid further complications. Kidneys are important organs which play a role of filtering or removing waste and regulating blood pressure and production or synthesis of red blood cells through the release of hormones. They also maintain fluid balance which helps in regulating the blood pressure. The conditions associated that can raise or increase the risk of CKD are diabetes, High blood pressure, and obesity. Lifestyle modifications and dietary changes are important in managing CKD, which includes proper exercise, treatment plans, and medical interventions in managing CKD. 

Epidemiology

CKD usually occurs in geriatric individuals who have diabetes and high blood pressure that could affect 10% of the population across the globe. We can see an increase in this number by 2040 which could be the major reason for deaths worldwide. It affects differently in various ethnic groups giving a proportion which is not stable. There is an increased mortality risk for people with CKD such as heart failures, infections, cancer. These risks are more in advanced kidney failure stages. In the final stages of CKD, there will be more medical costs involving medical treatment, dialysis, and transplantation. 

Anatomy

Pathophysiology

There are many causes for chronic kidney disease which include low blood flow to the kidneys which lead to reduced glomerular filtration rates, improper removal of fluids or wastes due to damaged nephrons. Secondary causes include inflammation which can be the major one. Inflammation can be high in individuals with diabetes and hypertension. The immune system which gets compromised, and the healthy tissues will be replaced by the tissues which have scars leading to major decrease in kidney function. Slowly, cells in the tissue and blood vessels will get damaged, being the reason for reduced blood flow which can worsen the disease more. Improper filtration can change the levels of electrolyte balance leading to more potassium and low sodium levels which is severe or dangerous. 

Etiology

The etiological factors for CKD are diabetes, uncontrolled blood sugar levels can damage the blood vessels. Hypertension is also the reason which can damage the blood vessels. The risk of CKD will be worsened due to the inflammation called glomerular nephritis. The formation of inherited growths or cysts also leads to reduced or decreased kidney function, and the condition is called polycystic kidney disease. The urine outflow is decreased in obstructive nephropathy leading to kidney damage. The spaces between the tubules of kidneys are affected by inflammatory processes and the condition is called interstitial nephritis. The complete damage to kidneys happens in lupus nephritis which is a complication of systemic lupus erythematosus. Other causes of CKD are abnormalities which are congenital and nephrotic syndrome along with additional toxins or NSAIDs which can lead to cellular damage increasing the risk of CKD. 

Genetics

Prognostic Factors

There are many factors that show how the progression of CKD will happen. The kidney disease stage which explains how much kidney function is compromised. The starting stages will be with low damage to kidneys, and it will progress towards increased damage in the end stage renal disease. Proteinuria also indicates damage to kidneys. High blood pressure should get controlled in a time bound manner because it was associated with ESRD. Reduction in the glomerular filtration rate will be another important factor. The conditions which can make CKD worse are diabetes and heart disease. 

Clinical History

There are no early signs for CKD. Symptoms appear much later after the damage. The proportion of damage to kidneys are different in different kidney failure stages. Older individuals are more prone to develop this disease. The other complications of CKD are diabetes, cardiovascular diseases, and hypertension. Smoking and obesity are also leading causes of CKD. As CKD worsens. The symptoms which appear are fatigue, nausea, vomiting, muscle cramps, itchiness, swelling in the feet and legs, appetite loss, and changes in the urine may occur. Final stages of kidney failure will result in anemia, bone disorders, and heart problems. 

Physical Examination

The physical examination of CKD include swelling in the lower limbs, face, and hands, high blood pressure, paleness due to anemia, tiredness, white urea crystals on the skin and changes like itchiness, dryness, and darkening of skin which happen due to accumulation of waste. Reporting of metallic tastes, bad breath, and uremic stomatitis in patients with CKD are due to inflammation of the mouth. Abdominal examination reveals enlargement of the kidneys from factors such as polycystic kidney disease or hydronephrosis in which there is an increased urine build up in the kidneys leading to pressure. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

  • 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

The individuals with CKD are required to consume low salt, potassium, and phosphorus. They need to take care of how many liquids they are consuming because of urine retention. Doing exercise regularly gives help to CKD people with diabetes and hypertension. Smoking should be stopped to avoid the complications of heart disease. Weight management should be taken care of. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of non-pharmacological approach for chronic kidney disease

Dietary changes include low salt, potassium, and phosphorous. Patients should stay hydrated. Drinking clean water and checking for fluid limits are important. Hygiene practices are important for infection prevention. 

 

Use of Calcium salts

Calcium acetate and calcium carbonate:  They play an important role in binding to phosphate from food inside the digestive system and form compounds which could not dissolve and are eliminated through bowel movements. 

Use of Vitamin D

  • Calcitriol:  It is vitamin D in the active form made from calcidiol in the kidneys. 
  • Paricalcitol: The synthetic form of calcitriol is paricalcitol which activates the vitamin D receptor in a few tissues which decreases the risk of high levels of calcium and phosphorus in the blood. 

 

Use of Hematopoietic Growth Factors

  • Darbepoetin alfa:  It is like artificial erythropoietin that makes the production of red blood cells in the bone marrow which is used in treating anemia and low hemoglobin levels which will be effective in CKD individuals. 
  • Use of Iron product 
  • Iron supplementation is needed for people who go for dialysis in which ferric pyrophosphate gets into the blood stream raising its levels during the treatment. 

Use of Calcimimetics

Cinacalcet: The calcium sensor in the parathyroid gland is controlled by the action of cinacalcet which results in the decreased production of parathyroid hormone (PTH). 

Sodium-Glucose Transporter-2 (SGLT2) Inhibitors

  • Dapagliflozin: It inhibits glucose reabsorption into the kidneys which leads to more urine glucose output resulting in the lowering of blood glucose levels. 
  • Canagliflozin: It acts by stopping reabsorption of glucose into the kidneys and into the blood stream. 

Use of Intervention with a procedure in treating chronic kidney disease

In ESRD, doctors go for kidney transplantation in which damaged kidneys are removed or replaced with donor kidney which gets placed in the recipient’s lower abdomen. The donor kidney blood vessels are connected to the recipient’s kidney and its ureter is attached to the bladder of the recipient. This is a major surgery that introduces a new kidney which is healthy into the body by taking out the old diseased kidney. 

Use of phases in managing chronic kidney disease

CKD is early detected by blood and urine tests and the factors responsible for this disease are obesity, diabetes, hypertension, and smoking which could raise the risk. There are many lifestyle modifications that need to be followed to reduce the effect of CKD which include dietary changes, weight loss, no smoking, and exercise. In the ESRD, dialysis and transplantation of the kidneys are suggested by doctors. 

Medication

 

darbepoetin alfa 

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



dapagliflozin 

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



epoetin alfa 

associated with anemia:

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



alfacalcidol 

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



zibotentan and dapagliflozin 

A recent clinical trial called the ZENITH-CKD trial, showed that the combination of zibotentan and dapagliflozin was more effective in reducing albuminuria than dapagliflozin alone. The trial also showed that the combination was well-tolerated and had a good safety profile. The ZENITH-CKD trial was a Phase 2b trial, which means that it was a small trial to test the safety and efficacy in a small group of people. Larger Phase 3 trials are required to confirm the safety and efficacy of the combination in a larger group of people and to see if it can delay or prevent the progression of CKD



 

darbepoetin alfa 

Indicated for Chronic kidney disease-associated anemia:


<18 years:
CKD on dialysis
0.45mcg/kg intravenous once a week

CKD not on dialysis
0.45mcg/kg intravenous once a week



epoetin alfa 

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



 

Media Gallary

Chronic Kidney Disease (CKD)

Updated : May 3, 2024




The gradual decline or reduction in the kidneys function over a period is called chronic kidney disease which should be addressed immediately to avoid further complications. Kidneys are important organs which play a role of filtering or removing waste and regulating blood pressure and production or synthesis of red blood cells through the release of hormones. They also maintain fluid balance which helps in regulating the blood pressure. The conditions associated that can raise or increase the risk of CKD are diabetes, High blood pressure, and obesity. Lifestyle modifications and dietary changes are important in managing CKD, which includes proper exercise, treatment plans, and medical interventions in managing CKD. 

CKD usually occurs in geriatric individuals who have diabetes and high blood pressure that could affect 10% of the population across the globe. We can see an increase in this number by 2040 which could be the major reason for deaths worldwide. It affects differently in various ethnic groups giving a proportion which is not stable. There is an increased mortality risk for people with CKD such as heart failures, infections, cancer. These risks are more in advanced kidney failure stages. In the final stages of CKD, there will be more medical costs involving medical treatment, dialysis, and transplantation. 

There are many causes for chronic kidney disease which include low blood flow to the kidneys which lead to reduced glomerular filtration rates, improper removal of fluids or wastes due to damaged nephrons. Secondary causes include inflammation which can be the major one. Inflammation can be high in individuals with diabetes and hypertension. The immune system which gets compromised, and the healthy tissues will be replaced by the tissues which have scars leading to major decrease in kidney function. Slowly, cells in the tissue and blood vessels will get damaged, being the reason for reduced blood flow which can worsen the disease more. Improper filtration can change the levels of electrolyte balance leading to more potassium and low sodium levels which is severe or dangerous. 

The etiological factors for CKD are diabetes, uncontrolled blood sugar levels can damage the blood vessels. Hypertension is also the reason which can damage the blood vessels. The risk of CKD will be worsened due to the inflammation called glomerular nephritis. The formation of inherited growths or cysts also leads to reduced or decreased kidney function, and the condition is called polycystic kidney disease. The urine outflow is decreased in obstructive nephropathy leading to kidney damage. The spaces between the tubules of kidneys are affected by inflammatory processes and the condition is called interstitial nephritis. The complete damage to kidneys happens in lupus nephritis which is a complication of systemic lupus erythematosus. Other causes of CKD are abnormalities which are congenital and nephrotic syndrome along with additional toxins or NSAIDs which can lead to cellular damage increasing the risk of CKD. 

There are many factors that show how the progression of CKD will happen. The kidney disease stage which explains how much kidney function is compromised. The starting stages will be with low damage to kidneys, and it will progress towards increased damage in the end stage renal disease. Proteinuria also indicates damage to kidneys. High blood pressure should get controlled in a time bound manner because it was associated with ESRD. Reduction in the glomerular filtration rate will be another important factor. The conditions which can make CKD worse are diabetes and heart disease. 

There are no early signs for CKD. Symptoms appear much later after the damage. The proportion of damage to kidneys are different in different kidney failure stages. Older individuals are more prone to develop this disease. The other complications of CKD are diabetes, cardiovascular diseases, and hypertension. Smoking and obesity are also leading causes of CKD. As CKD worsens. The symptoms which appear are fatigue, nausea, vomiting, muscle cramps, itchiness, swelling in the feet and legs, appetite loss, and changes in the urine may occur. Final stages of kidney failure will result in anemia, bone disorders, and heart problems. 

The physical examination of CKD include swelling in the lower limbs, face, and hands, high blood pressure, paleness due to anemia, tiredness, white urea crystals on the skin and changes like itchiness, dryness, and darkening of skin which happen due to accumulation of waste. Reporting of metallic tastes, bad breath, and uremic stomatitis in patients with CKD are due to inflammation of the mouth. Abdominal examination reveals enlargement of the kidneys from factors such as polycystic kidney disease or hydronephrosis in which there is an increased urine build up in the kidneys leading to pressure. 

  • Acute kidney injury (AKI) 
  • Glomerulonephritis 
  • Polycystic kidney disease (PKD) 
  • Nephrotic syndrome 
  • Diabetes mellitus 
  • Hypertension 
  • Lupus nephritis 
  • Obstructive uropathy 
  • Pyelonephritis
  • Drug-induced nephrotoxicity 

The individuals with CKD are required to consume low salt, potassium, and phosphorus. They need to take care of how many liquids they are consuming because of urine retention. Doing exercise regularly gives help to CKD people with diabetes and hypertension. Smoking should be stopped to avoid the complications of heart disease. Weight management should be taken care of. 

Dietary changes include low salt, potassium, and phosphorous. Patients should stay hydrated. Drinking clean water and checking for fluid limits are important. Hygiene practices are important for infection prevention. 

 

Calcium acetate and calcium carbonate:  They play an important role in binding to phosphate from food inside the digestive system and form compounds which could not dissolve and are eliminated through bowel movements. 

  • Calcitriol:  It is vitamin D in the active form made from calcidiol in the kidneys. 
  • Paricalcitol: The synthetic form of calcitriol is paricalcitol which activates the vitamin D receptor in a few tissues which decreases the risk of high levels of calcium and phosphorus in the blood. 

 

  • Darbepoetin alfa:  It is like artificial erythropoietin that makes the production of red blood cells in the bone marrow which is used in treating anemia and low hemoglobin levels which will be effective in CKD individuals. 
  • Use of Iron product 
  • Iron supplementation is needed for people who go for dialysis in which ferric pyrophosphate gets into the blood stream raising its levels during the treatment. 

Cinacalcet: The calcium sensor in the parathyroid gland is controlled by the action of cinacalcet which results in the decreased production of parathyroid hormone (PTH). 

  • Dapagliflozin: It inhibits glucose reabsorption into the kidneys which leads to more urine glucose output resulting in the lowering of blood glucose levels. 
  • Canagliflozin: It acts by stopping reabsorption of glucose into the kidneys and into the blood stream. 

In ESRD, doctors go for kidney transplantation in which damaged kidneys are removed or replaced with donor kidney which gets placed in the recipient’s lower abdomen. The donor kidney blood vessels are connected to the recipient’s kidney and its ureter is attached to the bladder of the recipient. This is a major surgery that introduces a new kidney which is healthy into the body by taking out the old diseased kidney. 

CKD is early detected by blood and urine tests and the factors responsible for this disease are obesity, diabetes, hypertension, and smoking which could raise the risk. There are many lifestyle modifications that need to be followed to reduce the effect of CKD which include dietary changes, weight loss, no smoking, and exercise. In the ESRD, dialysis and transplantation of the kidneys are suggested by doctors. 

darbepoetin alfa 

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



dapagliflozin 

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



epoetin alfa 

associated with anemia:

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



alfacalcidol 

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



zibotentan and dapagliflozin 

A recent clinical trial called the ZENITH-CKD trial, showed that the combination of zibotentan and dapagliflozin was more effective in reducing albuminuria than dapagliflozin alone. The trial also showed that the combination was well-tolerated and had a good safety profile. The ZENITH-CKD trial was a Phase 2b trial, which means that it was a small trial to test the safety and efficacy in a small group of people. Larger Phase 3 trials are required to confirm the safety and efficacy of the combination in a larger group of people and to see if it can delay or prevent the progression of CKD



darbepoetin alfa 

Indicated for Chronic kidney disease-associated anemia:


<18 years:
CKD on dialysis
0.45mcg/kg intravenous once a week

CKD not on dialysis
0.45mcg/kg intravenous once a week



epoetin alfa 

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



Free CME credits

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.
 
  • Registration with medtigo = 10 points
  • 1 visit to medtigo’s website = 1 point
  • Interacting with medtigo posts (through comments/clinical cases etc.) = 5 points
  • Attempting a game = 1 point
  • 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.

Our Certificate Courses

Up arrow