CKD 2

Question 1

CKD: Who is at risk?

Answer 1

● Age (>60 years), as we age, lose 1% of kidney fxn after 35 years
● Hypertension
● Diabetes
● Family History
● Vascular disease
● Nephrotoxic drugs (NSAIDS, lithium) - ppl taking NSAIDS regularly (even OTC)
● History of AKI (prior insults)
● Multisystem diseases with potential kidney
involvement (Lupus autoimmune disease)
● Health disparity (lower income)

Question 2

Symptoms of CKD

Answer 2

● General: fatigue, edema, decreased urine
output
● Cardiac: hypertension, heart failure,
pericarditis, athersclerosis
● Dermal: pruritis
● GI: anorexia, nausea/vomiting, altered
taste, constipation, bleeding
● Neuromuscular: restless leg syndrome,
muscle cramps, imparied cognition,
peripheral neuropathy
● Malnutrition
● Bone pain  (CDK mineral bone disease)

Question 3

stage 1 CKD

Answer 3

Kidney damage with normal
or ↑ GFR
GFR ≥ 90

• see damage with ultrasound

Question 4

stage 2 CKD

Answer 4

Kidney damage with mild
or decreased GFR
GFR 60-89

Question 5

stage 3 CKD

Answer 5

Moderate ↓ GFR

30-59

Question 6

stage 4 CKD

Answer 6

Severe ↓ GFR

15-29

Question 7

stage 5 CKD

Answer 7

Kidney Failure/End Stage
Renal Disease
< 15 or dialysis

Question 8

how is CKD defined?

Answer 8

Chronic kidney disease is defined as either kidney damage or GFR < 60 for ≥ 3 months

Question 9

read

Answer 9

• G1–GFR> 90 ml/min/1.73m2
• G2–GFR 60-89 ml/min/1.73m2
• G3a – GFR 45-59 ml/min/1.73m2
• G3b – GFR 30-44 ml/min/1.73m2
• G4 - GFR 15-29 ml/min/1.73m2
• G5 - GFR < 15 ml/min/1.73m2
 or on dialysis (5d)

Question 10

Staging via Albumin:Creatinine Ratio

what are the 3 stages

Answer 10

A1 – ACR <3.0mg/mmol (normal – high)
• A2 – ACR 3.0-30 mg/mmol (high)
• A3 – ACR>30 mg/mmol (very high)

Question 11

management of CKD

goals of therapy

Answer 11

● Stabilize renal function
● Delay progression to end stage renal disease
○ Dialysis
○ Transplant
● Treat/prevent complications of CKD

Question 12

Lifestyle Management

increases their heart rate

Answer 12

● Exercise: 30-60 minutes 4-7 days per week.
● Weight loss where required
● Smoking cessation
● Adequate fluid intake
● Low sodium diet (<2000mg/day)
● Other recommendations to reduce cardiovascular risk:
○ Limit alcohol intake < 2 standard drinks per day
○ Reduce dietary protein intake 0.8-1.0 g/kg/day

Question 13

Protein Restriction: 0.8-1.0g/kg/day

Too high protein can exacerbate progression of CKD

Answer 13

● May be recommended for adults not on dialysis :
○ Patients with >1g/day of proteinuria despite optimal BP control with an ACE inhibitor or ARB
● Avoid malnutrition
● Do not implement in patients who are < 80% IBW or with >10 g/day proteinuria

Question 14

Pharmacological Management

Answer 14

● Glycemic control
● Blood pressure control
○ <130/80 mmHg (diabetic)
○ <120/80 mmHg (non-diabetic kidney disease)
○ Often requires multiple agents to attain target
● Avoid potentially nephrotoxic drugs

Question 15

Renin Angiotensin Aldosterone System (RAAS) Inhibition:
ACE inhibitors and ARBS

drugs
which classes do we use?

Answer 15

Direct renin inhibitors not effectiv ein long term, adverse effects
We use ACEi and angio receptor blockers

ACEi:
● Ramipril
● Perindopril
● Lisinopril
● Enalapril
● Fosinopril
● Quinapril
ARB:
● Irbesartan
● Telmisartan
● Candesartan
● Olmesartan
● Valsartan
● Eprosartan

Question 16

ACEi & ARBs - Recommendations

Answer 16

● Diabetes - ACEi or ARB unless contraindicated
● Non-diabetes - ACEi or ARB if ACR > 3mg/mmol and no contraindications

Mechanism:
● Reduce intraglomerular hypertension by blocking the vasoconstrictive effect
of angiotensin II on the efferent arterioles
● Reduce hyperfiltration
● reduce/stabilize proteinuria

Question 17

Benefits of ARB and ACEi

Answer 17

● Reduce albuminuria
● Reduce progression to ESRD/Dialysis
● Reduce the development of new diabetic nephropathy
● Reduce progression of nephropathy in albuminuric normotensive patients.
● Benefits of ACEi and ARBs appear to be independent of their BP-lowering effective hence they are considered to be renoprotective

Question 18

Monitoring of ACEi and ARBs

Answer 18

● Risk of acute kidney injury due to the hemodynamic effects
○ Clinical setting of acute volume depletion: dehydration, heart failure
● Temporarily suspend therapy in the setting of acute illness (to prevent AKI)

● Contraindications: Pregnancy, bilateral renal artery stenosis
● Adverse effects:
○ ACEi: bothersome dry cough (Not seen with ARBS)
○ Angioedema (rare)
● Start with low doses and titrate upwards slowly
○ Expect ~20% increase in serum creatinine (corresponding decrease in GFR) within 1-2 weeks
- reversible
○ Monitor creatinine and potassium 1-2 weeks after initiation or dose increases, then every 3-6
months.

Question 19

Treatment of Proteinuria

Answer 19

● ACEi and ARBs are the drugs of choice
● Non-dihydropyridine calcium channel blockers (verapamil or diltiazem)
○ Not first line, but have some effectiveness, not as good as ACEI and ARB
● Spironolactone may decrease proteinuria in carefully selected patients
○ Caution re: hyperkalemia (already at risk of retaining K+)

Question 20

Sodium-glucose Co-transporter-2 Inihibitors
(SGLT-2 Inhibitors): empagliflozin,
dapagliflozin, canagliflozin

Answer 20

● Developed for management of blood glucose in diabetes
● Reduce cardiovascular outcomes
● Mechanism: Reduce renal tubular glucose reabsorption, thereby reducing
blood glucose levels.
● Possible mechanism for use in nephropathy:
○ Reduction of hyperfiltration by restoration of tubuloglomerular feedback

Question 21

SGLT-2 Inhibitors in CKD

Answer 21

● Reduce intraglomerular pressure in individuals with AND without diabetes
● Reno-protective - slow progression of CKD
● Type 2 DM + proteinuric CKD - progression to ESRD is reduced by canagliflozin, empagliflozin and dapagliflozin
● In patients with proteinuric CKD without type 2 DM, risk of kidney disease progression is reduced by dapagliflozin

Question 22

SGLT-2 Inhibitors - Recommendations

Answer 22

● In addition to traditional therapy with ACEi or ARB, SGLT-2 inhibitors should
be considered as add-on therapy in:
○ Patients with Type 2 DM, CKD with eGFR ≥ 25ml/min/1.73m2
○ Patients with non-diabetic CKD with eGFR ≥ 25ml/min/1.73m2
● Ongoing trials with patients with lower eGFR (< 25ml/min/1.73m2)
● Type 1 DM patients - trials ongoing

Question 23

Cardiovascular Risk Reduction

2 drugs to prescribe

Answer 23

● Lipids
○ Prescribe a statin unless contraindicated in all patients > 50 years
○ Prescribe a statin in patients 18-49 in patients at moderate-high risk
● ASA
○ Low dose 81 mg
○ Primary prevention - no
○ Secondary prevention - yes
Primary prevention - never had a heart attack
Secondary prevention - someone who has already had heart attack

ASA not shown to help for primary

CKD pt - should be prescribed a statin
Aspirin cardiprotective for pt who had heart attack

Question 24

CKD - Sick Day Management

Risk of pt taking these drugs is greater if dehydrated

Answer 24

● If unable to maintain adequate fluid intake during illness, potentially
nephrotoxic or renally excreted drugs be held until the patient has recovered.
S A D M A N S
● Sulfonylureas, ACEi, Diuretics, Metformin, ARB, NSAIDs, SGLT2 inhibitors