The Purple Book

CKD

CKD is classified according to estimated GFR (eGFR) and urine albumin:creatinine ratio (ACR). NICE CKD guidelines

Main causes:

• diabetes - 45%
• HTN - 25%
• immune/inherited - 15%
• other -15%

Symptoms

• usually asymptomatic
• end-stage manifestations will include:
  • chest pain - pericarditis
  • confusion, delirium - encephalopathy
  • peripheral neuropathy
  • GI symptoms - anorexia, nausea, vomiting, diarrhoea
  • skin symptoms - dryness, pruritis, ecchymosis
  • fatigue, somnolence

Signs

• usually only signs of complications or underlying cause
• depression in 50% who require dialysis

Tests

• electrolytes, FBC, clotting, bone profile, urinalysis
• serum and urine protein electrophoresis
• ANA and double stranded DNA for SLE
• complement levels, ANCA and P-ANCA, anti-GBM antibodies
• Hep B, C, HIV and VDRL
• USS, CT scan, MRI, renal biopsy

Management

• aggressive Mx of HTN - ACEi, ARB
• SGLT2 inhibitor - dapagliflozin
• aggressive Mx of diabetes
• Mx of PO4, Ca++, PTH

• Do not offer a combination of renin–angiotensin system antagonists to adults with CKD.
• Measure se K+ and estimate the GFR before starting renin–angiotensin system antagonists in people with CKD.
• Repeat bloods: 1-2/52 after starting renin–angiotensin system antagonists and after each dose increase.
• Do not routinely offer a renin–angiotensin system antagonist if pretreatment K+>5.0mmol/L and stop if >6

• calcium acetate - for CKD stage 4, 5 and hyperphosphataemia
• sevelamer carbonate - if calcium acetate is not indicated (eg. if hypercalcaemia or low parathyroid hormone)

KDIGO 2012