Category:

Clinical Management of Chronic Kidney Disease

Course Outline

Chronic kidney disease (CKD) describes any degree of kidney injury or impaired kidney function that persists for >3 months. CKD is used because it is understandable to clinicians and patients and replaces multiple terms previously used to describe various and frequently over-lapping stages of kidney disease. CKD is a nonspecific term that does not include the cause for the injury and/or impaired kidney function.

There is now compelling evidence of the need for early identification and management of patients with chronic kidney disease (CKD). The evidence also indicates that current care of CKD patients is suboptimal. Accumulating experience indicates that the development of multidisciplinary teams that collaborate to improve patient care should be encouraged. This is based on the observation that patients cared for in a multidisciplinary clinic have higher hemoglobin, albumin, and calcium levels at the start of dialysis, with better survival in the initial months of dialysis than patients treated by nephrologists alone. Numerous studies have also shown a survival advantage for patients referred to nephrologists early (for these studies, early was defined as >1 month before the start of renal replacement therapy [RRT]). Timeliness and appropriateness of referral to nephrologists is important.

The roles of primary care physicians (PCPs) and nephrologists in the care of patients are needed and should be defined. Although differences exist with respect to the recommended time of referral, this is optimally at least 1 year before the anticipated need for RRT in patients with slowly progressive disease.

The goals for CKD care include:

  • Delaying progressive loss of kidney function
  • Modifying the risk for developing comorbid conditions
  • Preventing complications of progressive CKD
  • Improving quality of life
  • Ensuring adequate preparation for RRT

About Authors

William M. McClellan, MD
Clinical Professor of Medicine
Emory University School of Medicine

Anton C. Schoolwerth, MD
Visiting Professor of Medicine
Hypertension/Nephrology
Darthmouth-Hitchcock Medical Center
Darthmouth Medical School

Todd Gehr, MD
Chairman, Department of Nephrology
Virginia Commonwealth University Health System
Medical College of Virginia Hospitals

Learning Objectives

After completing this course you’ll be able to:

  1. Define CKD.
  2. List the five broad categories of GFR and briefly describe each.
  3. Define GFR.
  4. State why the serum creatinine is a poor estimator of GFR.
  5. Describe the MDRD study equation and clinical trial.
  6. List several factors other than kidney disease that can account for a low estimated GFR.
  7. State the two important trends that will increase the number of ESRD patients in the future.
  8. Discuss the finding of NHANES regarding racial disparities.
  9. List the four patient groups at high risk for CKD.
  10. List predisposing factors, initiating factors and progression factors of CKD.
  11. Compare features of progressive CKD in type 1 and type 2 diabetic patients.
  12. Describe the microalbumin test and what conditions result in false positive results.
  13. List the three recommendations that those at high risk for diabetes should incorporate into their life style.
  14. List the three points of the UKPDS regarding blood pressure control.
  15. Describe the modifications of the DASH diet in stages 3 and 4 in CKD.
  16. Define malignant hypertension.
  17. Describe the AASK study.
  18. Compare mortality of dialysis patients and the general population.
  19. Describe smoking cessation and kidney disease.
  20. List the five diagnostic traits of the metabolic syndrome.
  21. List nontraditional risk factors for CVD and CKD.
  22. State the preferred first line therapy for hypertension in patients with either diabetic or
  23. Discuss the use of loop diuretics with hyperkalemia.
  24. List factors that contribute to hyperkalemia.
  25. Discuss albuminuria and macroalbuminuria.
  26. State at what point a nephrologist should be consulted.
  27. Discuss the incidence and cause of anemia in patients with CKD.
  28. Compare Procrit and Aransep (Table 10.1).
  29. List three reasons iron deficieincy is common in patients with CKD.
  30. Discuss the abnormalities of calcium and phosphorous in CKD.
  31. Discuss the role of Vitamin D in CKD.
  32. Discuss the restriction of dietary phosphorous and phosphorous binding agents.
  33. Compare Paracalcitrol and doxercalciferol.
  34. State how the central nervous system is affected by acidosis.
  35. Compare AVFs and AVGs.
  36. Discuss dyslipidemia and cardiovascular disease in the CKD patient.
  37. List and describe the three steps in drug dosing in the CKD.
  38. Explain Medicare coverage for ESRD.
  39. Describe the role of the primary care physician, nephrologist and other team members in

Course Contents

  1. Chronic Kidney Disease (CKD): Definition
  2. Detection of CKD: Estimation of Glomerular Filtration Rate
  3. Epidemiology of CKD
  4. Progression of CKD
  5. Diabetes and CKD
  6. Hypertension and CKD
  7. Management of Cardiovascular Risk Factors
  8. Central Role of Renin-Angiotensin-Aldosterone System Blockade
  9. Management of Proteinuria
  10. Management of Anemia
  11. Prevention of Renal Bone Disease
  12. Metabolic Acidosis in CKD
  13. Vascular Access and AV Fistula
  14. Diet and Nutritional Therapy
  15. Drug-Dosing Considerations
  16. Special Issues for the Patient Who Is Preparing for Dialysis
  17. CKD Clinics/Joint Management
    Index