Chronic Kidney Disease
Irreversible, progressive decline in kidney function occurring over months to years.
Emergency Management: Hyperkalemic emergency requiring IV Calcium Gluconate, Insulin+Dextrose, and emergent hemodialysis.
Progressive, irreversible decline in renal function characterized by structural or functional kidney abnormalities present for >3 months, typically classified by GFR <60 mL/min/1.73m2.
Detailed Overview
CKD is a global health burden predominantly driven by diabetes and hypertension. The progressive loss of nephrons triggers hyperfiltration in remaining nephrons, leading to glomerular sclerosis and further decline. It affects fluid balance, acid-base homeostasis, erythropoiesis, and bone mineral metabolism. Advanced stages lead to uremia requiring renal replacement therapy.
Epidemiology & Demographics
Affects ~15% of the US adult population (37 million people). Higher prevalence in African American and Hispanic populations.
Etiological Mechanism
Diabetic nephropathy (most common, ~40%), hypertensive nephrosclerosis (~27%), glomerulonephritis, polycystic kidney disease.
Primary Causes
Poorly controlled Type 2 Diabetes mellitus, prolonged systemic hypertension, chronic NSAID use.
Initial injury destroys nephrons. Surviving nephrons undergo compensatory hypertrophy and increase single-nephron GFR (hyperfiltration) mediated by efferent arteriolar vasoconstriction (angiotensin II dependent). This increases glomerular capillary hydrostatic pressure, endothelial injury, and podocyte detachment. Protein leaks into the filtrate, causing tubular inflammation and interstitial fibrosis, leading to an irreversible cycle of nephron loss.
Diagnostic Criteria & Guidelines
eGFR <60 mL/min/1.73m2 OR markers of kidney damage (albuminuria >30 mg/g, abnormal imaging, abnormal biopsy) present for >3 months.
BP control (<120/80 mmHg). ACE inhibitors (Lisinopril 10-40 mg PO daily) or ARBs (Losartan 50-100 mg daily) to reduce intraglomerular pressure and proteinuria. SGLT2 inhibitors (Dapagliflozin 10 mg PO daily) for diabetic and non-diabetic CKD with albuminuria to slow progression.
Second-Line & Adjunctive Therapy
Management of complications: Darbepoetin alfa for anemia (target Hb 10-11.5 g/dL). Sevelamer 800 mg PO TID with meals for hyperphosphatemia. Calcitriol 0.25 mcg PO daily for secondary hyperparathyroidism.
Surgical & Procedural Management
Creation of arteriovenous (AV) fistula in Stage 4 for hemodialysis access. Kidney transplantation is the definitive treatment for ESRD.
Patient Counseling & Advice
Educate that CKD is a silent disease; taking protective medications (ACEi, SGLT2i) is vital even if they feel well. NSAIDs like ibuprofen must be completely avoided.
Follow-Up & Monitoring Schedule
Every 3-6 months: Basic Metabolic Panel, Calcium, Phos, PTH, CBC, UACR.
Preventive Strategies
Strict glycemic control (HbA1c <7%) and BP control in diabetic patients.
Highly dependent on stage and proteinuria. Stage 5 requires lifelong dialysis (5-year survival ~40-50% on dialysis) or transplant.