Chapter 38: Renal Disorders

KIDNEY DISEASE, CHRONIC—MINERAL AND BONE DISORDERS (CKD-MBDs)

Population

• – Adults and children.

Recommendations

2017 KDIGO CKD-MBD Guidelines

• – Monitor serum calcium, phosphorus, immunoreactive parathyroid hormone (iPTH), and alkaline phosphatase levels:

  • Beginning with Stage G3a CKD (adults).

  • Beginning with Stage G2 CKD (children).

• – Measure 25-OH vitamin D levels beginning in stage G3a CKD.

• – Treat all vitamin D deficiency with vitamin D supplementation with standard recommended dosing. Decisions to treat should be based on trends of vitamin D levels, not a single level.

• – In Stages G3–5 CKD, consider a bone biopsy before bisphosphonate therapy if a dynamic bone disease is a possibility.

• – In Stages G3–5 CKD, aim to normalize calcium and phosphorus levels.

• – In Stage G5 CKD, seek to maintain a parathyroid hormone (PTH) level of approximately 2–9 times the upper normal limit for the assay.

Source

• – https://kdigo.org/wp-content/uploads/2017/02/KDIGO_CKD_MBD_Guideline_r6.pdf

Comment

1. Options for oral phosphate binders:

   1. Calcium acetate.

   2. Calcium carbonate.

   3. Calcium citrate.

   4. Sevelamer carbonate.

   5. Lanthanum carbonate.

KIDNEY DISEASE, CHRONIC

Population

• – Adults.

Recommendations

2012 KDIGO, 2014 NKF-KDOQI

• – Stage CKD based on cause, GFR category and albuminuria category with abnormalities being present for at least 3 mo.

  • Cause: Assign cause of CKD based on absence or presence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic abnormalities.

  • GFR category

    • G1: GFR >90 (mL/min/1.73 m²)

    • G2: GFR 60–89

    • G3a: GFR 45–59

    • G3b: GFR 30–44

    • G4: GFR 15–29

    • G5: GFR <15

  • Albuminuria category

    • A1: ACR (urine albumin-to-creatinine ratio) <3

    • A2: ACR 3–30

    • A3: ACR >30

• – Use creatinine and GFR estimating equation for initial assessment.

• – Evaluation for chronicity.

  • In those with GFR <60 mL/min/1.73 m² (GFR categories G3a–5), evaluate history of prior indicators for kidney disease and prior measurements.

  • If duration is >3 mo then CKD is confirmed. If not >3 mo CKS is not confirmed or is unclear.

• – Assess GFR and albuminuria at least annually for people with CKD. Assess more frequently for those at higher risk for progression. For people with CKD G3a measure serum cystatin C and calculate GFR using a GFR estimating equation and cystatin C if the confirmation of CKD is required.

• – Management of disease progression.

  • Control BP and individualize BP targets based on age, coexisting comorbidities, presence of retinopathy, and tolerance of treatment.

  • Recommend that an ACE-I or ARB be used in diabetic patients with CKD and urine albumin excretion of 30–300 mg/24 h (or equivalent).

  • Suggest lowering protein intake to 0.8 g/kg/d in adults with diabetes and nondiabetics with GFR categories G4–5.

  • Recommend a large hemoglobin A1C of approximately 7% in people with diabetes ...