Dr.

Fadhol

Renal Disease
Classifications

Stages of Chronic
Kidney Disease
1
2
3
4
5

Estimate Glomerular
Filtration Rate
(mL/min)
90*
60 89
30 59**
15 29
<15

*Kidney damage with normal or GFR

**CKD: kidney damage for 3 months with or
without GFR or GFR <60 mL/min/1.73 m2
for 3 months with or without kidney damage

Pharmacokinetic
alterations in CKD

Farmakoki
netik
Absorption
Distribution
Metabolism
Elimination

Parameters Alteration in CKD

believed to be reduced
reduced plasma protein binding
accumulation of active metabolites,
decrease in nonrenal clearance
increased accumulation

COMPLICATIONS FROM CKD

Complications

Possible Associations

Anemia

(see Table for anemia management target parameters

recommended by the NKF-KDOQI), Acute and Chronic Blood
loss, decrease erythropoietin production, decreased red
blood cell lifespan, inadequate dialysis, inadequate iron
store due to iron loss and decrease intake, and multiple comorbid complications, Hyporesponsive to erythropoiesis
stimulating agents

Cardiovascula
r

Problems (accounts for approximately 50% of all deaths)

Ischemic heart disease
Congestive heart failure
Hypertension
Pericarditis

Bone
Metabolism

Renal Osteodystrophy
Calcium, phosphate and vitamin D abnormalities
(hypocalcemia, decreased vitamin D production,
hyperphosphatemia)
Vascular calcification

Dialysis
Related

Hypotension
Dialyzer reactions
Dialysis technical problem

Electrolyte

Disorders Metabolic acidosis

Hyperkalemia and electrolytes abnormality

Fluid
Retention

Hypertension

Gastrointestin Hepatitis
al
Gastritis
Duodenitis
Peptic ulcer disease
Colonic arteriovenous malformations B or C virus

COMPLICATIONS FROM CKD

(cont)
Hematologic

Increased bleeding tendency

Infection

Vascular access
Weaken immune system

Intradialytic
Complications

Hypotension
Muscle cramps
Dialysis disequilibrium syndrome
Arrhythmias and angina
Cardiac arrest

Malnutrition

Occurs up to 50% of ESRD patients

Neurologic Problems

Diabetic peripheral neuropathy (may

respond to
tricyclic antidepressants, carbamazepine,
or
topical capsaicin)
Altered mental status
Uremic seizures

Uremia symptoms

Fatigue
Nausea
Pruritis
Amyloidosis

Special Issues

Diabetes care
Acquired Immunodeficiency Syndrome
Hyperlipidemia
Rehabilitation
Depression
Perioperative Management
Cancer Screening
Noncompliance
Kidney Transplantation
Insurance, medical and prescription
coverage

Sexual Dysfunction and

Pregnancy

Impaired libido
Impotence
Infertility

Dyslipidemias Management
in CKD
LDL >100 mg/dL or 3
months postlifestyle
modification

CKD stage 5, fasting

TG >500 mg/dL

Non-HDL >130 mg/dL

HMG CoA Reductase

Inhibitor (Statin)

Fibrates or Niacin
(Gemfiprozil, DOC)

Lifestyle modification
+
Statin (Fibrate if not
tolerate Statin)

Monitor: LFT, myopathy

CKD & HYPOGLYCEMIC

AGENTS

DRUG

DOSING RECOMMENDATION
CKD Stages 3, 4, or
Kidney Transplant

Dialysis

2nd-Generation Sulfonylureas
Glipizide
(Glucotrol)

Preferred

Preferred

Glimepiride
(Amaryl)

Initiate at Low Dose

Avoid

Gliclazide

Not available in USA

Other Agents

Thiazolidinediones:
Pioglitazone (Actos),
Rosiglitazone
(Avandia)

Meglitinides:
Repaglinide (Prandin)
(reduce dose)
Nateglinide (Starlix)
(reduce dose-CKD;
HDavoid)

Incretin:
Exenatide (Byetta)
Amylin: Pramlintide
(Symlin) (HD?)
DDP-4 inh: Sitagliptin
(Januvia) (reduce
dose)

DRUG

DOSING RECOMMENDATION
CKD Stages 3, 4, or
Kidney Transplant

Dialysis

AVOID
1st generation
sulfonylureas:
Acetohexamide
Chlorpropamide
(Diabinese)
Tolazamide (Tolinase)
Tolbutamide (Tol-Tab)
Insulin

2nd-gen SU:
Biguanides:
Glyburide (Micronase) Metformin
Alpha-glucosidase
(Glucophage)
inh:
Acarbose (Precose)
Miglitol (Glyset)