Fast Five Quiz: Is Your Knowledge of Chronic Kidney Disease Sufficient?

Vecihi Batuman, MD

Disclosures

April 20, 2018

Indications for renal replacement therapy in patients with CKD include the following:

  • Severe metabolic acidosis

  • Hyperkalemia

  • Pericarditis

  • Encephalopathy

  • Intractable volume overload

  • Failure to thrive and malnutrition

  • Peripheral neuropathy

  • Intractable gastrointestinal symptoms

  • In asymptomatic adult patients, a GFR of 5-9 mL/min/1.73 m², irrespective of the cause of the CKD or the presence of absence of other comorbidities

Treatment of abnormal mineral homeostasis in patients with CKD includes the following:

  • Maintaining serum calcium levels

  • Lowering serum parathyroid hormone levels

  • Providing osteoporosis prophylaxis

  • Lowering high serum phosphorus levels

Definitive evidence on the benefit of lowering phosphate levels in CKD is lacking, and guideline recommendations vary. The KDIGO Implementation Task Force guidelines recommend maintaining serum phosphate levels within the normal range in CKD stages 3-5 and lowering levels toward normal in stage 5D. United Kingdom National Institute for Health and Clinical Excellence (NICE) guidelines provide recommendations only for stages 4, 5, and 5D.

The evidence for the benefits and risks of correcting metabolic acidosis is limited, with no randomized controlled trials in patients who are not yet in ESRD, none in children, and only three small trials in dialysis patients. These trials suggest some beneficial effects on protein and bone metabolism, but the studies were underpowered and therefore did not provide robust evidence.

KDIGO guidelines recommend wider statin use among patients with CKD. Specific recommendations include the following:

  • Adults aged 50 years or older with an estimated GFR of < 60 mL/min/1.73 m2 who are not being treated with long-term dialysis or kidney transplantation should be treated with a statin or a statin plus ezetimibe

  • Treatment with statins or statin/ezetimibe should not be initiated in adults with dialysis-dependent CKD

  • Patients already being treated with a statin at the time of dialysis should continue

  • Adult kidney transplant patients should be treated with a statin because of an increased risk for coronary events

  • Adults aged 18-49 years with an estimated GFR of < 60 mL/min/1.73 m2 who are not being treated with dialysis or kidney transplantation should be treated with statins if they have coronary disease, diabetes, prior ischemic stroke, or an estimated 10-year incidence of coronary death or nonfatal myocardial infarction > 10%

  • Low-density lipoprotein cholesterol is an insufficient test for cardiovascular risk in individuals with CKD, and adults with newly diagnosed CKD should undergo lipid profile testing

  • Adults aged 50 years or older with CKD and an estimated GFR of 60 mL/min/1.73 m2 or higher should be treated with a statin

For more on the treatment of pathologic manifestations of CKD, read here.

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