KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

Kidney International, Journal Year: 2024, Volume and Issue: 105(4), P. S117 - S314

Published: March 13, 2024

This article is published as part of a supplement sponsored by Kidney Disease: Improving Global Outcomes (KDIGO). The opinions or views expressed in this are those the authors and do not necessarily reflect recommendations International Society Nephrology Elsevier. Dosages, indications, methods use for products that referred to may their clinical experience be derived from professional literature other sources.

Language: Английский

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Metabolic Acidosis in Chronic Kidney Disease: Pathogenesis, Clinical Consequences, and Treatment

Electrolytes & Blood Pressure, Journal Year: 2021, Volume and Issue: 19(2), P. 29 - 29

Published: Jan. 1, 2021

The kidneys play an important role in regulating the acid-base balance. Metabolic acidosis is common chronic kidney disease (CKD) patients and can lead to poor outcomes, such as bone demineralization, muscle mass loss, worsening of renal function. usually approached with evaluating serum bicarbonate levels but should be assessed by counting blood pH. Current guidelines recommend oral supplementation maintain within normal range. However, a slow decline glomerular filtration rate might occur, even though were Because decrease when metabolic advances, other biomarkers are necessary indicate acid retention for early diagnosis acidosis. For this, urine citrate ammonium excretion may used follow course CKD patients. treated increased fruit vegetable intake alkali supplementation. Previous studies have suggested that administration sodium preserve function without significant increases pressure body weight. Veverimer, non-absorbed, counterion-free, polymeric drug, emerging treat acidosis, further researches awaited. Further also needed clarify target therapeutic range drugs

Language: Английский

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Nutritional Approaches for the Management of Metabolic Acidosis in Chronic Kidney Disease

Nutrients, Journal Year: 2021, Volume and Issue: 13(8), P. 2534 - 2534

Published: July 24, 2021

Metabolic acidosis is a severe complication of chronic kidney disease (CKD) which associated with nefarious impairments such as bone demineralization, muscle wasting, and hormonal alterations, for example, insulin resistance. Whilst it possible to control this condition alkali treatment, consisting in the oral administration sodium citrate or bicarbonate, type intervention not free from side effects. On contrary, opting implementation targeted dietetic-nutritional treatment CKD metabolic also comes range additional benefits lipid profile control, increased vitamins, antioxidants intake. In our review, we evaluated main dietary-nutritional regimens useful counteract acidosis, Mediterranean diet, alkaline low-protein vegan analyzing potentialities limits every treatment. Literature data suggest that diets represent valid nutritional approach prevention correction early stages, while diet are more effective advanced stages. conclusion, propose tailored approaches should therapeutic alternative acidosis.

Language: Английский

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Sodium citrate versus sodium bicarbonate for metabolic acidosis in patients with chronic kidney disease: A randomized controlled trial

Medicine, Journal Year: 2024, Volume and Issue: 103(10), P. e37475 - e37475

Published: March 8, 2024

Background: Metabolic acidosis (MA) is frequently associated with chronic kidney disease (CKD) progression. Our aim was to compare the effect of oral sodium citrate (SC) that bicarbonate (SB) on renal function and serum correction, as well evaluate their safety profile in patients MA CKD. Methods: We conducted a prospective, single-center, randomized 1:1, parallel, controlled, unblinded clinical trial 124 CKD stages 3b 4. The primary outcome mean change estimated glomerular filtration rate (eGFR). secondary outcomes were level, eGFR decrease by 30%, 50%, dialysis, death or prolonged hospitalization, combined endpoint. Results: No significant difference found between groups terms [adjusted = −0.99 mL/min/1.73 m 2 (95% CI: −2.51 0.93, P .20)]. observed 6.15 mmol/L [(95% 5.55–6.74), < .001] SC group 6.19 5.54–6.83), SB group, but no 0.31 (−0.22 0.85), .25]. Cox proportional hazard analysis showed similar risks regarding 30% ( .77), 50% .50), dialysis .85), hospitalization .29), endpoint .57). Study drug discontinuation due adverse events significantly more common (17.7% vs 4.8%, .02). Conclusions: have decline, both improve higher rates medication events.

Language: Английский

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Dietary anions control potassium excretion: it is more than a poorly absorbable anion effect

AJP Renal Physiology, Journal Year: 2023, Volume and Issue: 325(3), P. F377 - F393

Published: July 27, 2023

The urinary potassium (K

Language: Английский

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Acidosis, cognitive dysfunction and motor impairments in patients with kidney disease

Nephrology Dialysis Transplantation, Journal Year: 2021, Volume and Issue: 37(Supplement_2), P. ii4 - ii12

Published: July 6, 2021

ABSTRACT Metabolic acidosis, defined as a plasma or serum bicarbonate concentration &lt;22 mmol/L, is frequent consequence of chronic kidney disease (CKD) and occurs in ~10–30% patients with advanced stages CKD. Likewise, transplant, prevalence rates metabolic acidosis range from 20% to 50%. CKD has recently been associated cognitive dysfunction, including mild impairment memory attention deficits, reduced executive functions morphological damage detectable imaging. Also, impaired motor loss muscle strength are often found CKD, which part may be attributed altered central nervous system (CNS) functions. While the exact mechanisms how cause dysfunction still debated, recent data point towards possibility that one modifiable contributor dysfunction. This review summarizes evidence for an association between discusses potential by impact CNS The also identifies important open questions answered improve prevention therapy setting

Language: Английский

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Conservative management of advanced chronic kidney disease in primary care setting

Singapore Medical Journal, Journal Year: 2025, Volume and Issue: 66(1), P. 41 - 46

Published: Jan. 1, 2025

Opening Vignette Mrs. Tan is an 85-year-old grandmother who visits the polyclinic for routine follow-up of her chronic conditions. She has underlying diabetes mellitus (DM), hypertension and hyperlipidaemia past 20 years. You notice that estimated glomerular filtration rate (eGFR) been falling by 3 mL/min/1.73 m2 per year over last years she now stage 4 kidney disease (CKD) with eGFR m2. Her DM are well controlled glycated haemoglobin (HbA1c) 6.9% average blood pressure (BP) 110/80 mmHg. does not smoke or drink alcohol. independent in activities daily living enjoys walking as a form exercise. usually comes to clinic unaccompanied adherent medications follow-ups. have advising about risk failure requiring dialysis visit nephrologist. However, refused, feels wish burden son care adhere schedule. asks if could continue at polyclinic, it convenient her.WHAT IS ADVANCED CKD? Chronic defined <60 months more, irrespective cause. Kidney severity classified into five stages according level GFR degree albuminuria/proteinuria. Advanced CKD includes 5 classification, <30 HOW RELEVANT THIS TO MY PRACTICE? In Singapore, prevalence was reported be 15.6% 2007. This projected increase 24.3% 2035.[1] The rise contributed our ageing population increasing (DM) hypertension.[2] associated many complications. Dialysis discussion planning initiated 4. patients older, frail multiple comorbidities, unclear whether improves health survival. There evidence suggest can negatively impact quality life functional status certain subsets patients, will instead benefit more from conservative management (CKM).[3,4] Efforts should focused on slowing progression optimising via shared decision-making promoting patient values preferences implementation advance (ACP) coordinated palliative care.[5] After formal review nephrologist decision CKM, this group between primary physicians specialists. also decline nephrology referrals but their providers. Therefore, important familiar principles nondialytic advanced disease.[6] article focuses conservatively managed. WHAT CAN I DO IN Slowing Optimising developed countries, leading causes CKD, especially elderly.[7] 70% new cases end-stage (ESKD) attributed DM.[8] Various guidelines differ regards recommendations target A1c CKD. KDIGO (Kidney Disease Improving Global Outcomes) clinical practice guideline commonly used local practice. An HbA1c 7%–7.5% suitable most CKD,[7] individualised, individuals comorbidities limited expectancy, where higher 8%–8.5% likely acceptable. Metformin stopped when falls below 30 (CKD 5). It recommended start sodium–glucose transport protein 2 (SGLT2) inhibitors <25 m2, these drugs continued till earlier course Similarly, there considerable variation suggested various guidelines. For managing elderly we BP <140/90 mmHg, lowered <130/80 mmHg tolerated.[7] Patients often renin–angiotensin system blockade, including angiotensin-converting enzyme (ACE-Is) angiotensin receptor blockers (ARBs), aim reduce proteinuria slow function. 4, ACE-I/ARBs still continued; however, 25% dose reduction may considered hyperkalaemia rapid (>4 year). When <15 ACE-I ARBs discontinued. proteinuric (with without DM) treatment SGLT2 inhibitors. According DAPA-CKD (Dapagliflozin Prevention Adverse Outcomes Disease) trial,[9] dapagliflozin reduced adverse renal cardiovascular outcome 39%. As mentioned above, Lifestyle changes Nutritional therapy delay facilitate better complications such electrolyte acid–base imbalances, water salt retention, mineral bone disorders thrive. Studies intake helps lower urea production. A very low diet (<0.6 g/kg/day) supplementation essential amino acids ketoacids (e.g., ketosteril) beneficial select groups. Dietary sodium restriction control fluid retention. established progression.[10] following CKD:[11] (a) maintain 0.8 g/kg/day <2 g/day; (b) undertake moderate-intensity physical activity cumulative duration least 150 min/week, compatible tolerance, possible; (c) stop smoking, smoking function, disease, cause mortality population. Medication Patients' medication list regularly reviewed, adjustments based These develop gout flares progresses.[11] advised avoid nonsteroidal anti-inflammatory cyclooxygenase-2 appropriate, urate-lowering considered. Managing multisystem Table 1 shows investigations screening intervals.Table 1: Recommended test intervals 5.[ 8 ]Anaemia anaemia, Anaemia Hb <13 g/dL males <12 females, 10 g/dL. undergo full count twice year. Those anaemia further evaluation serum iron, folate vitamin B12 levels. Ferritin >500 ng/mL transferrin saturation (Tsat) >20% maintained oral iron supplementation. Erythropoiesis-stimulating agents adequate reduces requirement transfusions exercise capacity. Commonly recombinant erythropoietin preparations include Recormon (epoetin beta), Aranesp/Nesp (darbepoetin alfa) Mircera (methoxy polyethylene glycol-epoetin which administered subcutaneously. erythropoietin, levels checked every months. Metabolic acidosis metabolic acidosis, lead increased loss, progression, hypoalbuminaemia insulin resistance. Multiple studies bicarbonate <22 mEq/L outcomes, demineralisation, skeletal muscle catabolism death, whereas >28 vascular calcification death.[12,13] started PO 500 mg BD (serum 19–21 mEq/L) g <18 achieve normal >22 mEq/L. titrated monthly up TDS. exceeding concentrations >29 mEq/L, since CKD.[7] Hyperkalaemia developing hyperkalaemia. They low-potassium raise potassium concentration. ACE-Is/ARBs need discontinued persistent managed refractory hyperkalaemia, prescribe regular polystyrene sulfonate three times week. Other like zirconium cyclosilicate (commonly known Lokelma) available Singapore prescribed nephrologists unable tolerate due gastrointestinal side effects. Fluid overload prone overload. generally respond combination dietary (<2 g/day) diuretic therapy. advisable keep weight diary; provide guidance range ideal titration diuretics. diuretics, frusemide, maximum dosage 120 volume overload, thiazide-like diuretics metolazone) addition loop short 2–3 days. Mineral suggested: screen calcium phosphate 3–6 check 25-hydroxyvitamin D correct any deficiency insufficiency strategies general Phosphate retention common patients. binders limit development secondary hyperparathyroidism. Calcium-based normophosphataemia. two acetate carbonate. non-calcium-based (lanthanum sevelamer). take meals. Preventive infections. Adults vaccinated influenza, coronavirus 2019, pneumococcal conjugate polyvalent vaccines, unless contraindicated.[7] Palliative Shared process healthcare professional works closely reach informed decision. involves information sharing risks, benefits possible consequences options, consideration patient's preferences, beliefs values. empowers make decisions would line goals time. Comprehensive actively symptoms, ACP provision appropriate care.[5,11] Advance national programme serves platform enables conversations caregivers, wherein goals, values, discussed. pathway feel despite worsening do think they serious life-limiting illness. acute deterioration becoming acutely symptomatic. If in-house programmes institution, referred providers (https://www.aic.sg/care-services/acp-directory). Estimating prognosis Unlike malignancy, prognostication ESKD challenging, median survival ranging 6 years.[14] reviews required monitor trajectory symptoms. prognostic tools assist clinicians predicting group. Some examples 'Predicting 6- 12-Month Mortality calculator' 'The Gold Standards Framework Centre End-of-Life Care 2011'. Basic provided physicians. aims improve illness families through prevention relief suffering. symptomatic (including decline), consider referral home hospice specialist review. services [Table 2]. deemed suitable, apply Agency Integrated (AIC) platform. indicate preference choice facility, considering factors location provided.Table 2: List different Singapore.Terminal extensive needs before death. Throughout trajectory, symptom high. symptoms management.[15] Pain Common pain osteodystrophy, peripheral neuropathy, ischaemic heart calciphylaxis. Where possible, treating pain, e.g., good wound case related ulcers use neuropathy. Otherwise, guided World Health Organisation ladder: mild: paracetamol, moderate: tramadol (dose adjusted creatinine clearance [CrCl] 10–30 mL/min; 50–100 BD; CrCl <10 mL/min), severe: fentanyl opioid CKD; morphine excreted renally avoided small doses (when necessary) longer intervals, (d) adjuvants: gabapentin/pregabalin require adjustment. Nausea/vomiting constipation Treatment same Haloperidol drug nausea uraemia. Metoclopramide stasis obstruction impeding gastric emptying, frequently seen diabetic prudent laxatives lots fluids, Fybogel. Diuretics status, poor vomiting dehydration, turn, worsens uraemia its Dyspnoea experience dyspnoea anxiety. Physicians try treat reversible appropriate. hypoxia offered oxygen Nonpharmacological measures, air circulation, respiratory physiotherapy occupation therapy, some relief. accumulation secretions tract complication near end life. decrease secretion production discomfort. N-butylscopolamine bromide (Buscopan) decreases subcutaneously Pharmacological measures opioids. Itch itch. uraemia, hyperphosphataemia, dry skin. relieve itch water-based emollients other adjuncts phototherapy acupuncture. required, pharmacological used. Antihistamines uraemic pruritus, sedative properties helpful sleep disorders. described gabapentin/pregabalin, serotonin (5-hydroxytryptamine type 3) selective reuptake Anxiety anxiety agitation, anxiolytics, mainly benzodiazepines, prescribed. Pill found 11 types medications, nonadherence. <3 months, recommend view pill priority changes. alleviate WHEN SHOULD REFER SPECIALIST? model collaboration among practitioners skills knowledge disciplines deliver tailored needs. involve physician, nephrology, no previous replacement (RRT) >5 year.[7] versus CKM complex dependent wishes, prognosis. refer initial explicitly state refuse medical optimisation hyperphosphataemia initiate hyperparathyroidism cases. then discharged comanaged progresses ESKD, crucial physician indicated, difficult manage psychological, social spiritual support required. Supplemental Digital Appendix https://links.lww.com/SGMJ/A161 summary TAKE-HOME MESSAGES refers planned, holistic patient-centred preferences. option frailty. high burden, assessed accordingly. (nephrology indicated). being community online AIC Closing Over family conference, you discuss Tan's expected family, counsel them RRT CKM. Mrs shares pursue hopes hospitalisations. wants respect wishes focus goal comfort. ACP. Six later, 15 finds leave house appointments. nonessential service.Financial sponsorship Nil. Conflicts interest Goh LH member SMJ Editorial Board thus involved peer publication article. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline submission: pm, 14 February 2025

Language: Английский

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Positive Effekte auf Muskulatur und Progression einer Nierenkrankheit - Behandlung der metabolischen Azidose bei chronischer Nierenkrankheit

Nephrologie aktuell, Journal Year: 2025, Volume and Issue: 29(03), P. 109 - 109

Published: April 1, 2025

Zusammenfassung Bei dem Vorliegen einer chronischen, metabolischen Azidose bei eingeschränkter Nierenfunktion und chronischer Nierenkrankheit (CKD) besteht immer wieder die Diskussion, ob eine Behandlung, welche einfach möglich ist, sinnvoll ist. Kleinere Studien haben gezeigt, dass Progression deutlich verzögert werden kann 1. Weiter gibt es Hinweise, Muskulatur Ausgleich besser erhalten 2. Die Evidenzlage ist aber nicht robust dies führt zu Diskussionen. Deshalb vorliegende Arbeit sehr wichtig, weil bekannten Evidenzen im Sinne Metaanalyse zusammengefasst werden.

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Metabolische Azidose bei Urämie

Nephrologie aktuell, Journal Year: 2025, Volume and Issue: 29(03), P. 132 - 138

Published: April 1, 2025

Zusammenfassung Die metabolische Azidose ist eine häufige Komplikation der chronischen Nierenerkrankung (CKD). Mit voranschreitendem GFR-Verlust sinkt die renale Säuresekretion und Pufferkapazität Nieren, was zu einer Instabilität des pH-Wertes damit ernsthaften Folgeerkrankungen führt. Stabilisierung das prioritäre Therapieziel wird folgend diskutiert.

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Effects of an Iso‐Osmotic Chloride‐Free Solution With High Strong Ion Difference vs. Ringer's Lactate on Non‐Lactate Metabolic Acidosis in Dogs

Journal of Veterinary Internal Medicine, Journal Year: 2025, Volume and Issue: 39(3)

Published: April 15, 2025

ABSTRACT Background Metabolic acidosis is a common acid–base disorder in critically ill dogs, with fluid therapy being key but debated treatment. Sodium bicarbonate's risks have spurred interest safer alternatives such as sodium lactate. Objectives To compare the efficacy of chloride‐free, high strong ion difference solution (H‐SID) to Ringer's lactate (RL) for treating metabolic acidosis, hypothesizing superiority H‐SID solution. Animals Forty‐six dogs from two veterinary hospitals. Methods Prospective randomized multicenter study. Dogs were randomly assigned receive either RL or at infusion rates 4 10 mL/kg/h h, based on their volume status. was compounded (145 mmol/L), potassium (10 and aspartate mmol/L) sterile water injection. Results The group showed significant increase BE‐ecf (mmol/L) ( p < 0.001) when compared group. At lower rate, median 4.1 mmol/L (95% CI: 3.37, 6.71), whereas exhibited variation −0.1 −0.75, 2.2). higher 11 8.16, 12.52) 1.3 0.01, 2.96). Conclusions Clinical Importance Our results indicate alkalizing effect non‐lactic demonstrating superior without notable adverse effects.

Language: Английский

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