Chronic Kidney Disease (CKD): Guide to All 5 Stages and Management Tips

It’s been quite a while since we've delved deep into clinical topics, discussing everything from philosophical themes to social issues. But all these discussions are only truly beneficial when we continuously revisit the broader picture of Chronic Kidney Disease (CKD) or “Gurde ka Daami Marz” as it’s known in Urdu. CKD is such a complex issue with numerous angles that if we focus too much on the details, we might miss the bigger picture. Therefore, I believe it’s the right time to have an episode that provides an overview of CKD, discussing its stages and basics in a comprehensive manner. This is precisely the aim of today’s episode.

Welcome to Today’s Discussion

Assalamu Alaikum! I’m Dr. Waiz, from Expert Kons Clinic, Lahore. Wearing my nephrology hat today, I’m coming to you from my home studio. The next few episodes will be recorded from a travel studio. In today’s episode, I’ll attempt to cover all five stages of CKD within 15 minutes—about three minutes per stage.

Stages One and Two: Early Detection is Key

Stages one and two of CKD are essentially about the risk of kidney damage or existing damage that has not yet manifested as high creatinine levels or low Glomerular Filtration Rate (GFR). The most common early sign of CKD is proteinuria, where protein appears in the urine. This indicates that structural damage has occurred in the kidneys, though the GFR remains normal, and creatinine is within the standard range.

Examples of conditions in stages one and two include:

1. Proteinuria: Protein in the urine suggests kidney damage.
2. Atrophied Kidney: One kidney may shrink.
3. Polycystic Kidney Disease: A genetic disorder leading to cysts in the kidneys.
4. Kidney Transplant Patients: Both recipients and donors fall into this category as they have undergone significant structural changes.

Even though the GFR is still above 60 mL/min and creatinine levels are normal, it’s crucial to diagnose kidney disease early. This includes understanding the etiology—why you have kidney disease, checking for proteinuria, and performing basic laboratory tests such as CBC, renal function tests, liver function tests, serum electrolytes, and others.

Management of Stages One and Two

Management at this stage focuses on controlling the underlying cause of kidney damage. For example, if diabetes is the culprit, managing diabetes is crucial. Similarly, autoimmune disorders might require immunosuppressive medications. Lifestyle changes are also essential at this stage, including regular exercise (45 to 60 minutes), maintaining an active lifestyle, getting adequate sleep (around seven hours), managing stress, and improving social health.

Dietary Recommendations

Though we won’t delve into detailed dietary recommendations here, the general advice is to eat healthily. I plan to cover this topic comprehensively in future episodes. The focus should be on consuming balanced, healthy food to maintain overall well-being.

Transitioning to Stage Three: The Critical Window

Stage three CKD is the most common stage and presents the best opportunity to manage the disease effectively. It’s when the GFR drops below 60 mL/min, and creatinine levels start to rise (possibly above 2.5, depending on age, weight, and gender). At this stage, proper management can significantly slow disease progression.

The first step is accurate diagnosis. It’s not just about asking your doctor to lower your creatinine levels; you need to understand why your creatinine is high. CKD is a symptom, not a disease itself. The underlying cause could be diabetes, high blood pressure, medications, or an autoimmune disorder. Understanding the cause is key to effective management.

Proteinuria in Stage Three

In stage three, knowing the exact amount of protein in your urine is crucial. There are three primary methods to measure this: 24-hour urine protein, urine protein-to-creatinine ratio, and urine albumin-to-creatinine ratio. I’ll link to videos explaining these in detail in the description below.

Laboratory Tests in Stage Three

You’ll need to repeat the basic laboratory tests mentioned earlier, including CBC, renal function tests, liver function tests, and serum electrolytes. Additionally, tests like lipid profiles and HbA1c (if you have diabetes) become important at this stage.

Management of Stage Three

Managing stage three involves addressing the cause of CKD—whether it's diabetes, glomerular diseases, or something else. If you have an autoimmune disorder, appropriate medications are necessary. Kidney-protective medications, such as ACE inhibitors or angiotensin receptor blockers (ARBs), should be a part of your regimen if you're a stage three CKD patient. Studies also suggest that if your cholesterol is not controlled through diet alone, you might need to be on statins.

Lifestyle Changes: Still Relevant

The lifestyle changes we discussed earlier remain crucial: regular exercise, sufficient sleep, stress management, and a balanced diet. Notably, there are no dietary restrictions in stages one through three. If you have a diet chart meant for CKD patients at home, discard it. You are free to eat all kinds of vegetables, pulses, meats, proteins, carbohydrates, and fats as long as they are healthy and consumed in reasonable amounts.

Stage Four CKD: The Challenge Begins

Stage four CKD is when the GFR drops below 30 mL/min, and creatinine levels may rise significantly (even above 3.5). This stage is critical, and it’s vital to understand the diagnosis—why you have reached stage four. Knowing your creatinine levels, GFR, and proteinuria status is essential. For diabetic or hypertensive patients, it's crucial to monitor these numbers closely.

Laboratory Tests in Stage Four

The basic laboratory tests remain the same, but now, serum electrolytes might show abnormalities that weren’t apparent before. For instance, calcium levels may drop, phosphorus levels might rise, bicarbonate may decrease, and parathyroid hormone levels may increase. Hemoglobin levels might also drop.

Managing Stage Four CKD

Managing stage four CKD involves continuing the treatment for the underlying cause, such as managing diabetes or blood pressure. Kidney-protective medications remain essential. If you haven’t started on a cholesterol-lowering medication like statins, your doctor might recommend it now.

Lifestyle and Diet in Stage Four

At stage four, dietary modifications become more critical. While there are still no severe restrictions, you’ll need to pay closer attention to your intake of certain nutrients like phosphorus, potassium, and sodium, as these can significantly affect your condition.

Conclusion: Preparing for Stage Five

As you approach stage five, the final stage of CKD, the challenges intensify. The focus shifts from managing the disease to preparing for possible dialysis or kidney transplant. It’s a complex and daunting stage, but with proper management and lifestyle changes, you can navigate it with resilience.

Stay tuned for future episodes where we will dive deeper into each stage, especially the more challenging aspects of stages four and five. Remember, understanding your condition and actively participating in your treatment plan are the keys to managing CKD effectively.