Introduction

{“title”:”Comprehensive Workup and Management of Chronic Kidney Disease in India”,”excerpt”:”A detailed guide on the diagnostic workup, imaging, laboratory tests, and pharmacologic management of CKD across stages as practiced in India.”,”content_html”:”n

Chronic Kidney Disease (CKD) is a growing public health issue in India, driven by diabetes, hypertension, glomerulonephritis, and infectious causes. Early diagnosis and stage‑specific management are essential to slow progression, prevent complications, and reduce mortality.

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1. Initial Clinical Assessment

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• History: Diabetes, hypertension, family history of kidney disease, exposure to nephrotoxins (e.g., herbal medicines), infections such as hepatitis B/C.

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• Physical Examination: Blood pressure, peripheral edema, ankle reflexes, and signs of volume overload.

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• Baseline Laboratory: Serum creatinine, eGFR (CKD‑EPI), urinalysis, urine albumin-to-creatinine ratio (ACR).

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2. Urine Tests – Core Screening

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• Spot Urine Albumin‑to‑Creatinine Ratio (ACR):
  • Microalbuminuria: ACR 30‑300 mg/g.
  • Macroalbuminuria: ACR >300 mg/g.

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• Urine Dipstick: Detects protein, hematuria, leukocytes.

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• 24‑Hour Urine Protein: Quantitative assessment for patients with equivocal dipstick.

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• Urine Culture (if infection suspected): Especially in patients with urinary symptoms.

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3. Imaging Studies – Anatomical and Functional Evaluation

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• Renal Ultrasound:
  • Kidney size, echogenicity, cortical thickness.
  • Detects obstruction (hydronephrosis) or cystic disease.

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• Doppler Ultrasound: Assess renal artery stenosis if hypertension is refractory.

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• CT Scan (if indicated): For complex cysts, tumors, or when ultrasound is inconclusive.

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• Renal Scintigraphy: GFR measurement and differential function in bilateral disease.

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4. Additional Laboratory Workup – Etiology & Risk Stratification

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• Serum Electrolytes: Sodium, potassium, chloride, bicarbonate.

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• Serum Calcium & Phosphorus: For mineral bone disorder.

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• Parathyroid Hormone (PTH): Secondary hyperparathyroidism.

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• Lipid Profile: Dyslipidemia common in CKD.

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• Liver Function Tests: Hepatitis B/C screening (HBsAg, anti‑HCV). Indian guidelines recommend routine hepatitis B vaccination for patients on dialysis.

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• Autoimmune Panel: ANA, anti‑dsDNA for lupus nephritis; ANCA for vasculitis.

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• HbA1c: For diabetic control assessment.

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• Blood Glucose Profile: Fasting & post‑prandial.

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• Cytokine Levels (optional): IL‑6, TNF‑α in research settings.

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5. Staging of CKD (KDIGO 2023)

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• Stage 1: eGFR ≥90 mL/min/1.73m² with kidney damage (proteinuria, imaging abnormality).

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• Stage 2: eGFR 60–89.

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• Stage 3a: eGFR 45–59.

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• Stage 3b: eGFR 30–44.

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• Stage 4: eGFR 15–29.

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• Stage 5: eGFR <15 or dialysis.

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6. Pharmacologic Management by Stage

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Common Pillars Across All Stages

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• A1‑C Receptor Blockers (ACEi/ARB): Enalapril 5‑20 mg, Ramipril 2.5‑10 mg, Lisinopril 10‑40 mg, or Losartan 25‑100 mg. Goal: Reduce intraglomerular pressure, lower proteinuria, and delay progression.

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• Statins: Atorvastatin 10‑20 mg daily for patients >40 years or with ASCVD risk.

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• Blood Pressure Control: Target <130/80 mmHg; Indian guidelines recommend ACEi/ARB as first line, followed by calcium channel blockers (amlodipine 5‑10 mg) or thiazide diuretics if needed.

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• Dietary Sodium Restriction: < 2 g/day; potassium restriction as per serum levels.

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• Protein Restriction: <0.8 g/kg/day in stages 4‑5; 1.0–1.2 g/kg/day in earlier stages.

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Stage‑Specific Medications

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• Stage 1–2: Continue ACEi/ARB; monitor serum creatinine & potassium every 4–6 weeks.

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• Stage 3a: Add low‑dose ACEi/ARB if proteinuria >300 mg/day. Consider SGLT2 inhibitors (empagliflozin 10 mg or dapagliflozin 5 mg) for diabetic CKD; Indian drug approval allows use in eGFR ≥30.

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• Stage 3b: Intensify ACEi/ARB dose; start SGLT2 inhibitors if not contraindicated. Add potassium‑binding resin (patiromer 8.4 g daily) if hyperkalemia.

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• Stage 4: Initiate erythropoiesis‑stimulating agents (epoetin alfa 5000 IU thrice weekly) if Hb <10 g/dL. Begin active vitamin D (calcitriol 0.5–1 μg daily) to control secondary hyperparathyroidism.

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• Stage 5 (pre‑dialysis): Continue ACEi/ARB until eGFR <15; then taper. Start phosphate binders (sevelamer 800 mg with meals) and vitamin D analogues (paricalcitol). Prepare for dialysis access – AV fistula preferred; central venous catheter if urgent.

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Management of Mineral Bone Disorder (MBD)

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• Serum Calcium: Maintain 8.5–9.5 mg/dL.

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• Serum Phosphate: Target 3.5–5 mg/dL; use sevelamer or calcium‑based binders.

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• PTH: Keep <300 pg/mL in stage 3–4; <200 pg/mL in stage 5.

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• Vitamin D: Calcitriol 0.5–1 μg daily; switch to paricalcitol if hypercalcemia.

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Special Situations

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• Diabetic CKD: Tight glycemic control (HbA1c <7%), SGLT2 inhibitors, GLP‑1 receptor agonists (liraglutide 0.6–1.8 mg daily) for cardio‑renal protection.

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• Hypertensive CKD: Triple therapy (ACEi/ARB + CCB + diuretic) if BP remains >140/90.

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• Glomerulonephritis: Immunosuppressants (cyclophosphamide, mycophenolate mofetil) per KDIGO guidelines; Indian cost‑effective regimens include low‑dose mycophenolate 1 g BID.

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• Infection‑related CKD: Treat underlying hepatitis B/C with
  
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