"CHRONIC KIDNEY DISEAS"
CHRONIC KIDNEY DISEAS Hisham Abdelwahab MRCP U.K MMed/SCI Common presentation of CKD Asymptomatic urine abnormalities : proteinuria/ hgaematuria Nephritic/Nephrotic syndrome Hypertension Unexplained anaemia Incidental finding of elevated serum Creatinine Uraemic emergencies Screening Methods Serum Creatinine Estimated glomerular filtration rate (GFR) Urine testing : Serum Creatinine Sr creatinine is poor reflection of early renal disease/failure Damage < 60% sr creatinine still normal Almost all early renal failure patients are asymptomatic SCREENING IS THEREFORE VERY IMPORTANT Estimated Glomerular Filtration rate •Estimate of GFR by the Cockcroft and Gault equation Man 1.23 x (140-Age) x BW Sr Cr (umol/l) Woman 1.04 x (140-Age) x BW Sr Cr (umol/l) Estimated Glomerular Filtration rate • MDRD eGFR (mL/min/1.73m2)= 186 x [SerumCreatinine(umol/L) x 0.0113]-1.154 x Age(years)-0.203 (x 0.742 if female) Continued. • The formula is named after the Modification of Diet in Renal Disease study in the USA. • The results are expressed relative to a standard body surface area of 1.73 m2 to allow for different body sizes. • The equation is only valid in persons over 17 years of age. • Results >60 mL/min/1.73m2 are likely to deviate from the true value and should not be relied upon. • The use of the eGFR in patients on dialysis is inappropriate and will give misleading results. Urine Testing Urine for protein Dipstick 24 hour urinary protein Urine microscopic examination For RBC / Pus Cell / Cast Urine for microalbuminuria On morning urine sample using strip for microalbumin Targets for Screening Hypertensive patients Renal calculi Diabetic patients Anemia of unknown Cardiovascular disease aetiology Proteinuria First and second degree Hematuria relatives of ESRD Those on regular Autoimmune disease NSAID/Herbs (SLE/RA) Reduction of kidney mass(Nephrectomy Screening for proteinuria Urine dipstick for protein Positive Overt Nephropathy Negative (Urine protein >300mg/l) Quantify excretion rate On 2 separate occasions 24HUP (exclude other causes) Screen for Microalbuminuria Positive (on early morning spot urine) 3-6 monthly follow-up of microalbuminuria Optimise glycaemic control Strict Bp control Retest twice in 3-6/12 Negative ACE/ARB Exclude other cause Stop smoking Lifestyle modification Treat hyperlipidaemia Avoid excessive protein intake If 2 of test are positive Monitor renal function Yearly test Diagnosis of microalbuminuria Monitor other endorgan Is established damage False +ve CKD Urinary Tract Infection Sepsis Heart Failure Strenous exercise Heavy protein intake Menses DHCCB Significance of proteinuria A dominant risk factor for deterioration of renal failure (besides HT) Marker of Increased Risk for CV mortality and morbidity (DM & non-DM) e.g. Microalbuminuria is associated with a 100- 150% increase in death rate (Mogensen CE, New Eng. J. Med 1984;310:310-60) Evaluation of Symptomatic Haematuria Detection of Microscopic hematuria >5RBC/hpf or +ve dipstik test Exclude benign causes : Menstruating women Women with UTI False +ve result Recent strenous exercise Sexual activity, viral illness,trauma etc Primary care investigation History Examination Renal function Urine microscopy and culture Proteinuria Isolated microscopic Red cell cast/dysmorphic red blood cells Renal Impairment haematuria and age >40 years Nephrological referral Consider Urological referral Who should take the lead? The primary care physician and The nephrologists PRIMARY CARE PHYSICIAN NEPHROLOGISTS Screening Diagnosis Diagnosis Management Treatment Pre Dialysis care R.R.T. TX GFR 30 mL/min Cr >3 mg/dL Pre-ESRD ESRD HD CRD (CRI, PRF) NKF-DOQI Adequacy Vascular Access Vascular Access Anemia Anemia Nutrition Nutrition Bone Bone Cardiovascular Cardiovascular PD CRD = chronic renal disease; CRI = chronic renal insufficiency; PRF = progressive renal failure; NKF = National Kidney Foundation. CKD Risk factors for progression of CKD • Hypertension • Hyperglycemia • Proteinuria • Coffe • Smoking • Salt ACE REIN CAPTOPRIL RENAAL IDNT (n=352) (n=409) (n=1513) (n=1715) 0% -10% relative risk (%) -20% -30% -40% -50% -60% CALM2000 Conclusion Management of ESRD poses an immense challenge to healthcare systems all over the world Incidence continue to increase and nearly half of the patients are diabetic Patients with ESRD have many other medical complications especially CVD Retarding the progression renal failure in patients with CKD may reduce the burden of ESRD • ACE I ,ARB & Non DHCCB (Verapamil) • < 25% deterioration in base line creatinine level is acceptable following introduction of ACE I ,ARB