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