CHRONIC KIDNEY DISEAS

Hisham Abdelwahab MRCP U.K MMed/SCI

Common presentation of CKDAsymptomatic urine abnormalities : proteinuria/ hgaematuria

Nephritic/Nephrotic syndrome

Hypertension

Unexplained anaemia

Incidental finding of elevated serum CreatinineUraemic emergencies

Screening Methods

Serum CreatinineEstimated 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

Man

Woman

1.23 x (140-Age) x BW Sr Cr (umol/l)

1.04 x (140-Age) x BW Sr Cr (umol/l)

•Estimate of GFR by the Cockcroft and Gault equation

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 proteinDipstick24 hour urinary protein

Urine microscopic examinationFor RBC / Pus Cell / Cast

Urine for microalbuminuriaOn morning urine sampleusing strip for microalbumin

Targets for Screening

Hypertensive patients Diabetic patients Cardiovascular disease Proteinuria Hematuria Those on regular

NSAID/Herbs

Renal calculi Anemia of unknown

aetiology First and second degree

relatives of ESRD Autoimmune disease

(SLE/RA) Reduction of kidney

mass(Nephrectomy

Screening for proteinuriaUrine dipstick for protein

Negative

Positive(Urine protein >300mg/l)On 2 separate occasions(exclude other causes)

Overt NephropathyQuantify excretion rate24HUP

3-6 monthly follow-up of microalbuminuriaOptimise glycaemic controlStrict Bp controlACE/ARBStop smokingLifestyle modificationTreat hyperlipidaemiaAvoid excessive protein intakeMonitor renal functionMonitor other endorgan damage

Screen forMicroalbuminuria(on early morning spot urine)

Negative

Yearly test

Positive

Retest twice in 3-6/12Exclude other cause

If 2 of test are positiveDiagnosis of microalbuminuria Is established

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

Primary care investigationHistoryExaminationRenal functionUrine microscopy and culture

Consider Urological referral

Exclude benign causes :Menstruating womenWomen with UTIFalse +ve result Recent strenous exerciseSexual activity, viral illness,trauma etc

ProteinuriaRed cell cast/dysmorphic red blood cellsRenal Impairment

Nephrological referral

Isolated microscopic haematuria and age >40 years

Diagnosis

Management

Pre Dialysis care

Screening

Diagnosis

Treatment

PRIMARY CARE PHYSICIAN NEPHROLOGISTS

Who should take the lead?

The primary care physician and

The nephrologists

R.R.T.

TX

HD

PD

ESRD

NKF-DOQI

AdequacyVascular AccessAnemiaNutritionBoneCardiovascular

Vascular AccessAnemia

NutritionBone

Cardiovascular

Pre-ESRD

CRD (CRI, PRF)

GFR 30 mL/minCr >3 mg/dL

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

-60%

-50%

-40%

-30%

-20%

-10%

0%

rela

tive

ris

k (%

)

REIN(n=352)

CAPTOPRIL(n=409)

RENAAL(n=1513)

IDNT(n=1715)

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