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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