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CKD update. Dr Saqib Mahmud MRCP(UK),MRCGP. Chronic kidney disease. Defined by a reduced eGFR, proteinuria, haematuria and/ or structural abnormalities persistent for more than 90 days. Introduction. Prevalence – over 13% of population; rising as a consequence of DM & Obesity - PowerPoint PPT Presentation
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CKD updateCKD update
Dr Saqib MahmudDr Saqib MahmudMRCP(UK),MRCGPMRCP(UK),MRCGP
Chronic kidney diseaseChronic kidney disease
Defined by a reduced Defined by a reduced eGFR, proteinuria, eGFR, proteinuria, haematuria and/ or haematuria and/ or
structural abnormalities structural abnormalities persistent for more than persistent for more than
90 days90 days
IntroductionIntroduction
• Prevalence – over 13% of Prevalence – over 13% of population; rising as a population; rising as a consequence of DM & Obesityconsequence of DM & Obesity
• Primarily a marker of CV riskPrimarily a marker of CV risk• Stage 3 CKD – 40 – 100% Stage 3 CKD – 40 – 100%
increased risk of CV eventsincreased risk of CV events• Minority at risk of progressive Minority at risk of progressive
decline in renal functiondecline in renal function
ClassificationClassification
• Stage 1 : GFR>90 Stage 1 : GFR>90 (presence of kidney damage (presence of kidney damage with N or raised GFR)with N or raised GFR)
• Stage 2 : GFR 60 – 89 Stage 2 : GFR 60 – 89 (presence of kidney (presence of kidney damage with mildly reduced GFR)damage with mildly reduced GFR)
• Stage 3A : GFR 45 – 59Stage 3A : GFR 45 – 59• Stage 3B : GFR 30 – 44 , Stage 3B : GFR 30 – 44 , moderately moderately
reduced GFRreduced GFR
• Stage 4 : GFR 15 – 29 Stage 4 : GFR 15 – 29 , , severely reduced GFRseverely reduced GFR
• Stage 5 : GFR <15 , Stage 5 : GFR <15 , end-stage RFend-stage RF
Basic investigationsBasic investigations
• Repeat U&E, eGFR (within 3/12)Repeat U&E, eGFR (within 3/12)• FBSFBS• FBCFBC• Dipstick urine for haematuriaDipstick urine for haematuria• Urine ACR or TPCRUrine ACR or TPCR• Ca, PO4Ca, PO4
Further investigationsFurther investigations
• Hypercalcaemia – inv for myelomaHypercalcaemia – inv for myeloma• LUTS, deteriorating renal function – LUTS, deteriorating renal function –
renal tract USSrenal tract USS• Significant proteinuria +/- Significant proteinuria +/-
haematuria –> primary glomerular haematuria –> primary glomerular disease or vasculitis– autoimmune disease or vasculitis– autoimmune screen/referscreen/refer
ManagementManagement
• Main aims ; slow deterioration of renal Main aims ; slow deterioration of renal function – tight control of BPfunction – tight control of BP
• Reduce CV risksReduce CV risks• Maintain SBP at 129-139, DBP below 80Maintain SBP at 129-139, DBP below 80• SBP below 100 – 110 may be SBP below 100 – 110 may be
detrimentaldetrimental• ACEI / ARB confer additional benefit, ACEI / ARB confer additional benefit,
slow decline of renal function & slow decline of renal function & proteinuriaproteinuria
MonitoringMonitoring
• U&E post ACEI mandatoryU&E post ACEI mandatory• Stable CKD3A & B – U&Es 6/12, Stable CKD3A & B – U&Es 6/12,
CKD4 -3/12CKD4 -3/12• d/c ACEI if SCr rises >30%, eGFR d/c ACEI if SCr rises >30%, eGFR
falls>15% baselinefalls>15% baseline• Thiazide diuretics lose their efficacy Thiazide diuretics lose their efficacy
in Rx of HTN in CKD as GFR decline in Rx of HTN in CKD as GFR decline – loop diuretics Rx of choice– loop diuretics Rx of choice
Drug administrationDrug administration
• Certain drugs CI, require dose Certain drugs CI, require dose adjustment adjustment
• d/c metformin if eGFR <30d/c metformin if eGFR <30• Insulin dose may need to be Insulin dose may need to be
reducedreduced
ReferralReferral
• Most CKD patients managed in primary Most CKD patients managed in primary carecare
• Consider referral; younger patients with Consider referral; younger patients with CKD any stageCKD any stage
• Deteriorating renal functionDeteriorating renal function• Significant protienuria >1g/d or Significant protienuria >1g/d or
proteinuria + haematuria>1+proteinuria + haematuria>1+• Poorly controlled HTN despite 4 drugsPoorly controlled HTN despite 4 drugs• Renal anaemiaRenal anaemia