An update on chronic renal failure: followup and when to refer

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An update on chronic renal failure follow-up and
when to refer ?

• Assoc Prof Johan Rosman
• Renal Department Waitemata DHB
• johan.rosman_at_waitematadhb.govt.nz
• Apollo Health Centre, Albany
• www.bloodpressure.org.nz

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Chronic renal failure

• Diagnosis
• Presentations and stages of CRF in general
• Causes of CRF
• Monitoring CRF
• Consequences of CRF
• Progression of CRF
• Principles of treatment

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Differentiation acute-chronic renal failure

• Short History (ds-wks)
• Normal Hb
• Normal renal size
• No osteodystrophy
• Periph neuropathy -
• Normal Ca and P
• Normal PTH

• Long history (mo-yrs)
• Low Hb
• Reduced renal size
• Often osteodystrophy
• Periph neuropathy
• Low Ca / elevated P
• Increased PTH

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Acute on chronic renal failure

• Recrudescence of primary disease
• Complication of primary disease
• Accelerated hypertension
• Volume depletion
• Cardiac failure
• Sepsis
• Nephrotoxins (radiocontrast, drugs)
• Renal artery occlusion
• Urinary tract obstruction
• Dietary protein load

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Presentation of CRF

• Asymptomatic serum biochemical abnormality
• Asymptomatic proteinuria/haematuria
• Hypertension
• Symptomatic primary disease
• Symptomatic uraemia
• Complications of renal failure

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Commonest causes of ESRF
(ANZData)

• Glomerulonephritis 30
• Diabetes 25
• Hypertension 10
• Polycystic kidney disease 5
• Vesicoureteral reflux 5
• Analgesic nephropathy 5
• Unknown 10
• Others 10

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GFR (glomerular filtration rate) equals
creatinine clearance ??

• The accurate assessment of GFR is desirable
• Planning for the treatment of end stage renal
  disease
• Referral to nephrology
• Trace the course of progression of chronic renal
  disease or response to therapy
• What is the best, most practical way to assess
  GFR?

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Creatinine an imperfect marker
Efferent arteriole
Afferent arteriole
Glomerulus
Filtered
Reabsorbed
Secreted
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Creatinines micromole/L
200 400 600 800 1000
20 40 60 80 100 120
GFR ml/min/1.73m2 BSA
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Normal GFR by Age
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Measuring glom. filtration rate

• Many formulas have attempted to predict GFR from
  a serum creatinine measurement only, most
  factoring in age, weight/height, and gender,
  which are all independent of serum creatinine in
  influencing GFR.
• This would be the easiest approach clinically
• a serum creatinine of 130 umol/l is normal in an
  athlete, but can mean dialysis dependency in a 80
  year old !

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Aids in monitoring GFR (creat clearance)

• Use the Cockroft Gault equation
• Use the MDRD equation
• But in the follow up of a patient stick to the
  same way of estimating GFR
• Formulas for free available on the web
  (spreadsheet) or free for Palmtop (Medcalc)
• Use 1/creatinine in individual patients to see
  whether a rise in creatinine represent an acute
  on chronic event

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Renal Screen

• BP
• MSU
• RBC morphology ACR 24-hour proteinuria
• Serum urea, creatinine, Na, K
• Ultrasound scan renal tract
• Albumin, calcium, phosphate
• PTH
• eGFR

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Why do 24-hour urine collection?

• Extremes of age / body size
• Malnutrition or obesity
• Catabolic states
• Amputees / paraplegia / mm. wasting
• Vegetarians / vegans
• Pregnancy
• Medication-dosing
• Rapidly changing renal function

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Problems of ESRD

• Cardiovascular disease
• Anaemia
• Renal Bone Disease
• Metabolic acidosis
• Malnutrition
• Sodium and water
• Potassium
• Bleeding Diathesis
• Dermatologic manifestations
• Neurologic manifestations
• Endocrine abnormalities
• Immunity
• Psychological manifestations

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Factors causing progression of CRF

• Cont activity of primary disease
• Systemic hypertension
• Intraglomerular hypertension
• Proteinuria
• Nephrocalcinosis (dystr and metast)
• Dyslipidaemia
• Imbalance renal energy demands and supply

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Cardiovascular Morbidity and Proteinuria
Proteinuria
40
30
p lt 0.001
Cumulative incidence () of CV morbidity
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Years
Adapted from Samuelsson et al. J Hypertens
1985372
RPLM Hoogma
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Relationship between BP and progression of CRF
MAP (mm Hg)
98
100
102
104
106
108
110
0
r 0.66 Plt0.05
2
4
GFR (mL/min per year)
6
8
10
Adapted with permission from Bakris. Diabetes Res
Clin Pract 199839S35
RPLM Hoogma
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Principles of treatment of pat with CRF

• Differentiate from ARF on CRF
• Establish aetiology
• Establish severity
• Seek and treat reversible factors
• Seek and treat complications
• Lifestyle improvements
• Seek and treat factors that promote progression
• Planned and timely refer to nephrologist

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When to refer to renal physician?

• eGFR lt 30 ml/min/1.73m2 BSA
• lt45 in diabetics anaemia (Hb lt 100g/L)
• Proteinuria gt 1G per 24 hours
• Glomerular haematuria
• Difficult to control hypertension
• Rapidly declining GFR
• gt15 in 3 months (Australia)
• Electrolytes, vascular disease, etc.

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Early detection is paramount

• CKD
• Preventable
• Growing _at_ 6pa
• Delayed progression
• Renal abnormality is prevalent!
• 16 of Australians (AusDIAB)
• 15 NZers (Simmonds)
• 20 x more likely to die than get RRT
• Keith et al. Arch Int Med 164659 2004
• Asymptomatic

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The key to good care

• Communication
• Communication
• Communication
• 021- KIDNEY
• (021-543639)