CHRONIC KIDNEY DISEAS

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CHRONIC KIDNEY DISEAS

• Hisham Abdelwahab MRCP U.K MMed/SCI

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Common presentation of CKD

• Asymptomatic urine abnormalities
• proteinuria/ hgaematuria
• Nephritic/Nephrotic syndrome
• Hypertension
• Unexplained anaemia
• Incidental finding of elevated serum Creatinine
• Uraemic emergencies

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Screening Methods

• Serum Creatinine
• Estimated glomerular filtration rate (GFR)
• Urine testing

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Serum Creatinine

• Sr creatinine is poor reflection of early renal
  disease/failure
• Damage lt 60 sr creatinine still normal
• Almost all early renal failure patients are
  asymptomatic
• SCREENING IS THEREFORE VERY IMPORTANT

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Estimated Glomerular Filtration rate

• Estimate of GFR by the Cockcroft and Gault
  equation

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

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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 gt60 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.

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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

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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

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Screening for proteinuria
Urine dipstick for protein
Positive (Urine protein gt300mg/l) On 2 separate
occasions (exclude other causes)
Overt Nephropathy Quantify excretion rate 24HUP
Negative
Screen for Microalbuminuria (on early morning
spot urine)
Positive
3-6 monthly follow-up of
microalbuminuria Optimise glycaemic
control Strict Bp control ACE/ARB Stop
smoking Lifestyle modification Treat
hyperlipidaemia Avoid excessive protein
intake Monitor renal function Monitor other
endorgan damage
Retest twice in 3-6/12 Exclude other cause
Negative
If 2 of test are positive Diagnosis of
microalbuminuria Is established
Yearly test
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False ve CKD

• Urinary Tract Infection
• Sepsis
• Heart Failure
• Strenous exercise
• Heavy protein intake
• Menses
• DHCCB

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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 1984310310-60)

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Evaluation of Symptomatic Haematuria
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Who should take the lead? The
primary care physician and The nephrologists
PRIMARY CARE PHYSICIAN
NEPHROLOGISTS
Diagnosis Management Pre Dialysis care
Screening Diagnosis Treatment
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CKD
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Risk factors for progression of CKD

• Hypertension
• Hyperglycemia
• Proteinuria
• Coffe
• Smoking
• Salt

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ACE
IDNT (n1715)
REIN (n352)
CAPTOPRIL (n409)
RENAAL (n1513)
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CALM2000
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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

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• ACE I ,ARB Non DHCCB (Verapamil)
• lt 25 deterioration in base line creatinine level
  is acceptable following introduction of ACE I ,ARB