Chronic Kidney Disease

1
Chronic Kidney Disease

• Dr S.K.Choudhary
• GPVTS-ST2

2
Introduction

• CKD describes abnormal kidney function and
  structure- gt3months
• Often coexists with other conditions-CVD,
  Multisystem disease ,Diabetes etc
• Usually asymptomatic but can be detected by
  simple tests.
• 30 of Advanced cases are referred late.
• Over 2 of total NHS budget is spent on RRT.

3
Aetiology

• DM
• Vascular disease/Hypertension
• Glomerulonephritides e.g-IgA/Vasculitis
• Reflux Nephropathy/CIN/Dysplasia
• Obstructive Nephropathy
• Genetic- e.g ADPKD, Alport syndrome

4
Pathophysiology

• Loss of Renal function is progressive
• From-Primary injury e.g-GN
• Intraglomerular Hypertension-SNGFR
  Hyperfiltration theory.
• Lost Nephron cannot be recovered.
• A minor raised S.Cr should not be
  overlooked-represents 50GFR loss

5
Measurement of Kidney Function

• GFR varies with Age.
• Muscle loss decreases with age as well - the
  normal range of S.cr remains same.
• A minor elevated S.Cr in elderlymay represents
  GFR of only-30ml/min.
• e-GFR-computer based assessment based on
  Race,Age,Sex,S.Cr.-Useful in follow up cases.
• e-GFR may be less reliable in oedematous
  states,ARF,Pregnancy,muscle wasting states. Also
  not validated for Asians, chinese.

6
Contd.

• Apply correction factor for ethnicity to reported
  e-GFR value e.g 1.21 for African-Caribbean
  ethnicity.
• Interpret reported values of e-GFR 60ml/min or
  more with caution-less reliable, Rather use rise
  in S.Cr conc. of more than 20 to infer
  significant reduction in Renal function.
• If highly accurate measure is reqd-use Inulin,
  EDTA or Iothalmate clearance
• Advise not to eat meat in the past 12 hrs of
  blood test and avoid delay in despatching sample.
  
• An e-GFR of 60 if new should be confirmed by
  repeat testing within 2 weeks. Allow for
  biological analytical variabilty of S.cr (/-
  5) when interpreting e-GFR.

7
Measurement of e-GFR-?How often

• Annually in all at risk groups.
• During intercurrent illness and Perioperatively
  in all Pts with CKD.
• Stage 12 -12 monthly (GFRgt 60 ml/min
• Stage 3a 3b- 6 monthly (GFR- 30-59 ml/min)
• Stage 4 -3 monthly (GFR-15-29 ml/min)
• Stage 5 -6weekly. (GFR lt15 ml/min).
• Exact frequency should be dependent on clinical
  situation.

8
Stages Use P/T 1 GFR Ml/min/1.73m2 gt90 Description Normal or Increased with other evidence of kidney damage.
2 60-89 Slight decrease with other evidence of kidney damage
3A 45-59 Moderate decrease with or without other evidence of damage
3B 30-44
4 15-29 Severe decrease with or without evidence of kidney damage
5 lt15 Established Renal Failure
9
Risk Factors for Progression

• Cardiovascular disease
• Proteinuria
• Hypertension
• Uncontrolled Blood Sugar
• Smoking
• NSAIDs Use
• Urinary Tract Obstruction
• Black or Asian ethnicity
• Defn Decline in eGFR gt5ml/min within 1yr or more
  than 10ml/min within 5 yrs.
• Obtain at least 3 GFR over period of not less
  than 3 months.
• Repeat eGFR within 2 weeks if new decline to R/O
  Acute.

10
Referral Criteria

• Stage 4 and 5 CKD-with/ without Diabetes
• Proteinura-ACR gt70mg/mmol or PCRgt100mg/mol unless
  known Diabetic.
• Proteinura-ACRgt30 or PCRgt50 together with
  hematuria ,must for Diabetic Pts.
• Rapidly decline eGFR gt5ml/min in 1yr or gt10
  ml/min in 5 yr.
• Poorly controlled BP despite use of 4 drug.
• Suspected Renal Artery Stenosis
• Suspected rare or Genetic Causes of CKD.

11
Management

• Life Style Advice
• Pharmacotharapy
• -BP control
• -Statins and Antiplatelets drugs
• -Bone metabolism
• -Anemia
• Avoidance of Nephrotoxic drugs
• Information and Education
• -Course and Prognosis
• -Renal Replacement therapy
• Multidisciplinary team involvement.

12
BP Control

• Nondiabetic- lt140/90 mmHg
• Diabetic- lt130/80 mmHg
• ACE/ARB Db and ACRgt2.5 in men or gt3.5 in women
  irrespective of HT and CKD Stage.
• ACE/ARB-Non Db with CKD and HT with
  ACR-30/PCR-50/U.Prot-0.5gm.
• ACE/ARB-Non Db with CKD and ACR-70/PCR-100/U.Prot-
  1gm irrespective of HT and CVS disease.
• Non Db with CKD and HT and ACR lt30/PCRlt50-Offer
  Anti HT as per NICE guidance on HT.

13
Practicalities with ACE/ARB

• Concordance can be improved if Pts are informed
  about Goal and monitoring eGFR and S.K.
• Baseline and then repeat after 1-2 weeks.
• Avoid if Baseline S.K is gt5.0
• Concurrent prescription of K retaining drug is
  not CI but requires close monitoring.
• Do not modify or stop if eGFR lt25 or S.cr gtless
  than 30 from baseline. Repeat test in 1-2 weeks
• If eGFR ltmore than 25 or S.Cr gt30 from
  baseline- 2 options Consider Vol depletion/RAS
• Reduce /stop
  ACE/ARB.
• Use of ACE should not be influenced by AGE.

14
Cardiovascular Risk Assesment

• Use Statins for Pr.Prevention of CVD as in Non
  CKD Pts.
• Offer Statins as Sec.Prvention of CVD to all
  patients of CKD irrespective of baseline Lipid
  value.
• Offer Aspirin as Sec.Prevention of CVD.Low dose
  Aspirin is NOT CI.
• Insufficient evidence to recommend routine use of
  Allopurinol in asymptomatic Hyperuricemia.

15
Bone Metabolism

• Routine measurement of Bone Profile,Vit D level
  and PTH is not recommended up to Stage 3B.
• Measure in Stage 4 (GFRlt30ml/min).Further testing
  as per clinical circumstances. Seek help
• Offer Biphosphonates if indicated for Prevention
  and Treatment of Osteporosis in people with Stage
  1,2,3A,3B CKD.
• Offer Alfacalcidol or Calcitriol to people with
  Stage 4 or 5 CKD.
• Monitor Symptoms/Bone profile and PTH Level.
• BEWARE OF ADYNAMIC BONE DISEASE.

16
Anemia

• Hb lt 11gms/dl.
• Check Hematinics and optimize.
• Normocytic and Normochronic
• Use of Erythropoeitin in stage 45
• Monitor BP more closely.

17
Summary

• Chronic Inflammatory State
• Multidisciplinary team Management
• Always consider Reversible factors
• Use BNF if using any new medicines
• Explanation and Counselling at each visit.
• Avoid Nephrotoxic/Herbal medicines
• Seek Specialist Opinion sooner than late.
• At any stage management should not be influenced
  by solely by AGE

18

• Thank you.