RENAL DISEASE

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RENAL DISEASE A GENERAL PRACTICE PERSPECTIVE

• Dr Shareen Hallas

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REMEMBER THE KIDNEYS?
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..AND THE NEPHRON?
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AND WHAT GOES ON THERE?
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WHATS IN THE NEWS?

• Apple Shape linked to higher risk of kidney
  disease. (BBC News 12th April 2013)

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RECENT RESEARCH

• BMJ 2013346f324
• Associations of estimated glomerular filtration
  rate and albuminuria with mortality and renal
  failure by sex a meta-analysis
• Over 2 million participants
• Cohort study
• Conclusions Both sexes face increased risk of
  all-cause mortality, cardiovascular mortality,
  and end stage renal disease with lower estimated
  glomerular filtration rates (lt45) and higher
  albuminuria (ACRgt30). These findings were robust
  across a large global consortium

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WHAT DO WE SEE IN PRIMARY CARE?
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SCENARIO 1

• A 60 year old man presents with urinary frequency
  and urgency. He is a smoker. He has hypertension
  and takes amlodipine 5mg. Urinalysis shows
  blood. No nitrites or leucocytes
• What will you do next?

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HAEMATURIA

• Visible haematuria
• REFER at any age to Urology
• 2 week rule if painless at any age
• Remember with renal stones up to 20 are negative
  for haematuria

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NON VISIBLE HAEMATURIA

• Is it blood? (beetroot, rifampacin etc)
• Exclude UTI, menstruation, exercise)
• Refer symptomatic non visible haematuria at any
  age

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SYMPTOMATIC NON VISIBLE HAEMATURIA

• Check UE, creat, eGFR, bp, ACR.
• Refer if over 40 to UROLOGY 2 weeks
• Likely needs referral to urology if symptomatic
  at any age

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ASYMPTOMATIC NON VISIBLE HAEMATURIA

• Check 3 urinalysis over a 2/52 period. If 2/3
  positive this is a positive result
• If over 40 refer to UROLGY
• If under 40 refer NEPHROLOGY if
• ACRgt30
• eGFRlt60ml/min (2 readings, no reversible cause)
• BPgt140/90
• If these referral criteria are not met, annual
  follow up as likelihood of serious pathology is
  8 and malignancy in 1.5

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REMEMBER

• Proteinuria is the best indicator of glomerular
  disease
• Approximately 10 people with non visible
  haematuria have a urological malignancy. The most
  common is bladder cancer
• Check a urinalysis when looking for causes of
  iron deficiency anaemia

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SCENARIO 2

• A 46 year old woman presents for follow up
  urinalysis after a recent UTI. No urinary
  symptoms. NoHx hypertension, diabetes. Not
  pregnant. No FH renal disease. Meds nil reg,
  intermittent NSAID for dysmennorhoea.
• O/E bp 140/80 no oedema.
• Urinalysis protein. Nil else.
• What will you do next?

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NSAIDS

• Most common cause of drug induced renal damage in
  general practice
• If on long term nsaids monitor renal function 2-3
  times per year.

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PROTEINURIA

• Positive urinalysis in 2 or more urine samples
  over a 1-2 week period. UTI can cause false
  positive
• Remember ACR has a greater sensitivity than PCR
• If ACR gt70mg/mmol (PCR gt100mg/mmol) REFER
  NEPHROLOGY
• If ACR gt30mg/mmol (PCR gt 50mg/mmol) WITH NON
  VISIBLE HAEMATURIA. REFER NEPHROLOGY

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OTHER INVESTIGATIONS

• UE, eGFR, BP, Hba1c
• Then select ix depending on potential cause
• May include C3, C4, Igs, electrophoresis, RF,
  ASOT, ANCA, ANA, dsDNA, cholesterol (raised in
  nephrotic synd)..
• What about renal ultrasound?

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LOTS OF CAUSES OF PROTEINURIA!

• Transient proteinuria
• Emotional stress.
• Exercise.
• Fever.
• Urinary tract infection.
• Orthostatic (postural) proteinuria.
• Seizures.
• Persistent proteinuria.
• Primary glomerular causes
• Focal segmental glomerulonephritis.
• IgA nephropathy (ie Berger's disease).
• IgM nephropathy.
• Membranoproliferative glomerulonephritis.
• Membranous nephropathy.
• Minimal change disease.
• Secondary glomerular causes
• Alport's syndrome.
• Amyloidosis.
• Sarcoidosis.

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NEPHROTIC SYNDROME

• Heavy proteinuria. PCR gt 200mg/mmol
• Hypoalbuminaemia lt30g/l
• Oedema, particulalry periorbital

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MODERATE PROTEINURIA (100-200MG/MMOL)

• May be tubular disease eg drug induced
  interstitial nephritis.

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PROTEINURIA WITH NVH MORE LIKELY TO BE

• IgA nephropathy (most common cause of acute
  glomerulonephritis, 80 in age 16-35), polycystic
  kidneys, vasculitis, collagen multisystem
  disease, post infectious glomerulonephritis

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WHAT ABOUT PRESCRIBING IN RENAL IMPAIRMENT?

• BNF - For many drugs with only minor or no
  dose-related side-effects very precise
  modification of the dose regimen is unnecessary
  and a simple scheme for dose reduction is
  sufficient. For more toxic drugs with a small
  safety margin, dose regimens based on GFR should
  be used
• Take care with many antibiotics, histamine
  H2-receptor antagonists, digoxin, anticonvulsants
  and NSAIDs, potassium sparing drugs, vit D,
  antacids (high Na content), ACE (watch out for
  renal artery stenosis), diuretics.
• Care after iodine contrast
• If patient on dialysis ask a specialist.

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SCENARIO 3

• A 55 year old woman presents after receiving a
  letter from the practice to come in to discuss he
  blood tests which show chronic kidney disease
  stage 3.
• She has hypertension controlled with amlodipine
  5mg. Bp 140/90. eGFR 50ml/min/1.73m2
• What will you do?

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WHAT IS CKD DEFINED AS?

• eGFR lt 60ml/min/1.73m2 for 3 months

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CKD

• Stage 1 eGFR gt90 with other evidence of kidney
  damage
• Stage 2 eGFR 60-90 with other evidence of kidney
  damage
• Stage 3A eGFR 45-59
• Stage 3B eGFR 30-44
• Stage 4 eGFR 15-29
• Stage5 EGFR lt15
• Use suffix p to denote proteinuria
• Chronic kidney disease affects 1016 of the
  general adult population in Asia, Europe,
  Australia, and the United States

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HOW OFTEN SHALL I MONITOR CKD?

• CKD 1 and 2 , yearly
• 3A and 3B, 6 monthly
• 4, 3 monthly
• 5, 6 weekly
• According to NICE CG 73
• NB CKD is a part of the QRISK 2 score

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REMEMBER

• Correct eGFR for ethnicity (African or Caribbean)
  X 1.21
• New low eGFR repeat within 2 weeks
• Measure minimum 3 eGFRs over 90 day period -
  need at least 2 to diagnose CKD
• DO NOT EAT MEAT for 12 hour pre-test for eGFR
• Measure ACR
• ACE inhibitors can reduce creatinine by up to
  20. If creat inc by gt20 or eGFR dec by gt15 can
  be due to renal artery stenosis.
• Serum creatinine has limitations - can remain
  within the normal range despite the loss of over
  50 of renal function

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CKD 3

• All cause mortality (and CVD mortality) is
  increased in stage 3 CKD, increase is much
  greater in stage 3B
• Progression of renal disease is rare (4 with
  esrf in 10 years)
• Cholesterol lowering in this group can reduce CV
  events (SHARP study)
• Over 10 years a patient with CKD 3 has a 25
  chance of dying from CVD
• Need pneumococcal and annual flu immunisations

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REMEMBER

• Will kidneys fail in your patients lifetime, or
  will they die of something else first?

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TIP

• CSA CKD explained mattandhazelsmith video youtube

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ACR IN DIABETES

• Normal is lt2.5 in men and lt3.5 in women
• In diabetes can get an initial increase in eGFR
  as glycosuria damages the basement membrane.
  Protein can therefore leak when the eGFR is still
  normal.
• EPO produced round prox tubules damaged in Dm,
  hence can get EPO deficiency earlier in diabetic
  kidney disease.

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ACE INHIBITORS

• Check ue 1-2 weeks after starting ACE
• If creatanine rises by gt20 or eGFR drops by gt15
  consider renal artery stenosis
• Repeat after dose increase
• Stop ACE in dehydrating illness
• Counsel women of childbearing age

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WHEN DO I DO A RENAL ULTRASOUND?

• Obstructive symptoms
• FH polycystic kidneys
• Haematuria, progressive CKD
• Stage 4 or 5 CKD

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WHEN DO I REFER A PATIENT WITH CKD?

• Stage 4 or 5 (check Hb and Ca/PO4)
• Proteinuria (ACR gt70)
• ACR gt30 AND haematuria
• Rapidly declining eGFR (gt5ml/min in one year)
• Poorly controlled hypertension despite 4 drugs
  (aim bp lt140/90)
• Suspected renal artery stenosis or rare cause CKD

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REMEMBER LIFESTYLE

• Stop smoking
• Reduce salt
• Men have bigger kidneys than women
• After age 40 renal function decreases by
  1ml/min/year

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DIALYSIS

• Around 40,000 people in the UK are having
  dialysis or have functioning kidney transplants

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DIALYSIS

• Usually starts when GFR 10 ml/min ( 15ml/min in
  diabetes)
• Indications
• Presence of clinical features of uraemia
  (eg, pericarditis, gastritis, hypothermia, fits
  or encephalopathy).
• Fluid retention leading to pulmonary oedema
  inability to reduce excess volume with diuretics
  with urine volume under 200 mL in twelve hours.
• Severe hyperkalaemia (potassium above 6.5 mmol/L)
  unresponsive to medical management.
• Serum sodium above 155 mmol/L or below 120
  mmol/L.
• Severe acid-base disturbance (pH under 7.0) that
  cannot be controlled by sodium bicarbonate.
• Severe renal failure (urea greater than 30
  mmol/L, creatinine greater than 500 µmol/L.
• Toxicity with drugs that can be dialysed

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HAEMODIALYSIS

• Arterio-venous fistula formed 3-6 months before
  starting dialysis
• Dialysis 3 times a week, 4 hours each time
• Complications
• Access-related local infection, endocarditis,
  osteomyelitis, creation of stenosis, thrombosis
  or aneurysm.
• Hypotension (common), cardiac arrhythmias, air
  embolism.
• Nausea and vomiting, headache, cramps.
• Fever infected central lines.
• Dialyser reactions anaphylactic reaction to
  sterilising agents.
• Heparin-induced thrombocytopenia, haemolysis.
• Disequilibration syndrome restlessness,
  headache, tremors, fits and coma.
• Depression.

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PERITONEAL DIALYSIS

• CAPD involves 4 exchanges of 20 minutes through
  the day
• Can do peritoneal dialysis at night too
• Greater flexibility
• Contra-indications to peritoneal dialysis
• Intra-abdominal adhesions and abdominal wall
  stoma.
• Obesity, intestinal disease, respiratory disease
  and hernias are relative contra-indications.
• Complications of peritoneal dialysis
• Peritonitis, sclerosing peritonitis.
• Catheter problems infection, blockage, kinking,
  leaks or slow drainage.
• Constipation, fluid retention, hyperglycaemia,
  weight gain.
• Hernias (incisional, inguinal, umbilical).
• Back pain.
• Malnutrition.
• Depression

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RENAL TRANSPLANT

• Good survival rates
•  1 year and 10 year graft survival rates are 89
  and 67 for adult kidneys from 'brain death
  donors' and 96 and 78 for kidneys from live
  donors.

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SCENARIO 4

• A 20 year old woman presents to you in tears as
  her mother is going to start dialysis for ESRF
  due to Polycystic kidney disease.
• She wants to know if she has this too, What is
  her risk? What are you going to do?

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ADULT POLYCYSTIC KIDNEY DISEASE

• Affects 1 in a 1000 (50 in ESRF by age 60)
• Accounts for 10 people on dialysis
• Autosomal dominant (but de novo mutation in 5
  cases)
• Loin pain is the most common symptom (60)
• Hypertension in 10-15 affected children and 50
  affected adults
• Intracranial berry aneurysms in 6 with no fh and
  16 with fh. If FH MRI scan 5 yearly.
• Mitral valve prolapse in 25
• When to screen family members? (uss after age 20)

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POST STREPTOCOCCAL GLOMERULONEPHRITIS

• Mainly in under 5s
• 7-14 days after group A B haemolytic strep
  infection , usually sore throat
• Accounts for 90 of acute glomerulophritis
• GFR usually returns to normal in 10-14 days
• 92-98 recover fully
• Haematuria may persist asymptomatically for 2
  years.

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HELP FOR YOUR PATIENTS

• http//pkdcharity.org.uk/
• http//www.kidneyresearchuk.org/home.php
• http//www.gosh.nhs.uk/medical-conditions/
• http//www.britishkidney-pa.co.uk/

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