approach to chronic kidney disease

DR.Basma M Abd El Aziz ,Family Medicine,SCU

Presented by Dr. Basma Mohamed Abd El Aziz

Assistant lecture of family medicine

2013

Approach to patient with chronic kidney disease


How many patient you seeHow many patient you see

have CKD have CKD


38%

Prevalence among patients with end-stage renal disease in 2010

Diabetic kidney disease


Objective Definition Screening Etiology Classification staging Clinical evaluation Management When to refer


What is chronic kidney What is chronic kidney disease?disease?


CKD: definition

1- Glomerular filtration rate (GFR) < 60mL/min/1.73m2 that is present for > 3 months with or without evidence of kidney damage,

oror 2- Evidence of kidney damage with or without decreased GFR

that is present for > 3 months as evidenced by any of the following:

– microalbuminuria, proteinuria, – glomerular haematuria. – pathological abnormalities (e.g. abnormal renal biopsy) – anatomical abnormalities(e.g. scarring seen on imaging or polycystic kidneys)


The serum creatinine alone is not an accurate measure of glomerular filtration rate.

Normal ranges for serum creatinine are misleading because they do not take into account the age, sex, or weight of the patient.

Why can’t I just use the serum creatinine?


Cockcroft-Gault equation :- [[140 - age(yr)]*weight(kg)]/[72*serum Cr(mg/dL)]

(0.85 for women)

MDRD equation 7 :- 170 * [serum creatinine (mg/dL)]-0.999 * [age (years)]-

0.176 * [0.762 if pt is female] * [1.180 if pt is black] * [BUN(mg/dL)]-0.170 * [albumin (g/dL)] +0.318

Equations for Estimating the GFR


Consider the following two patients with identical serum creatinines of 1.2 mg/dL.

Patient 1- a 60 year old 50 kg woman Patient 2- a 30 year old 90 kg man

The first patient has a GFR of 39 ml/min/1.73 m2, which is markedly abnormal, …………………………..while the second has a GFR of 115 ml/min/1.73 m2,well within the normal range.

Clinical example


Stages of CKD


Screening of CKDScreening of CKD


Annual CKD screening is recommended by the American Diabetes Association, the National Kidney Foundation for patients at risk, the Joint National Committee on Hypertensionf or

patients with diabetes and hypertension the American Heart Association for patients with

cardiovascular disease. The USPSTF concludes that the evidence is insufficient

to assess the balance of benefits and harms of routine screening for chronic kidney disease in asymptomatic adults.Grade: I Statement.

http://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irec


SCREENING TESTS

CKD is typically detected by measuring serum creatinine levels to calculate the GFR . urinary albumin/creatinine ratio to detect

proteinuria. Urinalysis.

AFFP ,2011


RISK FACTORS Older age Family history of CKD Minority status (e.g., blacks, American Indians, Asians, Pacific Islanders Exposure to certain chemicals and environmental conditions (e.g., lead, cadmium,

arsenic, mercury, uranium )Exposure to certain drugs ( Hypertension Diabetes mellitus Low birth weight Low income or education Lower urinary tract obstruction Neoplasia Nephrolithiasis Recovery from acute kidney injury Reduction in kidney mass Urinary tract infections Systemic infections Autoimmune disease


Causes of chronic kidney Causes of chronic kidney disease disease


Classification of CKDClassification of CKD


Microalbuminuria Microalbuminuria Patients with albumin/ creatinine ratios of 30 to

300 mg per g

Macroalbuminuria Macroalbuminuria those with ratios greater than 300 mg per g


Investigation and Investigation and clinical evaluation clinical evaluation


Clinical pictureClinical picture


Management of CKDManagement of CKD


Treatment to slow the progression of CKD


Clinical intervention of CKD


GFR is less than 30 mL per minute per 1.73 m2 severe cardiovascular disease. Anemia of CKD Bone and mineral disorder of CKD Difficult to manage adverse effects of medications

Hyperkalemia (potassium level > 5.5 mEq per L [5.50 mmol per L] despite treatment)

Refractory proteinuria (urinary protein/creatinine ratio > 500 to 1,000 mg per g or urinary albumin/creatinine ratio > 300 mg per g)

Resistant hypertension (target blood pressure not achieved with use of at least three antihypertensive drugs)

Stage 4 CKD (estimated GFR < 30 mL per minute per 1.73 m2) Unexplained decrease in estimated GFR > 30 percent over four months

Indications for referral to a Nephrologist


Thanks

approach to chronic kidney disease

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