Approach To Chronic Kidney Disease

Approach to Chronic
Kidney Disease
Dr SP Hariparshad
Outline
 Clinical assessment : History
Examination
 What is chronic kidney disease
 Stages
 Pathogenesis
 Causes
 Diagnosing CKD
 Investigations
 Specialist care
 Chronic dialysis programme
 Prevention
 Managemant
History
 Symptoms arise:
 Locally from kidneys or urinary tract
 Impaired salt and water handling
 Failing excretory or metabolic
functions
 Systemic disease causing dysfunction
 Early in disease : asymptomatic

Symptoms
 Pain : loin , ureteric or suprapubic
 Haematuria
 Change in urine appearance
 Change in urine volume - polyuric
- oliguria/ anuria
 Lower tract symptoms :
Obstructive : retention, force of urinary
stream, hesitancy, interrupted flow ,
incomplete emptying
Symptoms
 Storage (filling)
 Nocturia , daytime frequency , urgency
, dysuria
 Systemic conditions:
 Skin rashes, painfull joints, myalgia
fever , night sweats, mouth ulcers , dry
red or painful eyes , thromboembolic
episodes
Past medical history
 Childhood urinary problems –

infections
 Previous renal/urinary disease –
infections /stones
 Hypertension/ Diabetes
 Gout , vascular disease
 Previous urine testing
Drug and treatment
history
 BP treatment : When diagnosed,
treatment compliance , control
 Analgesics : NSAIDS
 OCP
 Steroids/ immunosupressives
Sexual , menstrual ,
obstetric history
 Decreased libido , impotence
 Irregular menses or subfertility
 Pregnancy complications : HPT
 Fetal outcomes
 Premature menopause
Dietary history
 Changes in appetite and weight

 Habits : vegan , ethnic, alcohol
 Ethnicity :
 IgA nepropathy- caucasians and asian
population
 Black , Asian : HPT , DM , Lupus
What is chronic kidney
disease?
 Abnormality in kidney structure or
function
 Present for > 3 months
 GFR < 60 ml/min
 Abnormal urine : protein or blood
 Structural : abnormal imaging
 Genetic disease: APCKD
 Histologically proven disease
 Prevalence unknown
 Under-recognised and untreated
 Prevalence increases with age

Stages of chronic kidney
disease
Pathogenesis of CKD
 Raised intra-gomerular pressure:
 Remaining nephrons –increased blood flow ,
increased glomerular permeability
 Glomerular damage:
 Strain on mesangial cells
 Proteinuria:
 Direct proximal cell tubular injury,
profibrotic
 Tubulointerstitial scarring:
 Chronic ischaemic damage
Causes of CKD
 Hypertension
 Diabetes Mellitus
 Glomerulonephritis
 HIV
 Reflux nephropathy
 Drugs : NSAIDs
 Connective tissue disease
 Inherited : Polycystic kidney disease
Diagnosing CKD
 Why is it important ?
Increased CV risk
Further investigation – renal biopsy
Slow progression
Complications: anaemia , bone disease
Prepare for renal replacement
 Who do you screen ?
Known risk factors
Unexplained oedema
CCF
Atherosclerosis
Multi-system disease
Chronic nephrotoxins
Bladder / urological disease
 Importance of proteinuria:
 Marker of ckd
 Prognostic - > protein > progression
 Cardiac risk marker
 Importance of BP:
 Cause of CKD and marker of
progression
 Control slows progression
Investigations:
 Urine dipsticks
 Urine microscopy
 Protein/creatinine ratio - > 50
mg/mmol
 U/E – eGFR
 ECG
 US kidneys
 Renal biopsy
When to refer to
specialist care
 AKI or abrupt fall in GFR
 GFR < 30 ml/min
 PCR > 50 mg/mmol
 Urinary red cell casts
 CKD + hypertension unresponsive to > 4
antihypertensive agents
 Serum K abnormalities
 Inherited kidney disease
 Recurrent stone disease
Can we treat all patients
with ESRD ?
 Cost per year : R100 000
 KZN : 2000 patients per year
 Expect the number to double in the

next decade
Chronic renal dialysis
programme
 FOREWORD
– End stage kidney disease is increasing amongst South Africans. Dialysis is the first
form of intervention to patients affected by kidney failure. If patients do not get
kidney donors they can wait for a long time on dialysis and that places a heavy
burden on national resources. It also makes it difficult for clinicians to decide who
can be accepted onto the program.
– The health system in South Africa, like in other countries, is characterized by the
existence of both a private and the public sector with different financial and human
resources. This has to a large extent contributed to the unequal access to chronic
renal dialysis for our people.
– The main objective of these guidelines is to assist the clinicians when making
decisions particularly on older patients and those affected by HIV taking into
consideration the resources available to them.
– It is my hope that these guidelines will contribute towards the realization of the
goals of the government of improving health service delivery and ensuring a better
life for all.
 MS BARABARA HOGAN, MP
 MINISTER OF HEALTH
 DATE: 3/3/2009
 CONTENTS
 PAGE
 Foreword ………………………………………………...…….. ii
 1. INTRODUCTION ……………..……………………......…. 01
 1.1 OBJECTIVES ..………………..……………..……......… 01
 2. PRINCIPLES …………………...……………….…....…… 02
 3. EXCLUSION CRITERIA ..…………………………..…… 03
 3.1 Medical Exclusion Criteria ....……………………..……… 03
 3.2 Psychological Exclusion Criteria ....……………......…… 04
 3.3 Compliance ……………………………..……….………… 04
 APPENDIX .............................................................................. 05
 DIALYSIS IN PATIENTS WITH HIV INFECTIONS...…….……. 05
 1. Introduction ............……………………...............…......... 05
 2. Dialysis in patients with HIV…. ………………...….......... 06
 2.1. Heamodialysis ............................................................... 07
 2.2 Peritoneal Dialysis ......................................................... 08
 3. Challenges and recommendations……...............……… 09
 ACRONYMS……………………………………………….......….
Progression of CKD
 Non modifiable factors:

 Underlying cause of disease
 Race : > progression in Black patients
 Modifiable factors:
 BP
 Proteinuria
 Nephrotoxic agents
 Disease activity
 Obstruction /uti
 Hypovolaemia/intercurrent illness
 Anaemia
 Smoking
 Blood glucose in DM
Preventing Progression
 BP
 PCR < 100 mg/mol : target 130/80
mmHg
 PCR > 100 mg/mol : 120/75 mmHg
 DM : 120/75
 What drug?
 ACE-I or Angiotensin receptor blockers
 Reduce BP and proteinuria
 Reduce fibrosis and scarring
 Batting order :
 Loop diuretics for salt and water
overload
 Calcium channel blockers
 B blockers
 Alpha blockers
 Other measures:
 Dyslipidaemia : statins
 Hyperphosphataemia : phosphate binders
 Anaemia: iron supplementation and
erythropoeitin
 Aspirin : CVS risk
 Avoid : hypovolaemia , uti , obstruction
drugs ( metformin GFR <
60ml/min), NSAIDs , radiocontrast
 Dietary protein restriction: 0.8 – 1
g/kg protein per day
 Stop smoking
 Limit alcohol to less than 3 units/day
 Weight reduction
 Aerobic exercise
 Vaccination : influenza and
pneumococcus
 Stage 4-5
 Refer to a renal unit , late referral
associated with worse prognosis
 Optimise calcium , phosphate and PTH
 Correct acidosis
Complications of
advanced CKD
 Fluid overload : salt and water
restriction
 Output + 500 ml/day
 Furosemide
 Monitor daily weight
 Hyperkalaemia:
 Dietary advice
 Stop/reduce ACE-I/ARB

Approach To Chronic Kidney Disease

Uploaded by

Copyright:

Available Formats

Approach To Chronic Kidney Disease

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Approach To Chronic Kidney Disease

Uploaded by

Copyright:

Available Formats

Approach to Chronic

 Early in disease : asymptomatic

 Childhood urinary problems –

 Changes in appetite and weight

 Under-recognised and untreated

 Prevalence increases with age

 KZN : 2000 patients per year

 Expect the number to double in the

 Non modifiable factors:

You might also like