Predisposing Conditions, Management and Prevention of Chronic ...

719 views
517 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
719
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
25
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Predisposing Conditions, Management and Prevention of Chronic ...

  1. 1. Predisposing Conditions, Management and Prevention of Chronic Kidney Disease Dr FA Arogundade FMCP FWACP, ISN Fellow Consultant Nephrologist, Obafemi Awolowo University, Ile-Ife.
  2. 2. Basic Anatomy and Physiology
  3. 9. Definition of Chronic Kidney Disease
  4. 10. Definition of CKD <ul><li>Progressive and persistent deterioration in kidney structure and function, ultimately resulting in accumulation of nitrogenous waste and disruption of acid base homeostasis. </li></ul><ul><li>In addition, CKD also leads to derangements of the kidney’s osmoregulatory, metabolic and endocrine functions. </li></ul><ul><li>Now CKD can be staged (KDOQI) </li></ul>
  5. 11. Stage 5 Stage 1 Stage 4 Stage 3 Stage 2 GFR >90 GFR 60-89 GFR 15-29 GFR 30-59 GFR <15 Staging of CKD
  6. 12. Epidemiology of CKD
  7. 13. <ul><li>Prevalence of CRF is largely unknown </li></ul><ul><li>Conceivably high due to the high prevalence of diseases that cause chronic renal failure: </li></ul><ul><li>HYPERTENSION: > 15% in adults </li></ul><ul><li>DIABETES MELLITUS:>2.5-4.0% </li></ul><ul><li>Chronic inflammation – endemicity of malaria, Hepatitis B,C, & HIV </li></ul><ul><li>Socio-cultural practices </li></ul><ul><li>Others </li></ul>Prevalence of CKD in Nigeria
  8. 14. Blood pressure distribution in respondents (13.6% had HT, only 3.6% were previously diagnosed) Systolic Blood pressure Diastolic Blood pressure Ulasi et al. Medical screening by NAN, 2005
  9. 15. The grading of proteinuria in respondents (19% had proteinuria) Ulasi et al. Medical screening by NAN, 2005
  10. 16. NHANES III 16,800 US Population CKD Prevalence Stage % number 1 GFR:>90 3.3 5.9 millions 2 89-60 3 5.3 3 59-30 4.3 7.6 4 29-15 0.25 400,000 5 <15 0.2 345,000 Total 11 19.2 Garg AX et al. Albuminuria and renal insufficiency prevalence guides population screening: results from the NHANES III. Kidney Int 2002; 61: 2165 – 2175.
  11. 17. AusDiab 11,247 <ul><li>Population-based cross-sectional study to determine the prevalence of DM,Obesity,CVD Risk factors,and Indicators of Kidney disease in Australian adults </li></ul><ul><li>11,247 Participants </li></ul><ul><ul><li>Renal impairment 9.7% </li></ul></ul><ul><ul><li>Haematuria 3.7% </li></ul></ul><ul><ul><li>Albuminuria 6% </li></ul></ul><ul><ul><li>Proteinuria 0.6 % </li></ul></ul><ul><li>Total 16% </li></ul>Chadban et al, Prevalence of kidney damage in Australian adults: The AusDiab Kidney Study. J Am Soc Nehrol 2003, 14: S131 – S138.
  12. 18. <ul><li>CRF accounts for 8–12% of hospital medical admissions </li></ul><ul><li>CRF is a leading cause of mortality among adults </li></ul><ul><li>Sentinel study: based on available hospital data </li></ul><ul><li>Prevalence of 300-400 per million population </li></ul>Hospital Data Akinsola, 1989; Kadiri et al 1997; Akinsola et al, 2004. Arogundade et al 2005
  13. 21. NHANES 4% NHANES 96% Aus-Diab 9.7% Aus-Diab 90.3%
  14. 22. Documented causes in Nigeria <ul><li>Hypertension </li></ul><ul><ul><li>Benign </li></ul></ul><ul><ul><li>Malignant </li></ul></ul><ul><li>Chronic glomerulonephritis – </li></ul><ul><ul><li>Causes unknown in the majority </li></ul></ul><ul><ul><li>Occurs post-infection </li></ul></ul><ul><ul><ul><li>Parasite – malaria; </li></ul></ul></ul><ul><ul><ul><li>Bacteria – sore throat or skin infections; </li></ul></ul></ul><ul><ul><ul><li>Helminths – Schistosoma, Filaria </li></ul></ul></ul><ul><ul><ul><li>Viruses - Hepatitis B, C, HIV </li></ul></ul></ul><ul><ul><ul><li>Fungal </li></ul></ul></ul><ul><ul><li>Toxins: Bleaching creams / soap </li></ul></ul>
  15. 23. Other documented causes in Nigeria <ul><li>Diabetes Mellitus </li></ul><ul><li>Chronic urinary tract infection </li></ul><ul><li>Obstructive Uropathies </li></ul><ul><li>Drugs – Analgesic abuse </li></ul><ul><li>Inherited kidney disease-ADPKD </li></ul><ul><li>Connective Tissue Disease - SLE, RA </li></ul><ul><li>Others </li></ul>
  16. 24. Arogundade et al, 2005
  17. 25. Management of CKD
  18. 26. Objectives of Clinical Evaluation <ul><li>Establishing that there is CKD </li></ul><ul><li>Defining the likely aetiology </li></ul><ul><li>Determining occurrence/presence of complications </li></ul><ul><li>Assessing prognosis and survival </li></ul>
  19. 27. Clinical Evaluation – Hx & Examination <ul><li>Polyuria & Nocturia </li></ul><ul><li>Frothiness of urine </li></ul><ul><li>Oliguria </li></ul><ul><li>Symptoms of prostatism </li></ul><ul><li>Features of uraemia </li></ul><ul><li>Use of Analgesics, Hg containing creams/soaps, other drugs, local herbs </li></ul><ul><li>Past Medical Hx – HT, DM, Body Swelling etc. </li></ul><ul><li>Family Hx – Renal Ds, </li></ul><ul><li>Social Hx – Alcohol, Smoking </li></ul>
  20. 28. Clinical Evaluation – Hx & Examination <ul><li>Presence of HT </li></ul><ul><li>Presence of oedema </li></ul><ul><li>Presence of Pallor </li></ul><ul><li>Presence of Uraemic features </li></ul><ul><li>Presence of heart failure </li></ul><ul><li>Presence of retinopathy </li></ul>
  21. 29. Investigations <ul><li>Blood </li></ul><ul><ul><li>Chemistry </li></ul></ul><ul><ul><ul><li>E/U/Cr </li></ul></ul></ul><ul><ul><ul><li>Ca, Po4, </li></ul></ul></ul><ul><ul><ul><li>Alb, Chol, lipid profile </li></ul></ul></ul><ul><ul><li>Haemogram </li></ul></ul><ul><ul><ul><li>Blood cell counts </li></ul></ul></ul><ul><ul><ul><li>Serology </li></ul></ul></ul><ul><ul><ul><li>Clotting profile </li></ul></ul></ul><ul><li>Urine </li></ul><ul><ul><li>Microscopy </li></ul></ul><ul><ul><li>Chemistry </li></ul></ul><ul><ul><ul><li>Full urinalysis </li></ul></ul></ul><ul><ul><ul><li>24 Hour profile </li></ul></ul></ul><ul><li>Imaging </li></ul><ul><ul><li>USS </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>ECHO </li></ul></ul><ul><li>ECG </li></ul><ul><li>Renal Biopsy </li></ul>
  22. 30. Management <ul><li>Conservative </li></ul><ul><ul><li>Control of risk factors </li></ul></ul><ul><ul><ul><li>Modifiable </li></ul></ul></ul><ul><ul><ul><li>Non modifiable </li></ul></ul></ul><ul><li>RRT </li></ul><ul><ul><li>PD </li></ul></ul><ul><ul><li>HD </li></ul></ul><ul><ul><li>Transplant </li></ul></ul>
  23. 31. CKD Hypertension Proteinuria Lipids Smoking alcohol Weight Risk Factors/Markers for progressive CKD Cal-phos Anaemia Nutrition Gender Race Ageing Card.VD CKD DM Infectns
  24. 32. JNC VII Classification and management of BP for adults Initial Drug Treatment Lifestyle Modific. DBP mmHg SBP mmHg BP Classificat. 2 drug combination Yes > 100 > 160 Stage 2 Drugs for compel. Indic. + antihypertensives Thiazide + others Yes 90-99 140-159 Stage 1 Yes 80-89 120-139 Pre-HT Drugs for compel. Indic. No antihypertensive needed Encour. <80 <120 Normal With Compel. Indic. Without Compelling Indic.
  25. 33. <ul><li>75.7% had hypoalbuminaemia ( mean ± SD for serum albumin; 29.5 ± 7.2 g/L). </li></ul><ul><li>88.9% had anaemia (Packed Cell Volume,‘PCV’ <33%) Mean ± SD; 24.2 ± 7.0%). </li></ul><ul><li>Arogundade et al , 2005 </li></ul>
  26. 34. Hypertension <125/75 Proteinuria <1g/d Lipids <5 Smoking STOP Alcohol Weight CKD Prevention – Modifiable risk factors = CVD Protection DM <7% ALB Ca-Ph <4.5 PCV 33-36
  27. 35. Choice of Antihypertensives <ul><li>Regimens that include angiotensin-converting enzyme inhibitors (ACEIs) are more effective than regimens that do not include ACEIs in slowing progression of both diabetic and non-diabetic kidney disease. </li></ul><ul><li>Combination therapy of ACEI and angiotensin receptor blocker (ARB) slows progression of both diabetic and non-diabetic kidney disease more effectively than either single agent. </li></ul>
  28. 36. <ul><li>ACEIs appear to be more effective than beta-blockers and dihydropyridine calcium channel blockers in slowing progressive kidney disease. </li></ul><ul><li>Beta-blockers may be more effective in slowing progression than dihydropyridine calcium channel blockers, especially in the presence of proteinuria. </li></ul>Choice of Antihypertensives
  29. 37. Arije et al, 1992&95, Arogundade et al, 2004 & 2005 1. Best QOL 2. Cheap ultim. 3. Best profile 1. Easy 2. Time constr. 3. 1. Diff. vasc. Access 2. Uncotr. HD HT. 3. Low HCT not desiring transf. USEFULNESS Arije et al, 1992&95, Arogundade et al, 2004 & 2005 Arije et al, 1992&95, Bamgboye 2002, Arogundade et al, 2005 Akinsola et al, 2000 References 1. Planning 2. Organ Sourc 3. Infrastruc. 4. Donor Probl Not affordable Readily TX 1. Hypotensn. 2. Reactions 3. Inf transm. 4. Blood loss Not affordable Readily HD 1. Softwa. sourc 2. Infections 3. Mechanical 4. Obesity Not Affordable Not readily PD LIMITATIONS AFFORDABILITY AVAILABILITY RRT
  30. 42. Prevention
  31. 43. Preventive Nephrology <ul><li>Primary Prevention </li></ul><ul><ul><li>Aims at preventing kidney disease from occurring at all </li></ul></ul><ul><ul><li>Calls for knowledge of </li></ul></ul><ul><ul><ul><li>risk factors that predispose to renal disease </li></ul></ul></ul><ul><ul><ul><li>risk factors that initiate renal damage. </li></ul></ul></ul><ul><ul><ul><li>modification, removal, or avoidance of factors. </li></ul></ul></ul><ul><ul><ul><li>development of a positive health seeking attitude and behaviour </li></ul></ul></ul><ul><li>Secondary Prevention </li></ul><ul><ul><li>Aims at identifying factors that aid or hasten progression of kidney disease and/or accelerate loss of kidney function, and preventing or removing such factors. While a few of these factors are not modifiable, majority of them could be modified, controlled or completely avoided. </li></ul></ul><ul><li>Tertiary Prevention </li></ul>
  32. 44. CKD Hypertension Proteinuria Lipids Smoking alcohol Weight Risk Factors/Markers for progressive CKD Cal-phos Anaemia Nutrition Gender Race Ageing Card.VD CKD DM Infectns Non Modifiable Modifiable
  33. 45. Hypertension <125/75 Proteinuria <1g/d Lipids <5 Smoking STOP Alcohol Weight CKD Prevention – Modifiable risk factors = CVD Protection DM <7% ALB Ca-Ph <4.5 PCV 33-36
  34. 46. Tertiary Prevention Hypertension <125/75 Proteinuria <1g/d Lipids <5 Smoking STOP Alcohol Weight DM <7% ALB Ca-Ph <4.5 PCV 33-36
  35. 47. Tertiary Prevention Contd <ul><li>Control of HT </li></ul><ul><li>Use of EPO & Parenteral Iron </li></ul><ul><li>Use of Vit D analogues </li></ul><ul><li>Use of Phosphate sequestering agents </li></ul><ul><li>Control of hyperlipidaemia </li></ul><ul><li>Control of Infections </li></ul><ul><li>Control of Heart Failure </li></ul>
  36. 48. When do we refer to Nephrologists <ul><li>CKD 4 & 5 </li></ul><ul><li>Resistant HT </li></ul><ul><li>Persistent proteinuria / haematuria </li></ul><ul><li>Difficulty achieving Bld sugar control </li></ul><ul><li>Established CKD </li></ul><ul><li>Uraemia </li></ul><ul><li>Heart failure </li></ul><ul><li>Anaemia </li></ul>
  37. 49. Thank you for listening

×