3. SLOWING PROGRESSION OF CKD
DIABETES AND CKD
KENYA RENAL ASSOCIATION
SYMPSIUM
PROF. M. S. ABDULLAH
AGA KHAN UNIVERSITY HOSPITAL
3rd. NOVEMBER, 2007
4. SLOWING PROGRESSION OF
CKD
ESRD A Growing Concern
• CKD is a growing epidemic being fuelled
by various contributing factors such as
hypertension, obesity, diabetes, infectious
diseases, dyslipidemias
• CKD is contributing to the growing ESRD
prevalence world wide
• ESRD is not equitably distributed and
seems to affects blacks, natives, Asians
more than the caucasians
5. SLOWING PROGRESSION OF CKD
DIABETES AND CKD
KENYA RENAL ASSOCIATION
SYMPSIUM
PROF. M. S. ABDULLAH
AGA KHAN UNIVERSITY HOSPITAL
3rd. NOVEMBER, 2007
RRT is a growing concern world wide
12. Risk Factors for progression ESRD
Systemic hypertension
Proteinuria
Hyperglycemia
Lipid abnormalities
Smoking
Underlying nephropathy
High dietary intake of protein
Age
Genetic factors
Obesity
Atherosclerosis
C.O. Alebiosu et al An update on 'progression promoters' in renal diseases J Natl Med Assoc. 2003:95:30-42.
14. Haemoglobin by estimated GFR
– PRESAM
16
14
12
10
8
Mean Hb (g/dl)
40.0–49.9
15
13
11
9
30.0–39.9 20.0–29.9 10.0–19.9 <10.0
Estimated GFR (ml/min)
Valderrábano et al NDT in press
15. CKD Anaemia Treatment
Slows Renal Deterioration
Treating anaemia early in CKD is more effective in
slowing the decline in renal function
Adapted from Gouva et al. Kidney Int 2004; 66:753-760
0
0
0.2
0.4
0.6
0.8
1.0
6 18 24 3012
Follow-up (months)
Proportionwithout
renalprogression
Early
Late
22. SLOWING PROGRESSION OF CKD
Observations:
(USRDS 2003 Report & UK CKD Guidelines
2005)
• CKD is very common in adult populations (12 –
16%)
• The same is true in Europe (? and Africa)
• Progression of CKD to ESRD continues to rise
• Change in GFR from 5 ml/min/1.73 m² to
2ml/min adds 30 yrs of life off dialysis to a 25 yr
old patient with early stages of CKD
23. SLOWING PROGRESSION OF CKD
Observations:
CKD is very common in adult populations (12 –
16%)
• The same is true in Europe (? and Africa)
• Kenya’s population is 42 million and about 14%
of adults have CKD = 2,856,000
• Change in GFR from 5 ml/min/1.73 m² to
2ml/min adds 30 yrs of life off dialysis to a 25 yr
old patient with early stages of CKD
24. SLOWING PROGRESSION OF CKD
• Stage I CKD with microalbuminuria shows
hypertension is more frequent
• Stage II CKD with microalbuminuria shows
more hypertension and increased PTH
• Stage III shows increased HTN,
decreased Ca. absorption, reduced
phosphate excretion, altered lipid
metabolism, increasing renal anemia, LVH
25. SLOWING PROGRESSION OF CKD
• STAGE IV shows all the Stage III plus
metabolic acidosis, hyperkalemia,
decreased libido
• STAGE V saline and volume retention,
with significant HTN, incipient heart failure,
anorexia and vomiting resulting in
malnutrition, pruritis and stress
26. SLOWING PROGRESSION OF CKD
• Some risk factors can be modified by life style
changes or pharmacotherapy
• These include diabetes, hypertension, obesity,
dyslipidemia, inflammation, anemia smoking and
life style modification
• Life style modification includes exercise, salt
reduction, weight reduction and stop smoking
• Early intervention can avert many cases from
going to ESRD prematurely
• Late referrals account for many unnecessary
problems with negative impact
27. SLOWING PROGRESSION OF CKD
• There is growing literature on negative impact of late
referral
• There is increased mortality, morbidity, hospital stay,
cost of treatment
• Major reasons being failure to correctly address
anemia, bone disease, glycemic control, hypertension,
acidosis
• Other reasons include failure to obtain appropriate
permanent access for dialysis or pre emptive Tx
• Now failure of timely referral in US is reason for a
successful lawsuit
28. SLOWING PROGRESSION OF CKD
• NICE guidelines for management of DM (2002)
recommend annual serum creatinine estimation
• SIGN guidelines for management of DM (2005)
recommend microalbumin estimations once a year
in addition to serum creatinine.
• Formula-based GFR rather than just serum
creatinine should now be preferred to assess CKD
• MDRD formula is most preferred (corrects for body
surface area – BSA)
• Cockcroft and Gault formula can however be used
• Screen only the at risk populations for CKD
29. SLOWING PROGRESSION OF CKD
DIABETES AND CKD
KENYA RENAL ASSOCIATION
SYMPSIUM
PROF. M. S. ABDULLAH
AGA KHAN UNIVERSITY HOSPITAL
3rd. NOVEMBER, 2007
30. SLOWING PROGRESSION OF CKD
DIABETES AND CKD
KENYA RENAL ASSOCIATION
SYMPSIUM
PROF. M. S. ABDULLAH
AGA KHAN UNIVERSITY HOSPITAL
3rd. NOVEMBER, 2007
Proteinuria is a good
and effective way of
assessing CKD.
Yet very few doctors
use this tool
31. SLOWING PROGRESSION OF CKD
FAMUS BP Control Study
677 hypertensive type 2 diabetics analysed
- 166 (24.5%) : had BP < 140/90
- 81 (7.53%) : had BP < 130/85
- 22 (3.25%) : had BP < 130/80
32. SLOWING PROGRESSION OF CKD
Recommendation
• Simple Screening includes:
• History of smoking, diet, and lifestyle
• Measurement of BP, Ht, Wt, waist & hip
circumferences and BMI
• Urine dipstix using more sensitive sticks
• Estimation of EMU or overnight urine for
protein or albumin to creatinine ratios
33. Strategies for reducing progression
• Correct diagnosis of the primary renal disease
• Co-morbids and systemic complications management
• Potentially reversible – may cause further decline in GFR
• Hypovolemia and hypotension- cirrhosis and the nephrotic
syndrome
• Obstructive uropathy
• Persistent UTI
• Occlusive renovascular disease
• NSAID use
• severe hypokalemia or hypercalcemia.
• BP and minimization of proteinuria are the two most
important measures to preserve residual kidney function
