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MSN Screening for CKD

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  • Screening

    1. 1. Early Detection Of Renal Disease
    2. 2. <ul><li>Asymptomatic urine abnormalities : </li></ul><ul><li>proteinuria/ haematuria </li></ul><ul><li>Nephritic/Nephrotic syndrome </li></ul><ul><li>Hypertension </li></ul><ul><li>Unexplained anaemia </li></ul><ul><li>Incidental finding of elevated serum Creatinine </li></ul><ul><li>Uraemic emergencies </li></ul>Common clinical presentations of kidney disease
    3. 3. <ul><li>Serum creatinine </li></ul><ul><li>Estimated glomerular filtration rate (GFR) </li></ul><ul><li>Urine testing : </li></ul>Screening method <ul><li>Urine dipstick </li></ul><ul><li>Urine microscopic examination </li></ul><ul><li>Urine microalbuminuria </li></ul>
    4. 4. <ul><li>Sr creatinine is poor reflection of early renal disease/failure </li></ul><ul><li>Damage < 60% sr creatinine still normal </li></ul><ul><li>Almost all early renal failure patients are asymptomatic </li></ul><ul><li>SCREENING IS THEREFORE VERY IMPORTANT </li></ul>Screening method Serum Creatinine
    5. 5. Relationship between serum creatinine and GFR
    6. 6. 1.23 x (140-Age) x BW Sr Cr (umol/l) 1.04 x (140-Age) x BW Sr Cr (umol/l) Estimated Glomerular Filtration rate Man Woman Screening method Estimated GFR
    7. 7. <ul><li>Urine for protein </li></ul><ul><ul><ul><li>Dipstick </li></ul></ul></ul><ul><ul><ul><li>24 hour urinary protein </li></ul></ul></ul><ul><li>Urine microscopic examination </li></ul><ul><ul><ul><li>For RBC / Pus Cell / Cast </li></ul></ul></ul><ul><li>Urine for microalbuminuria </li></ul><ul><ul><ul><li>On morning urine sample </li></ul></ul></ul><ul><ul><ul><li>using strip for microalbumin </li></ul></ul></ul>Screening methods Urine testing
    8. 8. Screening methods Microalbuminuria testing
    9. 9. <ul><li>Mass population screening is not cost effecive </li></ul><ul><li>Screening of high risk groups to develop renal disease/failure </li></ul>Target groups for screening
    10. 10. <ul><li>Renal calculi </li></ul><ul><li>Anemia of unknown aetiology </li></ul><ul><li>First and second degree relatives of ESRD </li></ul><ul><li>Autoimmune disease (SLE/RA) </li></ul><ul><li>Reduction of kidney mass(Nephrectomy ) </li></ul><ul><li>Hypertensive patients </li></ul><ul><li>Diabetic patients </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Proteinuria </li></ul><ul><li>Hematuria </li></ul><ul><li>Those on regular NSAID/Herbs </li></ul>Screening renal disease The High Risk Groups
    11. 11. Screening of renal disease : Hypertensive patients UFEME BUSE/Cr USS KUB Other test Young hypertensive Yearly Yearly UFEME BUSE/Cr All hypertensive Frequency Screening tests
    12. 12. <ul><li>BP </li></ul><ul><li>Urine Protein </li></ul><ul><li>Urine Microalbuminuria </li></ul><ul><li>BUSE/Creatinine yearly if normal </li></ul>When to screen Methods Screening of renal disease Diabetic Patients Type 1 Type 2 DM 5 years after diagnosis (age >12) Or earlier if CV risk yearly At diagnosis Frequency First screening
    13. 13. Urine dipstick for protein Positive (Urine protein >300mg/l) On 2 separate occasions (exclude other causes) Overt Nephropathy Quantify excretion rate 24HUP Negative Screen for Microalbuminuria (on early morning spot urine) Negative Yearly test Positive Retest twice in 3-6/12 Exclude other cause If 2 of test are positive Diagnosis of microalbuminuria Is established 3-6 monthly follow-up of microalbuminuria Optimise glycaemic control Strict Bp control ACE/ARB Stop smoking Lifestyle modification Treat hyperlipidaemia Avoid excessive protein intake Monitor renal function Monitor other endorgan damage Algorithm: Screening for proteinuria/microalbuminuria in DM
    14. 14. Proteinuria is a major manifestation of renal disease Screening of renal disease Proteinuria <20 <30 Normoalbuminuria >35 women >25 men >200 >200 >300 Overt Proteinuria 3.5-35 women 2.5-25 men 20-200 20-200 30-300 Microalbuminuria Urine Albumin:creatinine ratio (mg/mmol) Urine Albumin Concentration (mg/l) <3.5 women <2.5 men <20 First voided morning specimen Timed Collection (ug/min) 24 hr Collection (mg/24h) Specimen collected Albumin Excretion
    15. 15. <ul><li>Urinary Tract Infection </li></ul><ul><li>Sepsis </li></ul><ul><li>Heart Failure </li></ul><ul><li>Strenous exercise </li></ul><ul><li>Heavy protein intake </li></ul><ul><li>Menses </li></ul>Causes of false positive proteinuria
    16. 16. <ul><li>A dominant risk factor for deterioration of renal failure (besides HT) </li></ul><ul><li>Marker of Increased Risk for CV mortality and morbidity (DM & non-DM) </li></ul><ul><ul><ul><li>e.g. Microalbuminuria is associated with a 100- 150% increase in death rate </li></ul></ul></ul><ul><li>(Mogensen CE, New Eng. J. Med 1984;310:310-60) </li></ul>Significance of Proteinuria
    17. 17. History Physical Examination Urine Examination of Urinary sediment Abnorma l refer to a nephrologist Normal Repeat visit for a Qualitative proteinuria test Positive Do Renal profile Quantitate urinary protein Refer to nephrologist Negative Transient proteinuria Reassure Evaluation of persistent proteinuria
    18. 18. <ul><li>Definition: </li></ul><ul><li>> 3-5 rbc/hpf on urinary sediment examination </li></ul><ul><li>In clinical practice can be diagnosed by urine dipstick test </li></ul><ul><li>False positive </li></ul><ul><li>povidone-iodine </li></ul><ul><li>oxidising agents </li></ul><ul><li>False negative </li></ul><ul><li>vit C excretion </li></ul><ul><li>air-exposed dipsticks </li></ul>Screening of renal disease Hematuria
    19. 19. Detection of Microscopic hematuria >5RBC/hpf or +ve dipstik test <ul><li>Primary care investigation </li></ul><ul><li>History </li></ul><ul><li>Examination </li></ul><ul><li>Renal function </li></ul><ul><li>Urine microscopy and culture </li></ul>Urological referral <ul><li>Urological investigation </li></ul><ul><li>Radiological imaging </li></ul><ul><li>Cystourethroscopy </li></ul>Diagnosis And Treatment <ul><li>Menstruating women </li></ul><ul><li>Women with UTI </li></ul><ul><li>False +ve resul suspected </li></ul><ul><li>Recent strenous exercise </li></ul><ul><li>Proteinuria </li></ul><ul><li>Red cell cast </li></ul><ul><li>Renal Impairment </li></ul><ul><li>Nephrological referral </li></ul><ul><li>Observation </li></ul><ul><li>Investigation </li></ul><ul><li>Renal biopsy </li></ul>No diagnosis <ul><li>GP follow-up </li></ul><ul><li>Biennial urinalysis and BP </li></ul>Evaluation of asymptomatic hematuria
    20. 20. <ul><li>1. Proper investigation and accurate diagnosis </li></ul><ul><li>- definitive diagnosis relevant for: </li></ul>Benefits of early detection a) specific disease treatment e.g. immunosuppression b) future transplant – timing, risk of recurrent disease etc c) counselling and screening of relatives
    21. 21. <ul><li>2. Allows measures to retard disease progression to be instituted and maximised </li></ul><ul><li>3. Complications associated with failing </li></ul><ul><li>renal function can be addressed: </li></ul>Benefits of early detection <ul><li>anaemia </li></ul><ul><li>renal bone disease, </li></ul><ul><li>malnutrition </li></ul>
    22. 22. <ul><li>4. Enables timely referral to nephrologists </li></ul>Benefits of early detection <ul><li>Adequate time for preparation of patients for renal replacement therapy </li></ul><ul><li>Avoids the increased mortality and morbidity associated with temporary dialysis catheters and IPD </li></ul><ul><li>education regarding options </li></ul><ul><li>timely creation of AVF </li></ul><ul><li>placement of Tenckhoff catheters </li></ul>
    23. 23. Studies on Early vs late referral AV access use at initiation of HD increased with earlier referral time 499 ER < 1 mo LR > 12 mo USA 1995-1998 CHOICE study LR > ER 78 106 ER > 3 mo LR < 1 mo Brazil 1992-1995 Sesso et al LR > ER 2264 ER > 4 mo LR < 4 mo Texas 2002 Stack et al LR > ER 325 325 ER > 4 mo LR < 4 mo Edinburgh 1987-1992 Eadington et al LR > ER 153 65 ER > 6 mo LR < 1 mo Paris 1989-1991 Jungers et al LR > ER 32 23 ER > 1 mo LR < 1 mo Oxford 1981 Ratcliffe et al Mortality risk Mean length of hospital stay (days) No of patients Timing of referral Location/ year Source
    24. 24. THANK YOU