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 CKDhave CKD

DR.Basma M Abd El Aziz ,Family Medicine,S
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 kidneyWhat is chronic kidney
diseasedisease??

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.

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 kidneyCauses of chronic kidney
diseasedisease

Classification of CKDClassification of CKD

 MicroalbuminuriaMicroalbuminuria
Patients with albumin/ creatinine ratios of 30 to
300 mg per g
 MacroalbuminuriaMacroalbuminuria
those with ratios greater than 300 mg per g

Investigation andInvestigation and
clinical evaluationclinical 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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