Chronic Kidney Disease

Chronic Kidney Disease: 

Richard Bishop, ST3 27 October 2011 Chronic Kidney Disease

Overview: 

Definitions Complications Who should be tested? Diagnosis Treatment, Monitoring, and Referral Overview

Definitions: 

Microalbuminuria : ACR > 2.5 (or 3.5 in a woman) Proteinuria: ACR > 30 Heavy proteinuria: ACR > 70 Stages of CKD: 1) eGFR > 90 2) eGFR 60-89 3) eGFR 30–59 (3A eGFR 45-59, 3B eGFR 30-44) 4) eGFR 15-29 5) eGFR <15 Definitions

Complications: 

Hypertension (salt/water retention, increased sympathetic activity) Anaemia (reduced erythropoetin , reduced RBC survival, platelet dysfunction) Neuropathy (damage to nerves from uraemia) Renal bone disease (phosphate retention and reduced vitamin D, leading to secondary hyperparathyroidism and consequent high bone turnover) Lipid abnormalities (impaired clearance of triglycerides) Complications

Who should be tested?: 

Diabetes Hypertension Cardiovascular disease SLE BPH Renal stones Nephrotoxic drugs Hereditary kidney disease Urinalysis  blood or protein Who should be tested?

How to test for CKD: 

U&Es If eGFR <60 persistently (recheck at 2 weeks and at 3 months to confirm) ACR Over 70 (i.e. “heavy proteinuria”) or Over 30 (i.e. “proteinuria”) on two occasions, the second of which should be an early morning urine Urine dip Microscopic haematuria on 2 occasions (in absence of UTI) How to test for CKD

How to test for diabetic nephropathy: 

ACR In microalbuminuria range on 2 occasions (in absence of UTI) Query diagnosis if: No significant retinopathy Resistant hypertension Haematuria Heavy proteinuria Rapidly worsening eGFR How to test for diabetic nephropathy

Treatment, monitoring and referral: 

Start ACE inhibitor if: Heavy proteinuria (ACR>70) or Proteinuria (ACR>30) and hypertension Titrate up by doubling dose every 1-2 weeks (check U&Es and BP each time) Target BP is 140/90 (or (130/80 if heavy proteinuria) If diabetic nephropathy, start statin (and aspirin if age>40) Check ACR every 12 months Check eGFR every 12 months (stage 1-2), 6 months (stage 3), 3 months (stage 4), 6 weeks (stage 5) If stage 3-5, monitor FBC, calcium, phosphate, PTH, Vit D Treatment, monitoring and referral

Treatment, monitoring and referral: 

In Stage 1-2, refer if: Heavy proteinuria Proteinuria and haematuria Uncontrolled hypertension Genetic kidney disease Suspected renal artery stenosis In stage 3, also refer if: Evidence of anaemia or renal bone disease eGFR drops by >5 points in a year In stage 4-5, refer everyone (prepare for renal replacement therapy) Treatment, monitoring and referral