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Dr. Bassam A Alhelal Dr. Bassam A Alhelal Head of Nephrology and Dialysis Division Head of Nephrology and Dialysis Division Al Adan Hospital Al Adan Hospital.

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Presentation on theme: "Dr. Bassam A Alhelal Dr. Bassam A Alhelal Head of Nephrology and Dialysis Division Head of Nephrology and Dialysis Division Al Adan Hospital Al Adan Hospital."— Presentation transcript:

1 Dr. Bassam A Alhelal Dr. Bassam A Alhelal Head of Nephrology and Dialysis Division Head of Nephrology and Dialysis Division Al Adan Hospital Al Adan Hospital CKD Prevention and Treatment of CKD, Early Diagnosis and aggressive Treatment

2  Definition of CKD  Epidemiology of CKD  Screening & Diagnosis  Prognosis and Progression  Complications of CKD  Prevention of CKD progression Objective

3  Structure abnormality with or without low GFR  Imaging  Urinary abnormalities ( protein, blood)  Histological abnormalities  GFR less or equal 60 ml/min 1.73m2  Persistent for > 3 months Definition

4  Measured GFR  Estimated GFR GFR Measurement

5  Inulin GFR is the Gold standard modality  Not used often in practice  Cost $$$$  Time consuming  Useful in limited clinical scenarios  Kidney donors with borderline GFR  GFR > 60  Older patients (more accurate)  Nephrotoxic drug dosing  Post Transplant CKD Concerns of measured GFR

6  Cockroft-Gault Formula  Modification of Diet in Renal Disease (MDRD)  CKD Epidemiology Collaboration Equation (CKD-EPI) Estimated GRF

7 Cockroft-Gault equation Age Weight Cr

8 MDRD equation Age Sex Race Cr

9 CKD-EPI equation Age Sex Race Cr

10 Comments Cockroft-GaultEstimate CrCL not GFR (overestimate GFR) Not Accurate for GFR > 60 Issues with obese and elderly patients MDRDMore accuracy and precision over CG equation Validated for Af American, DM CKD and Tx Recipient Not validated in Elderly, Pregnant women and Children Underestimate GFR in patients with normal GFR (Type 1 DM and Kidney Donors) CKD-EPIMore accurate than MDRD esp for GFR >60 Replaces MDRD as per KDIGO 2012 recommendation

11  Common world wide disease  Incidence and prevalence increasing  Progressive  ESRD leads to  Increased cost on the health care system  52 Billion $ by 2030  2% of UK health service budget  Higher patient morbidity / mortality  lower quality of life despite the cost Epidemiology

12  Earlier report showed  Over all prevalence of CKD 11%  9% males  12% females  Factors affect the true prevalence  Most of the studies are based on single GFR result  Micro-albuminuria can be associated with other disorders & can be transient  Elderly patients (Age related low GFR rather than CKD)  Error in the measurement of GFR with formulas like CG and MDRD Epidemiology of CKD

13 StudyCountryDesignNumberMicro AlbCKD NHANES III USACS/L 15K 12% 11% PREVENDNetherlandCS/L 40K 7% NEOERICA UKCS 130K 17% HUNT II NorwayCS 65K 6% 10% EPIC- NORFOLK UKCS 24K 12% MONICAGermanyCS 2K 8% AusDiabAustraliaCS 11K 6% 10% TAIWANTaiwanCS/L 462K 12% BeijingChinaCS 14K 13% TakahatJapanCS 2K 14% Prevalence of CKD

14  About 1% of the prevalence of CKD  Improve patient survival on dialysis  Improve dialysis Therapy  Better management of CVS diseases  Improve management of ESRD  Anemia  CKD Epidemiology of ESRD

15 IncidencePrevalence USA Caucasians African Am Natives Am Hispanic Australia 115 aboriginal Japan UK France Germany Italy Spain Epidemiology of ESRD

16 YearNew Patients TransplantesPDDeathTotal Data from Kuwait

17 PopulationESRD Mubarak Al-Adan Farwania Jahra MK Total = Total = 787 Kuwait 4 centers ESRD prevalance Rate of ESRD based on 2005 censes is 1 per 1000 or 1000 per million population

18 Diagnosis and Prognosis

19  Screening for the general population is not cost- effective  NKF Recommend screening for all High risk population  Measure BP  Measuring serum CR  Measuring Urine for ACR  Urine for RBC and WBC  ACP 2013 clinical practice guideline recommend not to scren for albuminuria for patients already on ACEI or ARB Screening for CKD

20 Target GroupKDOQIUK NICECARICSN Elderly ✔ HTN ✔✔✔✔ DM ✔✔✔✔ Atherosclerosis ✔✔✔ CVS and Heart Failure ✔✔ Urological disease, Stone or UTI ✔✔ Systemic Autoimmune disease ✔✔✔ Nephrotoxic drugs ✔✔✔ High risk ethnic groups ✔✔✔ Family history if CKD ✔✔ International Recommendations for Target population Screening for CKD

21  New staging system is based on triad  GFR category  Albuminuria and ACR  Cause  Systemic or not Staging & Prognosis of CKD

22  GFR  Albuminuria  Cause  Systemic  Not  Stage 3 further divided to 1a & b Staging and Classification

23 Measurment of Albuminuria

24  Variable course of Progression  Disease related  Age  Ethnicity  Not all progress to ESRD  Many die from other causes esp CVS before reaching ESRD Natural History of CKD

25  Progression in descending order  DM (10 ml/min per year)  Chronic GN  HTN  Interstitial nephritis

26 Non-modifiableModifiable AgeHypertension GenderProteinuria RaceAlbuminuria, CKD & CVS GeneticsRAAS Loss of renal massGlycemic control Obesity Lipid Smoking Uric Acid Progression Factors

27 Risk Stratification & Prognosis

28

29  Progression of CKD  Drop of GFR > 25% from baseline with drop in GFR category  Sustained decline in GFR of > 5 ml/min/1.73 m 2 /yr that is Rapid progression Detecting CKD Progression and GFR monitoring

30 Slowing GFR progression

31 Relaxed Target blood Pressure as compared with previous recommendations. Current recommendation - Less than 140/90 -Less than 130/80 for those with proteinuria ACEI or ARB should be the first line therapy Lower BP (SBP < 120 and/or DBP < 70) should be avoided - No proven benefit - Increased CVS complication 1. BP Target

32  All CKD pts are a increased risk of AKI  Heavy proteinuria, DM & HTN increase likelihood  AKI impacts progression conversely  Extra care is taken during:  Major surgery, intercurrent illness, exposure to nephrotoxins 2. CKD and AKI

33  Diabetes is the leading cause of CKD worldwide  25-40% of T1 & T2 DM develop DKD within 20-25ys of onset  Mortality of DM with high AER is twice that of normal AER  Aim for HbA1c of 7% to prevent or delay DKD  Avoid HbA1c < 7% in pts at risk of hypoglycemia 3. Glycemic Control

34  High protein intake causes accumulation of uremic toxins  This may suppress appetite & cause muscle protein wasting  Poor protein intake may cause loss of LBM & malnutrition  Value of protein restriction in slowing GFR loss is unclear  Effect of good BP & BS control & proteinuria reduction?  Avoid high protein intake (>1.3g/kg/d) in progressive CKD  High intake of non-dairy animal protein must be avoided  Aim for protein intake of 0.8g/kg/d when GFR < 30 ml/min  Very low protein intake may not protect against GFR decline 4. Protein Intake

35  Lower salt intake to < 5 g/d  That is < 2 g/d or < 90 mmol/d of sodium  CKD pts have impaired sodium excretion  High sodium intake  Raises BP & proteinuria & induces glomerular hyperfiltration  Blunts the response to RAAS blockade  Salt restriction reduces albuminuria  Independent of effect of salt restriction on BP reduction 5. Salt Intake

36  Hyperuricemia (uric acid > 400) is common in CKD pts  Growing body of evidence implicate hyperuricemia in:  CKD progression  adverse CV outcome in CKD  Treatment of asymptomatic hyperuricemia may:  Delay progression of CKD  Improve LV mass & endothelial function  However, evidence are inadequate to support the recommendation of treating asymptomatic hyperuricimia 6. Uric Acid and CKD

37  Prevalence of acidosis in CKD:  GFR < 90 – 8.5%  GFR < 60 – 9.5%  GFR < 45 – 18%  GFR < 30 – 30%  Chronic metabolic acidosis is associated with:  Increased protein catabolism & muscle wasting  Uremic bone disease  Impaired glucose homeostasis  Impaired cardiac function  CKD progression & increased mortality 7. Metabolic Acidosis

38  CKD pts with HCO 3 < 22 should be given oral HCO 3  Reverses harmful effects of acidosis  Did not affect BP control or hospitalization for heart failure  These effects are seen with NaCl & not NaHCO 3 Cont, metabolic acidosis

39  Exercise 30 min 5 days a week  Keep BMI  Stop smoking 9. Life style modification

40  Refer to nephrology in the following circumstances:  AKI or abrupt sustained fall in GFR  GFR < 30 ml/min/1.73 m 2  Albuminuria > 300 mg/d or proteinuria > 500 mg/d  Progression of CKD  Drop of GFR > 25% from baseline with drop in GFR category  Sustained decline in GFR of > 5 ml/min/1.73 m 2 /yr Timing of Referral to Nephrologist

41  RBC casts or unexplained hematuria  CKD & HTN resistant to ≥ 4 antihypertensive agents  Hereditary kidney disease  Persistent K abnormalities  Recurrent or extensive nephrolithiasis Cont, referral to nephrologist


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