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Hisham Abdelwahab MRCP U.K MMed/SCI

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Presentation on theme: "Hisham Abdelwahab MRCP U.K MMed/SCI"— Presentation transcript:

1 Hisham Abdelwahab MRCP U.K MMed/SCI




5 Common presentation of CKD
Asymptomatic urine abnormalities : proteinuria/ hgaematuria Nephritic/Nephrotic syndrome Hypertension Unexplained anaemia Incidental finding of elevated serum Creatinine Uraemic emergencies

6 Screening Methods Serum Creatinine
Estimated glomerular filtration rate (GFR) Urine testing :

7 Serum Creatinine Sr creatinine is poor reflection of early renal disease/failure Damage < 60% sr creatinine still normal Almost all early renal failure patients are asymptomatic SCREENING IS THEREFORE VERY IMPORTANT

8 Estimated Glomerular Filtration rate
Estimate of GFR by the Cockcroft and Gault equation 1.23 x (140-Age) x BW Sr Cr (umol/l) Man 1.04 x (140-Age) x BW Sr Cr (umol/l) Woman

9 Estimated Glomerular Filtration rate
MDRD eGFR (mL/min/1.73m2)= 186 x [SerumCreatinine(umol/L) x ] x Age(years) (x if female)

10 Continued. The formula is named after the Modification of Diet in Renal Disease study in the USA. The results are expressed relative to a standard body surface area of 1.73 m2 to allow for different body sizes. The equation is only valid in persons over 17 years of age. Results >60 mL/min/1.73m2 are likely to deviate from the true value and should not be relied upon. The use of the eGFR in patients on dialysis is inappropriate and will give misleading results.

11 Urine Testing Urine for protein Urine microscopic examination
Dipstick 24 hour urinary protein Urine microscopic examination For RBC / Pus Cell / Cast Urine for microalbuminuria On morning urine sample using strip for microalbumin

12 Targets for Screening Hypertensive patients Diabetic patients
Cardiovascular disease Proteinuria Hematuria Those on regular NSAID/Herbs Renal calculi Anemia of unknown aetiology First and second degree relatives of ESRD Autoimmune disease (SLE/RA) Reduction of kidney mass(Nephrectomy

13 Screening for proteinuria
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) Positive 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 Retest twice in 3-6/12 Exclude other cause Negative If 2 of test are positive Diagnosis of microalbuminuria Is established Yearly test

14 False +ve CKD Urinary Tract Infection Sepsis Heart Failure
Strenous exercise Heavy protein intake Menses DHCCB

15 Significance of proteinuria
A dominant risk factor for deterioration of renal failure (besides HT) Marker of Increased Risk for CV mortality and morbidity (DM & non-DM) e.g. Microalbuminuria is associated with a % increase in death rate (Mogensen CE, New Eng. J. Med 1984;310:310-60)

16 Evaluation of Symptomatic Haematuria
Detection of Microscopic hematuria >5RBC/hpf or +ve dipstik test Primary care investigation History Examination Renal function Urine microscopy and culture Consider Urological referral Exclude benign causes : Menstruating women Women with UTI False +ve result Recent strenous exercise Sexual activity, viral illness,trauma etc Proteinuria Red cell cast/dysmorphic red blood cells Renal Impairment Nephrological referral Isolated microscopic haematuria and age >40 years

17 Who should take the lead?
The primary care physician and The nephrologists PRIMARY CARE PHYSICIAN NEPHROLOGISTS Screening Diagnosis Treatment Diagnosis Management Pre Dialysis care


19 CKD

20 Risk factors for progression of CKD
Hypertension Hyperglycemia Proteinuria Coffe Smoking Salt

21 They describe the loss of afferent arteriolar autoregulation and the subsequent
dilatation along with the relative constriction (mediated by angiotensinII) of the efferent arteriole. These combined changes lead to a rise in intraglomerular pressure (Glomerular hypertension)

22 Hyperglycemia is also associated with renal and glomerular hypertrophy
Hyperglycemia is also associated with renal and glomerular hypertrophy. The increased glomerular radius along with the increased pressure generates increased tension on the glomerular capillary wall.


24 ACE REIN (n=352) CAPTOPRIL (n=409) RENAAL (n=1513) IDNT (n=1715)


26 CALM2000

27 Conclusion Management of ESRD poses an immense challenge to healthcare systems all over the world Incidence continue to increase and nearly half of the patients are diabetic Patients with ESRD have many other medical complications especially CVD Retarding the progression renal failure in patients with CKD may reduce the burden of ESRD

28 ACE I ,ARB & Non DHCCB (Verapamil)
< 25% deterioration in base line creatinine level is acceptable following introduction of ACE I ,ARB

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