7Serum CreatinineSr creatinine is poor reflection of early renal disease/failureDamage < 60% sr creatinine still normalAlmost all early renal failure patients are asymptomaticSCREENING IS THEREFORE VERY IMPORTANT
8Estimated Glomerular Filtration rate Estimate of GFR by the Cockcroft and Gault equation1.23 x (140-Age) x BWSr Cr (umol/l)Man1.04 x (140-Age) x BWSr Cr (umol/l)Woman
9Estimated Glomerular Filtration rate MDRDeGFR (mL/min/1.73m2)= 186 x [SerumCreatinine(umol/L) x ] x Age(years) (x if female)
10Continued.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.
11Urine Testing Urine for protein Urine microscopic examination Dipstick24 hour urinary proteinUrine microscopic examinationFor RBC / Pus Cell / CastUrine for microalbuminuriaOn morning urine sampleusing strip for microalbumin
12Targets for Screening Hypertensive patients Diabetic patients Cardiovascular diseaseProteinuriaHematuriaThose on regular NSAID/HerbsRenal calculiAnemia of unknown aetiologyFirst and second degree relatives of ESRDAutoimmune disease (SLE/RA)Reduction of kidney mass(Nephrectomy
13Screening for proteinuria Urine dipstick for proteinPositive(Urine protein >300mg/l)On 2 separate occasions(exclude other causes)Overt NephropathyQuantify excretion rate24HUPNegativeScreen forMicroalbuminuria(on early morning spot urine)Positive3-6 monthly follow-up ofmicroalbuminuriaOptimise glycaemic controlStrict Bp controlACE/ARBStop smokingLifestyle modificationTreat hyperlipidaemiaAvoid excessive protein intakeMonitor renal functionMonitor other endorgandamageRetest twice in 3-6/12Exclude other causeNegativeIf 2 of test are positiveDiagnosis of microalbuminuriaIs establishedYearly test
15Significance 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)
16Evaluation of Symptomatic Haematuria Detection of Microscopic hematuria>5RBC/hpf or +ve dipstik testPrimary care investigationHistoryExaminationRenal functionUrine microscopy and cultureConsider Urological referralExclude benign causes :Menstruating womenWomen with UTIFalse +ve resultRecent strenous exerciseSexual activity, viral illness,trauma etcProteinuriaRed cell cast/dysmorphic red blood cellsRenal ImpairmentNephrological referralIsolated microscopic haematuria and age >40 years
17Who should take the lead? The primary care physician andThe nephrologistsPRIMARY CAREPHYSICIANNEPHROLOGISTSScreeningDiagnosisTreatmentDiagnosisManagementPre Dialysis care
20Risk factors for progression of CKD HypertensionHyperglycemiaProteinuriaCoffeSmokingSalt
21They describe the loss of afferent arteriolar autoregulation and the subsequent dilatation along with the relative constriction (mediated by angiotensinII) of theefferent arteriole. These combined changes lead to a rise in intraglomerularpressure (Glomerular hypertension)
22Hyperglycemia is also associated with renal and glomerular hypertrophy Hyperglycemia is also associated with renal and glomerular hypertrophy. Theincreased glomerular radius along with the increased pressure generates increasedtension on the glomerular capillary wall.
27ConclusionManagement of ESRD poses an immense challenge to healthcare systems all over the worldIncidence continue to increase and nearly half of the patients are diabeticPatients with ESRD have many other medical complications especially CVDRetarding the progression renal failure in patients with CKD may reduce the burden of ESRD
28ACE I ,ARB & Non DHCCB (Verapamil) < 25% deterioration in base line creatinine level is acceptable following introduction of ACE I ,ARB