1. Hisham Abdelwahab MRCP U.K MMed/SCI
CHRONIC KIDNEY DISEAS
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