Screening and early recognition of CKD. John Ngigi (FISN) Kidney specialist

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Dorthy Parks
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1 Screening and early recognition of CKD John Ngigi (FISN) Kidney specialist

3 screening Why? Who? When? How?

5 Primary diagnosis for patients who start dialysis Other 10% Glomerulonephritis 13% No. of dialysis patients (thousands) Diabetes 50.1% Hypertension 27% 243, ,355 No. of patients 95% CI 520,240 r 2 =99.8% United States Renal Data System 2000

6 Causes of ESRD among transplant reciepients interlife data

7 Change in the pattern of diabetic kidney disease Percent of all patients Chronic glomerulonephritis Diabetic nephropathy Year 2008

12 Prognosis Declines with CKD Progression CKD patients not on dialysis Hospitalisation CV events Death < < <15 Rates per 100 person years GFR (ml/min/1.73m 2 ) GFR (ml/min/1.73m 2 ) GFR (ml/min/1.73m 2 ) Decreasing GFR Increasing event rate Rates per 100 person years Rates per 100 person years Go et al. N Engl J Med. 2004;351:

13 Anaemia, Kidney Function and CHF Retrospective analysis in 142 patients LVEF (%) * *P < 0.05 between groups (ANOVA) 14 Creatinine (mg/dl) * Hb (g/dl)* I II III IV NYHA class Silverberg DS et al. J Am Coll Cardiol 2000

15 Uric acid and the kidney

17 Hypertension and Renal Disease The Mechanistic Links: The relationship between the kidney and HTN is indisputable and much work has been done to elucidate the mechanisms behind this deadly connection.

18 CMS

20 Atherosclerosis risk in communities (ARIC) study The prevalence of symptomatic coronary heart disease was 1 1% among persons with chronic kidney disease versus 4% in those without kidney disease. J AmColl Cardiol 41:47 55, 2003

21 Nurses Health Study, Higher levels of CRP, interleukin 6 (IL 6), and tumor necrosis factor (TNF) receptors I and II were associated with increased odds of coronary events in women with creatinine clearance <74 ml/min

22 HIV Renal Disease at Tygerberg Hospital WD Bates, N Muller, JW Schneider and MR Moosa Departments of Anatomical Pathology and Internal Medicine, University of Stellenbosch and Tygerberg Hospital NHLS

23 HIVAN Clinical and special investigations 2 HBsAg positive All proteinuria 23/31 24h over 3.5gm 6>15gm Haematuria Creatinine 708micromol/l mean 15> normal CD4 19/30 below %

25 summary Cardiovascular risks HIV Relatives have chronic kidney disease History of Acute disease...all at any opportunity!

26 Just how good are we at screening for CKD?

28 Aims Lack of chronic kidney disease (CKD) awareness is common. Recent data suggest that the presence of concurrent diabetes with CVD may heighten CKD awareness, Current data have not supported the hypothesis that healthcare delivery or insurance status improves awareness in the diabetic population. Hypothesizes that a highly prevalent co morbid condition such as CVD in patients with diabetes would predict CKD awareness.

29 Have you ever been told you have kidney disease? National Kidney Foundation Kidney Early Evaluation Program (KEEP ) Screening program designed to identify high risk individuals for CKD and promote awareness 77,077 KEEP participants, 20,200 with CKD and 23,082 with diabetes were identified

30 Prevalence of CVD according to CKD stage and diabetes status

31 Prevalence of CVD in patients with CKD according to awareness and diabetic status

32 summary Low awareness prevalence (< 10% of KEEP population) concomitant diabètes and CVD increased awareness of CKD (15%) kidneys, A high level of co morbidity does facilitate care giver patient and/or provider patient discussion about kidney function.

33 Communication between caregiver and patient to increase CKD awareness is important and lacking!

34 CKD and screening for proteinuria

35 Significance of Proteinuria Proteinuria results from injury to glomerular circulation Increased proteinuria is associated with progressive kidney disease In diabetes and hypertension, proteinuria is also an indicator of injury in the systemic circulation Proteinuria is associated with increased cardiovascular risk

36 Screening for Proteinuria ADA recommends screening in all type 2 diabetics at the time of diagnosis of diabetes and annually thereafter 30% to 40% prevalence of Microalbuminuria In type 2 diabetes Microalbuminuria progresses to overt Proteinuria in up to 50% of patients with type 2 diabetes within 5 to 10 years

37 scr 120, CrCl 29 ml/min scr 120, CrCl 130 ml/min

38 Calculations for estimating GFR Serum creatinine should not be used alone Kidney function should be assessed by estimating the level of GFR from serum creatinine CG (1973) MDRD( 1999) Cockcroft and Gault formula [140 age] x weight Serum creatinine (μmol/l) x 1.04 (women) 1.23 (men)

39 Advantages of a good screening program

40 Focus screening Early detection of CKD Intervention that delay progression Prevention of uremic Complications Modifications of Comorbidity Preparation for RRT ACE Inibitors Malnutrition Cardiac disease Education Blood Preassure Control Anemia Vascular disease Informed choice of RRT Blood sugar Control Osteodistrohy Neuropathy (in diabetics) Timely access placement Protein restriction? Acidosis Retinopathy (in diabetics) Timely initiation of dialysis Obrador: J Am Soc Nephrol, 9:S44 S54, 1998

41 Timely referral:guidelines GFR <60 ml/min: Consider referral to Nephrology team to prevent progression of renal failure & associated morbidity <30 ml/min: Mandatory referral to Nephrology Team; Refer the pts to a pre end stage Renal Disease program Treatment options education Participate in PEP (individual info from nurse,social worker,dietitian, physiotherapist) If possible transplantation should be discussed ml/min: Modality selection and access planning are advised 8 10 ml/min: Initiation of RRT is advised EBPG for Haemodialysis (part 1). Nephrology Dial Transplant 2002;17(Suppl 7):7 15

42 Consequences of late referral Dialysis start under non optimal conditions: Most cases start as emergency dialysis during a major complications No time to educate patients Lack of permanent vascular access, uncomfortable acute access Hypertension, anemia, bone disease, metabolic acidosis Higher comorbidity and mortality Increased costs Lack of choice between dialysis modalities. Lamiere N, Wauters JP,Gorriz et al. Kidney Int. 2002;61 (Suppl. 80): 27 34

43 KHDC PROGRAMME Programme for Detection and Management of Chronic Kidney Disease Hypertension Diabetes Cardiovascular Disease in Developing Countries

44 KHDC PROGRAMME A template for Low cost detection programme Treatment programme based on Diabetes control BP control ACE inhibitor

45 Ron and Richard Herrick Boston 1950 s ID twins

47 ?

Update on HIV-Related Kidney Diseases. Agenda

Update on HIV-Related Kidney Diseases ANDY CHOI THE MEDICAL MANAGEMENT OF HIV/AIDS DECEMBER 15, 2006 Agenda 1. EPIDEMIOLOGY: A) END STAGE RENAL DISEASE (ESRD) B) CHRONIC KIDNEY DISEASE (CKD) 2. HIV-ASSOCIATED