Screening and early recognition of CKD John Ngigi (FISN) Kidney specialist
screening Why? Who? When? How?
Primary diagnosis for patients who start dialysis Other 10% Glomerulonephritis 13% No. of dialysis patients (thousands) 700 600 500 400 300 200 100 0 Diabetes 50.1% Hypertension 27% 243,524 281,355 No. of patients 95% CI 520,240 r 2 =99.8% 1984 1988 1992 1996 2000 2004 2008 United States Renal Data System 2000
Causes of ESRD among transplant reciepients interlife data
Change in the pattern of diabetic kidney disease Percent of all patients 80 60 40 20 Chronic glomerulonephritis Diabetic nephropathy 0 2000 2001 2002 2003 2004 2005 2006 2007 Year 2008
Prognosis Declines with CKD Progression CKD patients not on dialysis Hospitalisation CV events Death 150 40 15 30 20 10 0 60 45 59 30 44 15 29 <15 60 45 59 30 44 15 29 <15 60 45 59 30 44 15 29 <15 Rates per 100 person years 100 50 0 10 5 0 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;351:1296 1305
Anaemia, Kidney Function and CHF Retrospective analysis in 142 patients LVEF (%) * 40 35 30 25 2.2 *P < 0.05 between groups (ANOVA) 14 Creatinine (mg/dl) * 1.6 12 Hb (g/dl)* 1.0 10 I II III IV NYHA class Silverberg DS et al. J Am Coll Cardiol 2000
Uric acid and the kidney
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.
CMS
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
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
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
HIVAN Clinical and special investigations 2 HBsAg positive All proteinuria 23/31 24h over 3.5gm 6>15gm Haematuria 0-+++ Creatinine 708micromol/l mean 15>1000 5 normal CD4 19/30 below 200 63%
summary Cardiovascular risks HIV Relatives have chronic kidney disease History of Acute disease...all at any opportunity!
Just how good are we at screening for CKD?
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.
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
Prevalence of CVD according to CKD stage and diabetes status
Prevalence of CVD in patients with CKD according to awareness and diabetic status
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.
Communication between caregiver and patient to increase CKD awareness is important and lacking!
CKD and screening for proteinuria
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
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
scr 120, CrCl 29 ml/min scr 120, CrCl 130 ml/min
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)
Advantages of a good screening program
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
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 15 25 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
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
KHDC PROGRAMME Programme for Detection and Management of Chronic Kidney Disease Hypertension Diabetes Cardiovascular Disease in Developing Countries
KHDC PROGRAMME A template for Low cost detection programme Treatment programme based on Diabetes control BP control ACE inhibitor
Ron and Richard Herrick Boston 1950 s ID twins
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