APPROACH TO CHRONIC KIDNEY DISEASE
1.How many adults worldwide have some form of kidney damage?
CKD as a Public Health Issue
Pakistan
-15 to 20 percent of persons 40 years of age or older had a reduced estimated GFR in a survey from Karachi
hypertension is even higher affecting about one third of Pakistanis over 45 years according to the 1990–1994 National Health Survey of Pakistan and verified in 2017
Gaps in CKD Diagnosis‘
Improved Diagnosis…
Studies demonstrate that clinician behavior changes when CKD diagnosis improves. Significant improvements realized in:
Impact of primary care CKD detection with a patient safety approach
Screen patients with the following for CKD
Diabetes, Cardiovascular disease, Hypertension/PIH, Hyperlipidemia Obesity Metabolic syndrome Smoking Hepatitis B/C Malignancy F/H of CKD >60 years History of potentially nephrotoxic drugs
Recovery from AKI Stones UTI Autoimmune disease Systemic infections Hakim medications
Criteria for CKD
Abnormalities of kidney structure or
function, present for >3 months, with implications for health
Either of the following must be
present for >3 months:
ACR >30 mg/g ( albumin
mg:creatinine g ratio)
Markers of kidney damage (one or
more*)
GFR <60 mL/min/1.73 m2
*Markers of kidney damage can
include nephrotic syndrome, (biopsy) nephritic syndrome, tubular syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic radiologic abnormalities (polycystic), hypertension due to kidney disease.
Proteinuria
Screening Tools: EGFR
Considered the best overall index of kidney function.
Normal GFR varies according to age, sex, and body size, and
declines with age.
The NKF recommends using the CKD-EPI Creatinine Equation
(2009) to estimate GFR
GFR calculators are available online at www.kidney.org/GFR.
Calculation of Glomerular Filtration Rate
\
Calculation of GFR
Chronic Kidney Disease and CV Risk
Traditional risk factors | Non-traditional risk factors |
Age Sex Hypertension HDL and LDL cholesterol Diabetes Smoking Physical activity Family history of CVD LVH | Albuminuria Homocysteine LP(a) and apolipoproteins Anaemia Ca/phosphate metabolism Salt and water overload Oxidative stress Inflammation Malnutrition Thrombogenic factors Sleep disturbance NO/endothelin balance… |
Cardio-Metabolic Protection
Valsartan Significantly Reduces Risk of New-onset Atrial Fibrillation vs. Amlodipine
Valsartan Reduces The Rate of New-onset AF in Patients on Standard CHF Therapy
Valsartan Reduces incidence of Stroke in Post-MI Patients Similar to Captopril
Valsartan Significantly Reduces The Risk of New-onset Diabetes Compared to Amlodipine
Valsartan Reduces The Risk of Diabetes in Patients with High CV Risk on Monotherapy
Summary: Valsartan Provides Proven Cardio/Reno/Metabolic protective Benefits
Protects the vasculature and improves vascular structure/function
Positively impacts hypertension, oxidative stress and effects of angiotensin II
Blocks the negative effects of angiotensin II at the AT1 receptor
Acts at the source of vascular damage
Improves vasodilation and arterial compliance, and reduces oxidative stress
Improves left ventricular ejection fraction and left ventricular internal dimension at end diastole in patients with heart failure
Improves endothelial function
Proven benefits in HF and post-myocardial infarction patients
Significantly reduces UAER in patients with Type 2 diabetes mellitus
Conclusions
Microalbuminuria is frequent in hypertension and is
associated with target organ damage and the incidence of CV complications
The pathophysiological link between microalbuminuria and
CV risk is not completely understood but it may be due to endothelial
dysfunction with an impaired NO balance, activation of local mediators and
increased activity of the RAAS system
Blockade of the RAAS with ACE inhibitors or AT1 receptor blockers is an important therapeutic approach to reduce
microalbuminuria and to prevent the development of CV and renal complications
in hypertension
What can
primary care providers do?
First Line of Defense!
Identify CKD.
Recognize and test at-risk patients
Monitor eGFR and
ACR (encourage labs to report these tests)
Manage blood
pressure and diabetes
Evaluate and
manage anemia, malnutrition, CKD-MBD, hyperkalemia, metabolic acidosis and
other complications in at-risk patients
Refer to
dietitian for nutritional guidance
Consider patient
safety issues in CKD
Educate patients
about CKD and treatment
Address other
CVD risk factors to improve patient
outcomes.
Additional
Online Resources for CKD Learning
National
Kidney Foundation: www.kidney.org
United
States Renal Data Service: www.usrds.org
CDC’s CKD
Surveillance Project: http://nccd.cdc.gov/ckd
National Kidney
Disease Education Program (NKDEP): http://nkdep.nih.gov
Facebook pages:
HealthNet Echo Pakistan and Kidney Diseases in Pakistan
Summary
High CKD
prevalence
Underdiagnosed
Use equations
to calculate creatinine clearance
Asymptomatic