Predisposing Conditions, Management and Prevention of Chronic Kidney Disease

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Predisposing Conditions Management and
Prevention of Chronic Kidney Disease

• Dr FA Arogundade FMCP FWACP ISN Fellow
• Consultant Nephrologist
• Obafemi Awolowo University
• Ile-Ife.

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Basic Anatomy and Physiology
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Definition of Chronic Kidney Disease
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Definition of CKD

• Progressive and persistent deterioration in
  kidney structure and function ultimately
  resulting in accumulation of nitrogenous waste
  and disruption of acid base homeostasis.
• In addition CKD also leads to derangements of
  the kidneys osmoregulatory metabolic and
  endocrine functions.
• Now CKD can be staged (KDOQI)

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Staging of CKD
Stage 1
Stage 2
Stage 3
GFR gt90
GFR 60-89
Stage 4
GFR 15-29
GFR 30-59
Stage 5
GFR lt15
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Epidemiology of CKD
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Prevalence of CKD in Nigeria

• Prevalence of CRF is largely unknown
• Conceivably high due to the high prevalence of
  diseases that cause chronic renal failure
• HYPERTENSION gt 15 in adults
• DIABETES MELLITUSgt2.5-4.0
• Chronic inflammation endemicity of malaria
  Hepatitis BC HIV
• Socio-cultural practices
• Others

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Blood pressure distribution in respondents (13.6
had HT only 3.6 were previously diagnosed)
Diastolic Blood pressure
Systolic Blood pressure
Ulasi et al. Medical screening by NAN 2005
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The grading of proteinuria in respondents (19
had proteinuria)
Ulasi et al. Medical screening by NAN 2005
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NHANES III16800
US Population CKD Prevalence Stage number 1
GFRgt90 3.3 5.9 millions 2 89-60 3 5.3 3
59-30 4.3 7.6 4 29-15 0.25 400000 5 lt15
0.2 345000 Total 11 19.2
Garg AX et al. Albuminuria and renal
insufficiency prevalence guides
population screening results from the NHANES
III. Kidney Int 2002 61 2165 2175.
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AusDiab11247

• Population-based cross-sectional study to
  determine the prevalence of DMObesityCVD Risk
  factorsand Indicators of Kidney disease in
  Australian adults
• 11247 Participants
• Renal impairment 9.7
• Haematuria 3.7
• Albuminuria 6
• Proteinuria 0.6
• Total 16

Chadban et al Prevalence of kidney damage in
Australian adults The AusDiab Kidney Study. J
Am Soc Nehrol 2003 14 S131 S138.
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Hospital Data

• CRF accounts for 812 of hospital medical
  admissions
• CRF is a leading cause of mortality among adults
• Sentinel study based on available hospital data
• Prevalence of 300-400 per million population

Akinsola 1989 Kadiri et al 1997 Akinsola et
al 2004. Arogundade et al 2005
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NHANES 4
Aus-Diab 9.7
NHANES 96
Aus-Diab 90.3
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Documented causes in Nigeria

• Hypertension
• Benign
• Malignant
• Chronic glomerulonephritis
• Causes unknown in the majority
• Occurs post-infection
• Parasite malaria
• Bacteria sore throat or skin infections
• Helminths Schistosoma Filaria
• Viruses - Hepatitis B C HIV
• Fungal
• Toxins Bleaching creams / soap

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Other documented causes in Nigeria

• Diabetes Mellitus
• Chronic urinary tract infection
• Obstructive Uropathies
• Drugs Analgesic abuse
• Inherited kidney disease-ADPKD
• Connective Tissue Disease - SLE RA
• Others

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Arogundade et al 2005
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Management of CKD
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Objectives of Clinical Evaluation

• Establishing that there is CKD
• Defining the likely aetiology
• Determining occurrence/presence of complications
• Assessing prognosis and survival

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Clinical Evaluation Hx Examination

• Polyuria Nocturia
• Frothiness of urine
• Oliguria
• Symptoms of prostatism
• Features of uraemia
• Use of Analgesics Hg containing creams/soaps
  other drugs local herbs
• Past Medical Hx HT DM Body Swelling etc.
• Family Hx Renal Ds
• Social Hx Alcohol Smoking

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Clinical Evaluation Hx Examination

• Presence of HT
• Presence of oedema
• Presence of Pallor
• Presence of Uraemic features
• Presence of heart failure
• Presence of retinopathy

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Investigations

• Blood
• Chemistry
• E/U/Cr
• Ca Po4
• Alb Chol lipid profile
• Haemogram
• Blood cell counts
• Serology
• Clotting profile
• Urine
• Microscopy
• Chemistry
• Full urinalysis
• 24 Hour profile
• Imaging
• USS
• CXR
• ECHO

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Management

• Conservative
• Control of risk factors
• Modifiable
• Non modifiable
• RRT
• PD
• HD
• Transplant

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Risk Factors/Markers for progressive CKD
alcohol
CKD
Proteinuria
Smoking
Cal-phos
Card.VD
Race
Infectns
Hypertension
Gender
Anaemia
Weight
CKD
Ageing
Lipids
Nutrition
DM
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JNC VII Classification and management of BP for
adults
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• 75.7 had hypoalbuminaemia ( mean SD for serum
  albumin 29.5 7.2 g/L).
• 88.9 had anaemia (Packed Cell VolumePCV lt33)
  Mean SD 24.2 7.0).
• Arogundade et al 2005

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CKD Prevention Modifiable risk factors
Proteinuria lt1g/d
PCV 33-36
Alcohol
DM lt7
Hypertension lt125/75
ALB
Lipids lt5
Weight
Smoking STOP
Ca-Ph lt4.5
CVD Protection
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Choice of Antihypertensives

• Regimens that include angiotensin-converting
  enzyme inhibitors (ACEIs) are more effective than
  regimens that do not include ACEIs in slowing
  progression of both diabetic and non-diabetic
  kidney disease.
• Combination therapy of ACEI and angiotensin
  receptor blocker (ARB) slows progression of both
  diabetic and non-diabetic kidney disease more
  effectively than either single agent.

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Choice of Antihypertensives

• ACEIs appear to be more effective than
  beta-blockers and dihydropyridine calcium channel
  blockers in slowing progressive kidney disease.
• Beta-blockers may be more effective in slowing
  progression than dihydropyridine calcium channel
  blockers especially in the presence of
  proteinuria.

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Prevention
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Preventive Nephrology

• Primary Prevention
• Aims at preventing kidney disease from occurring
  at all
• Calls for knowledge of
• risk factors that predispose to renal disease
• risk factors that initiate renal damage.
• modification removal or avoidance of factors.
• development of a positive health seeking attitude
  and behaviour
• Secondary Prevention
• Aims at identifying factors that aid or hasten
  progression of kidney disease and/or accelerate
  loss of kidney function and preventing or
  removing such factors. While a few of these
  factors are not modifiable majority of them
  could be modified controlled or completely
  avoided.
• Tertiary Prevention

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Risk Factors/Markers for progressive CKD
CKD
Proteinuria
Smoking
Race
Card.VD
Infectns
Cal-phos
Hypertension
Ageing
Anaemia
alcohol
Weight
CKD
DM
Gender
Lipids
Nutrition
Non Modifiable
Modifiable
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CKD Prevention Modifiable risk factors
Proteinuria lt1g/d
PCV 33-36
Alcohol
DM lt7
Hypertension lt125/75
ALB
Lipids lt5
Weight
Smoking STOP
Ca-Ph lt4.5
CVD Protection
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Tertiary Prevention
Proteinuria lt1g/d
PCV 33-36
Alcohol
DM lt7
Hypertension lt125/75
ALB
Lipids lt5
Weight
Smoking STOP
Ca-Ph lt4.5
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Tertiary Prevention Contd

• Control of HT
• Use of EPO Parenteral Iron
• Use of Vit D analogues
• Use of Phosphate sequestering agents
• Control of hyperlipidaemia
• Control of Infections
• Control of Heart Failure

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When do we refer to Nephrologists

• CKD 4 5
• Resistant HT
• Persistent proteinuria / haematuria
• Difficulty achieving Bld sugar control
• Established CKD
• Uraemia
• Heart failure
• Anaemia

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