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Kidney Disease

Facts

  • Chronic kidney disease (CKD) is a rapidly evolving major clinical problem.

  • Diabetes is the main cause; others include hypertension, glomerulonephritis esp. IgA nephropathy, drugs, CTDs.

  • Consider the diagnosis of CKD in patients presenting with:

    • – unexplained poor health, esp. fatigue, malaise, anv

    • – unexplained anaemia

    • – history of diabetes, hypertension, coronary heart disease, CTDs

    • – neurological disturbances, e.g. confusion, twitching, coma

  • An improved laboratory reporting method is the estimated glomerular filtration rate (eGFR) using the CKD–EPI (chronic kidney disease–epidemiology) collaboration. Laboratories now report this with every request for s. creatinine clearance. Other basic tests include ACR and urinary ultrasound.

  • ACE inhibitors or ARB agents are the key drugs in management of renal failure but monitor with care. Other basic tests—ACR, urinary ultrasound

Definition of CKD

  • GFR <60 mL/min/1.73 m2 for ≥3 mths ± evidence of kidney damage or

  • Evidence of kidney damage (±↓ GFR) for ≥3 mths, as evidenced by the following:

    • – microalbuminuria (urinary albumin excretion rate 30–300 mg/d)

    • – macroalbuminuria (urinary albumin excretion rate >300 mg/d)

    • – persistent haematuria (where other causes such as urologic conditions have been excluded)

    • – pathologic abnormalities (e.g. abnormal renal biopsy)

    • – radiologic abnormalities (e.g. scarring or polycystic kidneys) on renal US scan

Proteinuria Can be confirmed with a 24-h urine protein estimation or (preferably) an albumin–creatinine ratio (ACR).

Guidelines:

  • normal albuminuria: ACR <3.5 mg/mmol; <2.5 mg/mmol

  • microalbuminuria: ACR 3.5–35 mg/mmol; 2.5–25 mg/mmol

  • macroalbuminuria: ACR >35; >25

The ‘triple whammy’

  • NSAIDs/COX-2s

  • ACE inhibitor

  • Diuretic

These 3 agents, individually or in combination, are implicated in >50% of cases of iatrogenic kidney failure.

Table K1Classification of CKD stage
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Table K1 Classification of CKD stage

CKD stage

GFR mL/min

Clinical action plan

1 US evidence of damage (e.g. scarring) Proteinuria/haematuria

>90

2 Evidence of kidney damage Mild kidney failure

60–89

Further investigation for those at risk:

  • assessment of proteinuria

  • BP

  • cardiovascular risk reduction

  • cholesterol, blood glucose, smoking, obesity

3 Moderate kidney failure

30–59

As above plus:

  • avoid nephrotoxic drugs

  • monitor eGFR 3 mths

  • prescribe antiproteinuric drugs; ACE inhibitors or AIIRA (if appropriate)

  • correct anaemia, acidosis, hyperparathyroidism

  • ensure drug dosages appropriate for level of kidney function

  • consider referral to nephrologist

3a

44–59

3b

30–44

4 Severe kidney failure

15–29

As above plus:

  • referral to nephrologist

  • prepare for dialysis or transplantation (if appropriate)

5 End stage kidney failure

<15 or on dialysis

As above plus

  • institute dialysis or transplantation (if appropriate)

Targets: management goals

The following are the optimal targets for patients with CKD to reduce cardiovascular risk.

View Table||Download (.pdf)

  • BP

<140/90 mmHg if proteinuria

≤130/80 mmHg if albuminuria, diabetes

  • Cholesterol

total <4.0 mmol/L

LDL <2.5 mmol/L

  • Blood sugar

preprandial 4.4–6.7 mmol/L

HbA1c ≤7%

  • Haemoglobin

110–115 ...

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