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CHRONIC KIDNEY

DISEASE

Based on Malaysian CPG


2011

SCREENING
AND
INVESTIGATIO
NS FOR CKD IN
PATIENTS WITH
DIABETES

Annual screening for patients


with diabetes mellitus and/or
hypertension

SCREENING AND
INVESTIGATIONS
FOR CKD IN
PATIENTS
WITHOUT
DIABETES

Screening of general
population is not costeffective. It is only done
for people with high
risks for developing
CKD.

TREAT
MENT
FOR
CKD

Renal profile
should be
carefully
monitored
following

Any class of antihypertensive


agents can be used to treat
hypertension in CKD patients
without proteinuria. The
choice will depend on the
patients co-morbidity
ACEi/ARB should be used as
first-line agent in
Non-diabetic CKD with
urinary protein excretion
>0.5g/d in the presence of
hypertension
Non-diabetic CKD when
urinary protein excretion
>1.0g/d irrespective of
presence of hypertension
All diabetes patients with
albuminuria (micro- or
macroalbuminuria)

PROTEINURIA
Microalbuminuria
Urinary albumin excretion rate 20 200mcg/min/24h or 30-300mg/24h
Cannot be detected with usual urine dipstick
Earliest sign of diabetic kidney disease

Macroalbuminuria aka overt proteinuria


Urinary albumin excretion rate >200mcg/min/24h or >300mg/24h

Proteinuria is an independent predictor for renal disease


progression
The magnitude of baseline proteinuria has a linear
relationship with progression of CKD and risk of CV events

HAEMATURIA
May indicate infection, renal calculi, primary
glomerulonephritis, malignancy
Isolated non-visible haematuria is associated with a modest
increased risk of progressive kidney disease
Positive dipstick test (1+ or more) for blood on 2 out of 3
occasions may warrant a microscopic examination
Presence of dysmorphic red blood cells and red cell casts
indicate glomerular disease

RENAL FUNCTION
Renal function should be
assessed with MDRD eGFR.
Serum creatinine should be used
in combination with eGFR in
assessment of renal function.
When eGFR is not available, other
methods of estimation may be
used.

RENAL TRACT ULTRASOUND


Identifies obstructive uropathy, renal size and symmetry,
renal scarring and polycystic disease

STAGING (NKF-KDOQI)
Staging CKD is based on
GFR (level of kidney function)
Pathological changes (kidney damage)
Presence of abnormality for at least 3
months
Kidney damage is defined as either
Persistent microalbuminuria
Perisistent proteinuria
Persistent haematuria
Radiological evidence of structural
abnormalities of kidneys
Biopsy proven glomerulonephritis

At any stage of CKD, presence of proteinuria


Is associated with doubling of CV risk and mortality
Predicts progression and development of ESRF
The diagnosis of CKD in the elderly should not solely rely on eGFR
estimation
The NKF-KDOQI classification may lead to overdiagnosis of CKD
particularly in the elderly
Elderly patients (>70 years old) with stable stage 3A of kidney disease
are not likely to develop CKD-related complications

TREATMENT TARGETS
Target BP <140/90mmHg (SBP range 120-139mmHg)
Target BP <130/80mmHg (SBP range 120-129mmHg)
In patients with proteinuria >1g/d
In patients with diabetic kidney disease

Strict BP lowering is better for renal disease and stroke


reduction but worse for CVD outcomes
Proteinuria should be reduced to <1g/d for non-diabetic CKD
and to normoalbuminuria for DKD if can be safely achieved

TREATMENT CHOICES: ACEI


AND ARB
ACEi and ARB: renoprotective + cardioprotective
In patients with diabetes mellitus with kidney disease,
Risk of ESRF reduced by 40% with ACEi and 22% with ARB
Progression of micro to macroalbuminuria reduced by 45% with ACEi and
51% with ARB.

In non-diabetic CKD patients,


No significant risk of renal disease progression if proteinuria <1g/d at
any BP level
Signficant risk of renal disease progression if proteinuria >1g/d and SBP
>130mmHg
No benefit of ACEi use if non-diabetic CKD with hypertension and
proteinuria <0.5g/d

ACEi/ARB should be avoided or used with caution in patients


with
Renal artery stenosis
Elderly
Concomitant NSAIDs use
Concomitant medications predisposing to hyperkalemia (eg beta
blockers and aldosterone antagonists)
Hypoperfusion states (eg congestive cardiac failure, dehydration and
sepsis)

These patients should be monitored more frequently.

TREATMENT CHOICES: CCB


AND AA
Nonhydropiridine CCB eg verapamil
can be considered in hypertensive patients with proteinuria either as an
alternative in patients intolerant/contraindicated to ACEi/ARB or in
combination with ACEi/ARB for additional proteinuria reduction

Aldosterone antagonist eg spironolactone


Controversial results
Long-term effects on renal outcome, mortality and safety not established

TREATMENT CHOICES:
OTHER DRUGS ON TRIAL
Renin inhibitor eg Aliskiren
Licensed as antihypertensive agent
Renoprotection effect not established

Miscellaneous agent eg Sulodexide


Not proven effective antiproteinuria

OPTIMAL CONTROL: RENAL


FUNCTION
Reassess renal profile within 2 weeks of starting/increasing
ACEi/ARB
If there is
a sustained rise in creatinine levels >30% or
eGFR reduces >25% from the baseline or
serum potassium >5.6mmol/L during the first 2 months after
commencement of ACEi/ARB,
reduce or discontinue the ACEi/ARB after excluding other precipitating
factors and refer to a nephrologist

OPTIMAL CONTROL: HBA1C,


STATIN, ANTIPLATELET
Target HbA1c should be <7% in patients with diabetes. Iron and
erythropoietin can cause a significant fall in HbA1c values without a
change to glycaemic control in patient with DM and CKD. Regular
capillary glucose measurements are needed for a more accurate
assessment of glycaemic control.
Statin should be offered to patients with CKD for primary and
secondary prevention of cardiovascular events. There is no evidence
of lipid lowering in retarding the progression of CKD or reduction of
proteinuria.
Aspirin should be used in patients with CKD for secondary prevention
of cardiovascular events. Combination of clopidogrel and aspirin
should be avoided as there is an increase in overall mortality by 60%.

DIET
Low protein diet (0.6-0.8g/kg/d) with adequate energy intake
(30-35kcal/kg/d) may be given to patients with chronic kidney
disease stage 3-5
Dietary protein restriction should be supervised by a dietitian
due to complication of protein-calorie malnutrition associated
with a low protein diet
Sodium restriction (total intake <2,400mg/d) should be
initiated in patients with CKD

PREGNANCY
Pregnancy may be considered in women with CKD having
mild renal impairment (serum creatinine <124umol/L) and
well-controlled blood pressure
Women with moderate to severe renal impairment should be
counselled to avoid pregnancy due to greater adverse
maternal and fetal outcomes
Method of contraception used would depend on the
underlying cause of renal disease and associated comorbidities

REFERRAL
Immediate referral is indicated in
patients with
Acute renal failure superimposed
on CKD
Newly detected ESRF (GFR
<15ml/min/1.73m2)
Accelerated or malignant
hypertension
Hyperkalemia (serum potassium
>7mmol/L)
Suspected glomerulonephritis
When referring to a nephrologist,
ensure patient has a recent renal