An update on chronic renal failure follow up and when to refer
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An update on chronic renal failure: follow-up and when to refer ?. Assoc Prof Johan Rosman Renal Department Waitemata DHB [email protected] Apollo Health Centre, Albany www.bloodpressure.org.nz. Chronic renal failure. Diagnosis Presentations and stages of CRF in general

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An update on chronic renal failure follow up and when to refer

An update on chronic renal failure: follow-up and when to refer ?

Assoc Prof Johan Rosman

Renal Department Waitemata DHB

[email protected]

Apollo Health Centre, Albany

www.bloodpressure.org.nz


Chronic renal failure

Chronic renal failure

  • Diagnosis

  • Presentations and stages of CRF in general

  • Causes of CRF

  • Monitoring CRF

  • Consequences of CRF

  • Progression of CRF

  • Principles of treatment


Differentiation acute chronic renal failure

Short History (ds-wks)

Normal Hb

Normal renal size

No osteodystrophy

Periph neuropathy -

Normal Ca and P

Normal PTH

Long history (mo-yrs)

Low Hb

Reduced renal size

Often osteodystrophy

Periph neuropathy +

Low Ca / elevated P

Increased PTH

Differentiation acute-chronic renal failure


Acute on chronic renal failure

Acute on chronic renal failure

  • Recrudescence of primary disease

  • Complication of primary disease

  • Accelerated hypertension

  • Volume depletion

  • Cardiac failure

  • Sepsis

  • Nephrotoxins (radiocontrast, drugs)

  • Renal artery occlusion

  • Urinary tract obstruction

  • Dietary protein load


Presentation of crf

Presentation of CRF

  • Asymptomatic serum biochemical abnormality

  • Asymptomatic proteinuria/haematuria

  • Hypertension

  • Symptomatic primary disease

  • Symptomatic uraemia

  • Complications of renal failure


Commonest causes of esrf

Commonest causes of ESRF

(ANZData)

  • Glomerulonephritis30%

  • Diabetes25%

  • Hypertension10%

  • Polycystic kidney disease5%

  • Vesicoureteral reflux5%

  • Analgesic nephropathy5%

  • Unknown10%

  • Others10%


Gfr glomerular filtration rate equals creatinine clearance

GFR (glomerular filtration rate) equals creatinine clearance ??

  • The accurate assessment of GFR is desirable

    • Planning for the treatment of end stage renal disease

    • Referral to nephrology

    • Trace the course of progression of chronic renal disease or response to therapy

  • What is the best, most practical way to assess GFR?


Creatinine an imperfect marker

Creatinine: an imperfect marker

Efferent arteriole

Afferent arteriole

Glomerulus

Filtered

Reabsorbed

Secreted


An update on chronic renal failure follow up and when to refer

2004006008001000

[Creatinine]s micromole/L

20406080100120

GFR ml/min/1.73m2 BSA


Normal gfr by age

“Normal” GFR by Age


Measuring glom filtration rate

Measuring glom. filtration rate

  • Many formulas have attempted to predict GFR from a serum creatinine measurement only, most factoring in age, weight/height, and gender, which are all independent of serum creatinine in influencing GFR.

  • This would be the easiest approach clinically

  • a serum creatinine of 130 umol/l is normal in an athlete, but can mean dialysis dependency in a 80 year old !


Aids in monitoring gfr creat clearance

Aids in monitoring GFR (creat clearance)

  • Use the Cockroft Gault equation

  • Use the MDRD equation

  • But: in the follow up of a patient stick to the same way of estimating GFR

  • Formula’s for free available on the web (spreadsheet) or free for Palmtop (Medcalc)

  • Use 1/creatinine in individual patients to see whether a rise in creatinine represent an acute on chronic event


Renal screen

Renal Screen

  • BP

  • MSU

    • RBC morphology; ACR; 24-hour proteinuria

  • Serum urea, creatinine, Na+, K+

  • Ultrasound scan renal tract

  • Albumin, calcium, phosphate

  • PTH

  • eGFR


Why do 24 hour urine collection

Why do 24-hour urine collection?

  • Extremes of age / body size

  • Malnutrition or obesity

  • Catabolic states

  • Amputees / paraplegia / mm. wasting

  • Vegetarians / vegans

  • Pregnancy

  • Medication-dosing

  • Rapidly changing renal function


Problems of esrd

Problems of ESRD

  • Cardiovascular disease

  • Anaemia

  • Renal Bone Disease

  • Metabolic acidosis

  • Malnutrition

  • Sodium and water

  • Potassium

  • Bleeding Diathesis

  • Dermatologic manifestations

  • Neurologic manifestations

  • Endocrine abnormalities

  • Immunity

  • Psychological manifestations


Factors causing progression of crf

Factors causing progression of CRF

  • Cont activity of primary disease

  • Systemic hypertension

  • Intraglomerular hypertension

  • Proteinuria

  • Nephrocalcinosis (dystr and metast)

  • Dyslipidaemia

  • Imbalance renal energy demands and supply


Cardiovascular morbidity and proteinuria

No Proteinuria

Cardiovascular Morbidity and Proteinuria

Proteinuria

40

30

p < 0.001

Cumulative incidence (%)

of CV morbidity

20

10

0

0

1

2

3

4

5

6

7

8

9

10

Years

Adapted from Samuelsson et al. J Hypertens 1985;3:72

RPLM Hoogma


Relationship between bp and progression of crf

Clinical trials of >3–years duration

Relationship between BP and progression of CRF

MAP (mm Hg)

98

100

102

104

106

108

110

0

r = 0.66; P<0.05

–2

–4

GFR (mL/min per year)

–6

–8

–10

Adapted with permission from Bakris. Diabetes Res Clin Pract 1998;39:S35

RPLM Hoogma


Principles of treatment of pat with crf

Principles of treatment of pat with CRF

  • Differentiate from ARF on CRF

  • Establish aetiology

  • Establish severity

  • Seek and treat reversible factors

  • Seek and treat complications

  • Lifestyle improvements

  • Seek and treat factors that promote progression

  • Planned and timely refer to nephrologist


When to refer to renal physician

When to refer to renal physician?

  • eGFR < 30 ml/min/1.73m2 BSA

    • <45 in diabetics; anaemia (Hb < 100g/L)

  • Proteinuria > 1G per 24 hours

  • Glomerular haematuria

  • Difficult to control hypertension

  • Rapidly declining GFR

    • >15% in 3 months (Australia)

  • Electrolytes, vascular disease, etc.


Early detection is paramount

Early detection is paramount

  • CKD

    • Preventable

    • Growing @ 6%pa

    • Delayed progression

    • Renal abnormality is prevalent!

      • 16% of Australians (AusDIAB)

      • 15% NZers (Simmonds)

    • 20 x more likely to die than get RRT

      • Keith et al. Arch Int Med 164:659; 2004

    • Asymptomatic


The key to good care

The key to good care

Communication

Communication

Communication

021- KIDNEY

(021-543639)


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