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7/28/2019 Predisposing Conditions, Management and Prevention of Chronic Kidney Disease..ppt
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Predisposing Conditions,
Management and Prevention ofChronic Kidney Disease
Dr FA Arogundade FMCP FWACP, ISN FellowConsultant Nephrologist,
Obafemi Awolowo University,Ile-Ife.
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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 basehomeostasis.
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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Stage 5
Stage 4
GFR 15-29
Staging of CKD
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Stages of Chronic Kidney Disease
Stage 1 Kidney damage withnormal or GFR
GFR 90 ml/min/1.73m2
Stage 2 Kidney damage withmild GFR
GFR 60-89
Stage 3 Moderate GFR GFR 30-59
Stage 4 Severe GFR GFR 15-29
Stage 5 Kidney failure GFR
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CKD Risk Factors
Diabetes Mellitus
Hypertension
Cardiovascular
Disease
Obesity
Metabolic Syndrome
Age and Race Acute Kidney Injury
Malignancy
Family history of CKD
Kidney Stones
Infections like Hep C
and HIV
Autoimmune diseases
Nephrotoxics like
NSAIDS
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CKD - Causes
Diabetic Non Diabetic
Glomerular
Nephritic: PIGN, IgA, MPGN Nephrotic: FSGS, Membranous, Amyloidosis
Tubulointerstitial: Analgesic, Reflux, Ch. Obs
Vascular: Vasculitis, HTN, RAS
Cystic: ADPKD
CKD in transplantation
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Prevalence of CRF is largely unknown
Conceivably high due to the high
prevalence of diseases that cause
chronic renal failure:
HYPERTENSION: > 15% in adults
DIABETES MELLITUS:>2.5-4.0%
Chronic inflammation endemicity
of malaria, Hepatitis B,C, & HIV
Socio-cultural practices
Others
Prevalence of CKD in Nigeria
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0
10
20
3040
50
60
%
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47
110
0 134
0 7 0 00
20
40
60
%
nil trace 30 100 500
Male
Female
mg/dl
The grading of proteinuria in respondents
(19% had proteinuria)
Ulasi et al. Medical screening by NAN, 2005
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NHANES III
16,800
US Population CKD Prevalence
Stage % number
1 GFR:>90 3.3 5.9 millions
2 89-60 3 5.3
3 59-30 4.3 7.6
4 29-15 0.25 400,000
5
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AusDiab
11,247
Population-based cross-sectional study to determine
the prevalence of DM,Obesity,CVD Risk factors,and
Indicators of Kidney disease in Australian adults
11,247 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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CRF accounts for 812% of hospital
medical admissions
CRF is a leading cause of mortalityamong adults
Sentinel study: based on available
hospital data
Prevalence of 300-400 per million
population
Hospital Data
Akinsola, 1989; Kadiri et al 1997; Akinsola et al, 2004. Arogundade et al 2005
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0
100
200
300
400
500
600
700
800
1989 1991 1993 1995 1997 1999 2001 2003
Total medical
admissionsCRF admissions
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0
2
4
6
8
10
12
14
16
18
1989 1994 1999
CRF
admissions as
percentage of
Medical
admissions
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NHANES
4%
NHANES
96%
Aus-Diab
9.7%
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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010
20
30
40
5060
70
1989-
1993
1994-
1998
1999-
2003
Hypertension
CGN
Diabetic Nephropathy
Obstructive Uropathy
TIN
Arogundade et al, 2005
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Objectives of Clinical Evaluation
Establishing that there is CKD
Defining the likely aetiology
Determining occurrence/presence ofcomplications
Assessing prognosis and survival
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Clinical Evaluation Hx & Examination
Polyuria & NocturiaFrothiness of urine
Oliguria
Symptoms of prostatism
Features of uraemia
Use of Analgesics, Hg containingcreams/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
ECG
Renal Biopsy
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Management
Conservative
Control of risk factors
Modifiable
Non modifiable
RRT
PD
HD
Transplant
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CKDHypertension
Proteinuria
Lipids
Smoking
alcohol
Weight
Risk Factors/Markers for progressive CKD
Cal-phos
Anaemia
Nutrition
Gender
Race
Ageing
Card.VD
CKDDM
Infectns
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BP
Classificat.
SBP
mmHg
DBP
mmHg
Lifestyle
Modific.
Initial Drug Treatment
Without
Compelling
Indic.
With
Compel.
Indic.
Normal 100 Yes 2 drug
combination
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
Volume,PCV
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Hypertension
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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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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.
Choice of Antihypertensives
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RRT AVAILABILITY AFFORDABILITY USEFULNESS LIMITATIONS
PD Not readily Not Affordable 1. Diff. vasc.Access
2. Uncotr. HDHT.
3. Low HCT not
desiring transf.
1. Softwa.
sourc
2. Infections3. Mechanical
4. Obesity
HDReadily Not affordable 1. Easy
2. Time constr.
3.
1. Hypotensn.
2. Reactions
3. Inf transm.
4. Blood loss
TX Readily Not affordable 1. Best QOL2. Cheap ultim.
3. Best profile
1. Planning
2. Organ Sourc
3. Infrastruc.
4. Donor Probl
Reference
s
Akinsola et al,
2000
Arije et al, 1992&95,
Bamgboye 2002,
Arogundade et al,
2005
Arije et al,
1992&95,
Arogundade et
al, 2004 & 2005
Arije et al,
1992&95,
Arogundade et
al, 2004 & 2005
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Fig 1: COMPARING HRQOL IN THE PATIENT'S GROUPS
0
5
10
15
20
25
30
Livingre
lated
Rec
ipien
ts(Group
II)
Emo
tiona
lly
relatedRec
ipien
ts
(Gro
up
III)
Main
tenance
haem
odialys
is
Pa
tient
s(Group
I)
Patients Groups
Num
bero
fPa
tien
ts
Karnofsky Score =90 Karnofsky Score = 80 Karnofsky score = 70 Karnofsky score = 50
Fi 2 C l ti b t Q lit f Lif
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Fig 2: Correlation between Quality of Life
Scores and Age in all studied subjects
(r=-0.363, P
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Fig 3: Correlation between Quality of Life
Scores and Serum Creatinine in all subjects
(r=-0.502, P
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Fig 4: Correlation between Quality of Life
Scores and Haemoglobin (g/dL) in all subject
(r=0.705, P
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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. Whilea few of these factors are not modifiable, majority of themcould be modified, controlled or completely avoided.
Tertiary Prevention
Ri k F /M k f i CKD
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CKDHypertension
Proteinuria
Lipids
Smoking
alcohol
Weight
Risk Factors/Markers for progressive CKD
Cal-phos
Anaemia
Nutrition
Gender
Race
Ageing
Card.VD
CKDDM
Infectns
Non ModifiableModifiable
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Hypertension
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Tertiary Prevention
Hypertension
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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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