ASSESSMENT OF THE PATIENT WITH CHRONIC KIDNEY DISEASE

Arwedi Arwanto

HIGHTLIGHTS

Patients with CKD require comprehensive assessment Assessment and management is guided by the stage of CKD

Assessment and Management

How to assess and manage patients according to the stage of chronic kidney disease
Stage of CKD
1. 2. 3. 4.

Based on GFR()
90 6089 3059 1529

Direct assessment and management to(b)

Primary disease, cardiovascular risk Early hyperparathyroidism, progression of CKD Anaemia, dyslipidaemia, ECFV Electrolyte abnormalities, preparation for dialysis, and transplanation

5.

< 15

Complications of advanced CKD and dialysis

() In mL/min/1.73 m2. (b) May apply for any stage beyond that in which first mentioned.

Initial Assessment
How to initially assess the patient with chronic kidney disease :

Full personal and family medical history Comprehensive physical examination Serum biochemistry and full blood count Urinalysis (for protein, glucose, blood, leucocytes, nitrite), albumin : creatinine ratio Renal ultrasound Other test based on cause and stage of CKD

Comprehansive Assessment
How to comprehensively assess the patient with chronic kidney disease :

Establish the cause of CKD Differentiate from acute kidney disease Quantify GFR Calculate the rate of progression of CKD Quantify urinary protein excretion Assess cardiovascular risk Look for reversible renal dysfunction Assess lifestyle risks Look for specific complications of the primary disease Assess suitability for dialysis Assess suitability for transplantation Assess medications

Establish the cause

Establish the cause of CKD as many diagnoses carry additional implications, including a familial nature and recognized complications.

Differentiate from acute kidney disease

Differentiate CKD from acute kidney disease by means of renal USG, Hb level and serial assessment of renal function. The presence of small renal size, a loss of corticomedullary differentiation and an increased renal echogenicity on ultrasound, normochromic normocytic anaemia hyperphosphataemia, and a reduction in GFR for more than 3 months are indicative of chronic disease

Examine urinary sediment

Examine the urinary sediment in a fresh centrifuged sample, transported in boric acid to preserve casts. The presence of red or white cell cast indicates an inflammatory process, usually acute, Broad casts are suggestive of advanced renal disease.

Quantify GFR

Quantify the GFR to assign the stage of CKD. This is usually done by using the Cockroft-Gault formula to first determine the uncorrected creatinine clearance:
Creatinine Clearance (males)(mL/min)
=

(14C age) body weight (kg) 0.814 plasma creatinine (mol/L)

Calculate the rate of progression

Calculate the rate of progression of CKD by serial (quarterly) calculation of GFR. Look for factors that may accelerate its progression and also at how adequate the treatment is at slowing the progression ( e.g. glucose control, blood pressure control, minimization of proteinuria).

KIDNEY FUNCTION DECLINE IN CKD

K/DOQI 2004

YEARS UNTIL KIDNEY FAILURE

BASE ON LEVEL OF GFR AND RATES OF GFR DECLINE

K/DOQI 2004

Quantify urinary protein excretion

Quantify the urinary protein excretion by an initial timed urinary collection for protein and creatinine, Follow the response to anti-proteinuric therapy with assessment of serial (e,g. quarterly) spot urinary protein:creatinin ratios or albumin:creatinine ratios.

Asses cardiovascular risk

By personal and family history Examination relevant to heart and vasculature (bp, smoking) Plasma lipid level EKG and Echo KG Doppler of carotid, abdominal, lower limb vessels Measure non traditional risk factors

Algorithm for screening for chronic kidney disease and reducing cardiovascular disease risk

Looks for reversible renal dysfunction

Look for factors causing acute, reversible deterioration of renal function, Including abnormal ECFV (usually vol depletion) Hypotension or severe hypertension Cardiac failure Lower urinary tract obstruction Systemic sepsis Electrolyte derangements (hypercalcemia) Nephrotoxic drugs Other nephrotoxins

Assess lifestyle risks

Assess lifestyle factors that might contribute to comobidity Including body habitus (BMI), Diet, Smoking, Exercise

Complications of the primary disease

Concider the possibility of complications relevant to the primary disease, including: Diabetes-macrovaskular & microvaskular disease Primary & secondary glomerulonephritides-acute disease flare Polycystic kidney disease-cerebral aneurysm (new or atypical headache, family history), obstruction (calculi), infection (UTI,cyst) & cyst (rupture, infection, bleed) Reflux nephropathy-UTI Renovascular disease-renal artery occlusion Analgesic nephropathy-obstruction (sloughed papilla), transitional cell carcinoma

Complications relevant to the stage of CKD

Look for complications relevant to the stage of CKD: Stage 2: abnormal calcium, phosphate & PTH levels; hypertension Stage 3: low 25-hydroxy & 1.25-dihydroxyholecalciferol levels; anemia; fluid overload Stage 4: abnormal electrolytes-potassium, bicarbonate, uric acid, magnesium Stage 5: clinical evidence of bleeding diathesis, serositis, sexual dysfunction, neuropathy, malnutrition

RR of death according to Ca x P product in maintenance haemodialysis

Cumulative survival according to the self-reported appetite status In haemodialysis patients

Assess suitability for dialysis

Sites for dialysis access Personal coping mechanisms, social supports, transport and flexibility of employment Hepatitis B and C, HIV, MRSA and VRE status, and vaccination status

Asses suitability for transplantation

Potential living donors Risk of malignancy Cardiovascular risk Other significant comorbidity

Assess medications

Regularly assess the appropriateness of all medications and commence a personal medication list for each patient.