1. Chronic Kidney Disease

2. Session Outline Four Activities, each designed to address one learning objective Each table must allocate a scribe Each activity to be discussed with members at your table Each table must commit to answering the activity questions and be prepared to demonstrate reasoning Scribe to write answers in LARGE writing on designated A4 Answer Card Scribes to stand when requested to allow for comparison of answers across different tables

3. Doctor of Medicine Learning objectives By the end of this teaching session you should be able to – 1.Define CKD and describe the stages of CKD 2. Discuss the detection and diagnosis of CKD 3.Identify the biochemical and haematological changes that occur at different stages of CKD 4.Discuss some basic principles of management of CKD

4. Doctor of Medicine 4.5+ MILLION AT RISK 836,000 17,500 39,400 808,200 Stage 5 CKD Stage 4 CKD Stage 3 CKD Hypertension or Diabetes Stage 1 – 2 CKD Kidney Disease in Australia Kidney Disease in Australia AusDiab data, 2005; White et al 2010; Jun 09 ABS data Australians aged ≥ 25 years CKD staging is according to the CKD-EPI equation

5. Doctor of Medicine How do you define CKD? Chronic kidney disease is defined as: GFR 3 months with or without evidence of kidney damage. OR Evidence of kidney damage (with or without decreased GFR) for >3 months: microalbuminuria proteinuria glomerular haematuria pathological abnormalities (eg. on renal biopsy) anatomical abnormalities (eg. cysts on ultrasound)

6. Doctor of Medicine Stages of CKD GFR (ml/min/1.73 m 2 )Description 1≥ 90Normal or increased GFR, with other evidence of kidney damage 260–89Slight decrease in GFR, with other evidence of kidney damage 3A45–59Moderate decrease in GFR, with or without other evidence of kidney damage 3B30–44 415–29Severe decrease in GFR, with or without other evidence of kidney damage 5< 15Established renal failure

7. Who develops CKD? What are the commom causes?

8. Risk factors and Causes CKD Risk factors-?Modifiable ?Fixed Causes Diabetic nephropathy Hypertensive nephrosclerosis Glomerulonephritis ADPKD Reflux nephropathy

9. Urine test for Proteinuria Excessive amounts of proteins in the urine are =key marker of kidney damage =indicator of renal progression towards ESKD Proteins are mainly albumin (albuminuria), but also consist of low molecular weight immunoglobulin, lysozyme, insulin and beta-2 microglobulin.The preferred method for assessment of albuminuria in both diabetes and non-diabetes is urinary ACR measurement in a first void spot specimen =albuminuria independent risk factor for cardiovascular disease

10. Doctor of Medicine Albuminuria Albumin creatinine ratio (mg/mmol) specimen: first voided morning urine Female Male Normal 0–3.5 0–2.5 Microalbuminuria 3.6–35.0 2.6–25.0 Macroalbuminuria >35.0 >25.0 Correlating the alb/cr ratio ACR to protein/cr ratio PCR: –if the ACR is 30 mg/mmol, this is approximately equivalent to PCR 50 mg/mmol =half gram/day –if the ACR is~ 70 mg/mmol this is approximately equivalent to PCR 100mg/mol =1g/day

11. Activity 1-BLUE Learning Objective- Define CKD and describe the stages of CKD 3 cases for review Definition of CKD and Stages of CKD on your desk for reference For each case, apply the definition of CKD and identify the stage of CKD On the A4 Blue card scribe to write down the stage of CKD for each case

12. Activity 2-GREEN Learning Objective- Discuss the detection and diagnosis of CKD Read the case of 58 year old Sally On the A4 card headed Activity 2-Green Write down 4 investigations that you would refer Sally for to investigate her proteinuria

13. Doctor of Medicine Evaluation of patient with CKD  Blood  FBE  Calcium and phosphate  PTH  HbA 1c  LFTs  Uric acid  Iron studies, B12, folate  +/- myeloma screen  Urine  Urinalysis with microscopy  Spot urine for microalbumin/protein  24-urine collection for protein and creatinine clearance  Imaging  Renal tract ultrasound

14. Doctor of Medicine Haematuria Glomerular pathology -dysmorphic RBC on light microscopy Non Glomerular-Intrarenal, Extrarenal ‘Benign’ causes: - menstrual periods or UTI - false + (iodine, oxidising agents) - recent strenuous exercise - sexual activity, trauma

15. Activity 3-Yelllow Learning Objective- Identify the biochemical and haematological changes that occur at different stages of CKD Review the investigations of Mrs Ubud Write on the A4 card headed Activity 3- Yellow - Four haematological or biochemical complications of CKD

16. Doctor of Medicine Metabolic changes Monitor and treat biochemical abnormalities –Anaemia –Metabolic acidosis –Calcium/phosphate/PTH management –Dyslipidemia –Nutrition

17. Doctor of Medicine Anaemia Common in CKD, Why? Correction can improve energy levels, sleep, cognitive function, and quality of life in dialysis In CKD aim for correction with Hb 100-120g/l Use of EPO

18. Doctor of Medicine Metabolic acidosis Problems - Muscle catabolism - Metabolic bone disease - Reduced immune function Treatment: Sodium bicarbonate –Maintain serum bicarbonate > 20 mmol/L –Watch for sodium loading Volume expansion Hypertension - Treatment with bicarbonate may also slow down renal progression

19. Doctor of Medicine A systemic disorder defined by Laboratory investigations Bone abnormalities Calcification of soft tissues CKD-MBD

20. Doctor of Medicine Dyslipidemia Abnormalities in the lipid profile –Triglycerides –Total cholesterol Targets for lipid-lowering therapy considered the same as those for the secondary prevention of CV disease

21. Doctor of Medicine Nutrition Think about uremia –Catabolic state –Anorexia –Decreased protein intake Consider referral to a renal dietician

22. Activity 4-WHITE Learning Objective- Discuss some basic principles of management of CKD Read the case of Mrs Smith Write down 3 key management issues to reduce decline in her renal function and CV risk

23. Doctor of Medicine Ischaemic heart disease Cardiovascular disease is leading cause of death in CKD patients Patients with CKD are 20 times more likely to die from cardiovascular events than survive to reach dialysis Patients with CKD have poor prognosis after myocardial infarction

24. Doctor of Medicine Hypertension People with CKD need to be treated with blood pressure lowering drugs to maintain a BP consistently below 140/90mmHg Patients with Albuminuria (urine ACR >3.5 mg/mmol in females & >2.5 mg/mmol in males) should maintain a BP below 130/80mmHg Patients with Diabetes should maintain a BP below 130/80mmHg Klahr S et al.,, NEJM 1994

25. Doctor of Medicine Diabetic control Understand the importance glycaemic control in CKD Pre-prandial BSL 6-8, Post prandial 6-10 HbA1c < 7.0% Intensive blood glucose control significantly reduces the risk of developing microalbuminuria, macroalbuminuria and/or overt nephropathy in people with Type 1 and Type 2 diabetes Management – Lifestyle modification – Oral hypoglycaemic agents – Insulin

26. Doctor of Medicine Reducing Proteinuria Lowering blood pressure Use of: –ACE inhibitors –Angiotensin receptor blockers –Spironolactone

27. Doctor of Medicine Improving Outcomes in CKD: Lifestyle Modification SNAP factors (Smoking, Nutrition, Alcohol and Physical activity) –At least 50% reduction in risk of diabetes –Cessation of smoking would be expected to reduce the risk of progressive CKD by at least 50% ModificationRecommendation~SBP Reduction Weight reductionAim >5% wt loss if obese or overweight 5-10mmHg/10kg loss Healthy dietFruit & veges, low fat, low chol, high fibre 8-14mmHg Dietary salt restriction<100 mmol/d2-8 mmHg Physical activity30 mins/5d each wk4-9 mmHg Moderate alcohol consumption <1-2 standard drinks/d2-4 mmHg

28. Doctor of Medicine Learning objectives By the end of this teaching session you should be able to – 1.Define CKD and describe the stages of CKD 2. Discuss the detection and diagnosis of CKD 3.Identify the biochemical and haematological changes that occur at different stages of CKD 4.Discuss some basic principles of management of CKD

29. Reinforcement Activity-MCQ Evaluation Thank you!