RENAL DISEASE – A GENERAL PRACTICE PERSPECTIVEDr Shareen Hallas

REMEMBER THE KIDNEYS?

…..AND THE NEPHRON?

…AND WHAT GOES ON THERE?

WHAT’S IN THE NEWS?

“Apple Shape” linked to higher risk of kidney disease. (BBC News 12th April 2013)

RECENT RESEARCH BMJ 2013;346:f324 Associations of estimated glomerular

filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis

Over 2 million participants Cohort study Conclusions Both sexes face increased risk

of all-cause mortality, cardiovascular mortality, and end stage renal disease with lower estimated glomerular filtration rates (<45) and higher albuminuria (ACR>30). These findings were robust across a large global consortium

WHAT DO WE SEE IN PRIMARY CARE?

SCENARIO 1

A 60 year old man presents with urinary frequency and urgency. He is a smoker. He has hypertension and takes amlodipine 5mg. Urinalysis shows blood++. No nitrites or leucocytes

What will you do next?

HAEMATURIA

Visible haematuria REFER at any age to Urology 2 week rule if painless at any age Remember with renal stones up to 20% are

negative for haematuria

NON VISIBLE HAEMATURIA

Is it blood? (beetroot, rifampacin etc) Exclude UTI, menstruation, exercise) Refer symptomatic non visible haematuria at

any age

SYMPTOMATIC NON VISIBLE HAEMATURIA

Check U&E, creat, eGFR, bp, ACR. Refer if over 40 to UROLOGY 2 weeks Likely needs referral to urology if

symptomatic at any age

ASYMPTOMATIC NON VISIBLE HAEMATURIA

Check 3 urinalysis over a 2/52 period. If 2/3 positive this is a positive result

If over 40 refer to UROLGY If under 40 refer NEPHROLOGY if: ACR>30 eGFR<60ml/min (2 readings, no reversible

cause) BP>140/90 If these referral criteria are not met, annual

follow up as likelihood of serious pathology is 8% and malignancy in 1.5%

REMEMBER

Proteinuria is the best indicator of glomerular disease

Approximately 10% people with non visible haematuria have a urological malignancy. The most common is bladder cancer

Check a urinalysis when looking for causes of iron deficiency anaemia

SCENARIO 2

A 46 year old woman presents for follow up urinalysis after a recent UTI. No urinary symptoms. NoHx hypertension, diabetes. Not pregnant. No FH renal disease. Meds nil reg, intermittent NSAID for dysmennorhoea.

O/E bp 140/80 no oedema. Urinalysis protein++. Nil else. What will you do next?

NSAIDS

Most common cause of drug induced renal damage in general practice

If on long term nsaids monitor renal function 2-3 times per year.

PROTEINURIA

Positive urinalysis in 2 or more urine samples over a 1-2 week period. UTI can cause false positive

Remember ACR has a greater sensitivity than PCR

If ACR >70mg/mmol (PCR >100mg/mmol) REFER NEPHROLOGY

If ACR >30mg/mmol (PCR > 50mg/mmol) WITH NON VISIBLE HAEMATURIA. REFER NEPHROLOGY

OTHER INVESTIGATIONS

U&E, eGFR, BP, Hba1c Then select ix depending on potential cause May include; C3, C4, Igs, electrophoresis, RF,

ASOT, ANCA, ANA, dsDNA, cholesterol (raised in nephrotic synd)……..

What about renal ultrasound?

LOTS OF CAUSES OF PROTEINURIA! Transient proteinuria

Emotional stress.

Exercise.

Fever.

Urinary tract infection.

Orthostatic (postural) proteinuria*.

Seizures.

Persistent proteinuria.

Primary glomerular causes

Focal segmental glomerulonephritis.

IgA nephropathy (ie Berger's disease).

IgM nephropathy.

Membranoproliferative glomerulonephritis.

Membranous nephropathy.

Minimal change disease.

Secondary glomerular causes

Alport's syndrome.

Amyloidosis.

Sarcoidosis.

Drugs (eg non-steroidal anti-inflammatory drugs (NSAIDs), penicillamine,gold, angiotensin-converting enzyme (ACE) inhibitors).

Anderson-Fabry disease.

Sickle cell disease.

Malignancies (eg lymphoma, solid tumours).

Infections (eg HIV, syphilis, hepatitis, post-streptococcal infection).

Tubular causes

Aminoaciduria.

Drugs (eg NSAIDs, antibiotics).

Fanconi's syndrome.

Heavy metal ingestion.

Overflow causes

Haemoglobinuria.

Multiple myeloma.

Myoglobinuria.

Other important causes (likely to have multiple pathologies)

Pre-eclampsia/eclampsia.

 

NEPHROTIC SYNDROME

Heavy proteinuria. PCR > 200mg/mmol Hypoalbuminaemia <30g/l Oedema, particulalry periorbital

MODERATE PROTEINURIA (100-200MG/MMOL)

May be tubular disease eg drug induced interstitial nephritis.

PROTEINURIA WITH NVH MORE LIKELY TO BE:

IgA nephropathy (most common cause of acute glomerulonephritis, 80% in age 16-35), polycystic kidneys, vasculitis, collagen multisystem disease, post infectious glomerulonephritis

WHAT ABOUT PRESCRIBING IN RENAL IMPAIRMENT? BNF - For many drugs with only minor or no

dose-related side-effects very precise modification of the dose regimen is unnecessary and a simple scheme for dose reduction is sufficient. For more toxic drugs with a small safety margin, dose regimens based on GFR should be used

Take care with many antibiotics, histamine H2-receptor antagonists, digoxin, anticonvulsants and NSAIDs, potassium sparing drugs, vit D, antacids (high Na content), ACE (watch out for renal artery stenosis), diuretics.

Care after iodine contrast If patient on dialysis ask a specialist.

SCENARIO 3

A 55 year old woman presents after receiving a letter from the practice to come in to discuss he blood tests which show chronic kidney disease stage 3.

She has hypertension controlled with amlodipine 5mg. Bp 140/90. eGFR 50ml/min/1.73m2

What will you do?

WHAT IS CKD DEFINED AS?

eGFR < 60ml/min/1.73m2 for 3 months

CKD Stage 1 eGFR >90 with other evidence of

kidney damage Stage 2 eGFR 60-90 with other evidence of

kidney damage Stage 3A eGFR 45-59 Stage 3B eGFR 30-44 Stage 4 eGFR 15-29 Stage5 EGFR <15 Use suffix p to denote proteinuria Chronic kidney disease affects 10–16% of the

general adult population in Asia, Europe, Australia, and the United States

HOW OFTEN SHALL I MONITOR CKD?

CKD 1 and 2 , yearly 3A and 3B, 6 monthly 4, 3 monthly 5, 6 weekly According to NICE CG 73 NB CKD is a part of the QRISK 2 score

REMEMBER Correct eGFR for ethnicity (African or

Caribbean) X 1.21 New low eGFR repeat within 2 weeks Measure minimum 3 eGFRs over 90 day

period - need at least 2 to diagnose CKD DO NOT EAT MEAT for 12 hour pre-test for

eGFR Measure ACR ACE inhibitors can reduce creatinine by up to

20%. If creat inc by >20% or eGFR dec by >15% can be due to renal artery stenosis.

Serum creatinine has limitations - can remain within the normal range despite the loss of over 50% of renal function

CKD 3

All cause mortality (and CVD mortality) is increased in stage 3 CKD, increase is much greater in stage 3B

Progression of renal disease is rare (4% with esrf in 10 years)

Cholesterol lowering in this group can reduce CV events (SHARP study)

Over 10 years a patient with CKD 3 has a 25% chance of dying from CVD

Need pneumococcal and annual flu immunisations

REMEMBER

Will kidneys fail in your patient’s lifetime, or will they die of something else first?

TIP

CSA CKD explained mattandhazelsmith video youtube

ACR IN DIABETES

Normal is <2.5 in men and <3.5 in women In diabetes can get an initial increase in

eGFR as glycosuria damages the basement membrane. Protein can therefore leak when the eGFR is still normal.

EPO produced round prox tubules – damaged in Dm, hence can get EPO deficiency earlier in diabetic kidney disease.

ACE INHIBITORS

Check u&e 1-2 weeks after starting ACE If creatanine rises by >20% or eGFR drops by

>15% consider renal artery stenosis Repeat after dose increase Stop ACE in dehydrating illness Counsel women of childbearing age

WHEN DO I DO A RENAL ULTRASOUND?

Obstructive symptoms FH polycystic kidneys Haematuria, progressive CKD Stage 4 or 5 CKD

WHEN DO I REFER A PATIENT WITH CKD?

Stage 4 or 5 (check Hb and Ca/PO4) Proteinuria (ACR >70) ACR >30 AND haematuria Rapidly declining eGFR (>5ml/min in one

year) Poorly controlled hypertension despite 4

drugs (aim bp <140/90) Suspected renal artery stenosis or rare cause

CKD

REMEMBER LIFESTYLE

Stop smoking Reduce salt Men have bigger kidneys than women After age 40 renal function decreases by

1ml/min/year

DIALYSIS

Around 40,000 people in the UK are having dialysis or have functioning kidney transplants

DIALYSIS Usually starts when GFR 10 ml/min ( 15ml/min in

diabetes) Indications: Presence of clinical features of uraemia

(eg, pericarditis, gastritis, hypothermia, fits or encephalopathy).

Fluid retention leading to pulmonary oedema: inability to reduce excess volume with diuretics with urine volume under 200 mL in twelve hours.

Severe hyperkalaemia (potassium above 6.5 mmol/L) unresponsive to medical management.

Serum sodium above 155 mmol/L or below 120 mmol/L.

Severe acid-base disturbance (pH under 7.0) that cannot be controlled by sodium bicarbonate.

Severe renal failure (urea greater than 30 mmol/L, creatinine greater than 500 μmol/L.

Toxicity with drugs that can be dialysed

HAEMODIALYSIS Arterio-venous fistula formed 3-6 months before

starting dialysis Dialysis 3 times a week, 4 hours each time Complications: Access-related: local infection, endocarditis,

osteomyelitis, creation of stenosis, thrombosis or aneurysm.

Hypotension (common), cardiac arrhythmias, air embolism.

Nausea and vomiting, headache, cramps. Fever: infected central lines. Dialyser reactions: anaphylactic reaction to sterilising

agents. Heparin-induced thrombocytopenia, haemolysis. Disequilibration syndrome: restlessness, headache,

tremors, fits and coma. Depression.

PERITONEAL DIALYSIS CAPD involves 4 exchanges of 20 minutes through the day Can do peritoneal dialysis at night too Greater flexibility Contra-indications to peritoneal dialysis Intra-abdominal adhesions and abdominal wall stoma. Obesity, intestinal disease, respiratory disease and

hernias are relative contra-indications. Complications of peritoneal dialysis Peritonitis, sclerosing peritonitis. Catheter problems: infection, blockage, kinking, leaks or

slow drainage. Constipation, fluid retention, hyperglycaemia, weight gain. Hernias (incisional, inguinal, umbilical). Back pain. Malnutrition. Depression

RENAL TRANSPLANT

Good survival rates  1 year and 10 year graft survival rates are

89% and 67% for adult kidneys from 'brain death donors' and 96% and 78% for kidneys from live donors.

SCENARIO 4

A 20 year old woman presents to you in tears as her mother is going to start dialysis for ESRF due to Polycystic kidney disease.

She wants to know if she has this too, What is her risk? What are you going to do?

ADULT POLYCYSTIC KIDNEY DISEASE Affects 1 in a 1000 (50% in ESRF by age 60) Accounts for 10% people on dialysis Autosomal dominant (but de novo mutation in

5% cases) Loin pain is the most common symptom (60%) Hypertension in 10-15% affected children and

50% affected adults Intracranial berry aneurysms in 6% with no fh

and 16% with fh. If FH MRI scan 5 yearly. Mitral valve prolapse in 25% When to screen family members? (uss after

age 20)

POST STREPTOCOCCAL GLOMERULONEPHRITIS

Mainly in under 5s 7-14 days after group A B haemolytic strep

infection , usually sore throat Accounts for 90% of acute glomerulophritis GFR usually returns to normal in 10-14 days 92%-98% recover fully Haematuria may persist asymptomatically

for 2 years.

HELP FOR YOUR PATIENTS

http://pkdcharity.org.uk/ http://www.kidneyresearchuk.org/home.php http://www.gosh.nhs.uk/medical-conditions/ http://www.britishkidney-pa.co.uk/