DEPT. OF MEDICINE,BHARATI HOSPITAL AND RESEARCH CENTRE,PUNE.

Role of Family Physician in the control of chronic kidney

disease(CKD).

Problem statement.

India is moving ahead in all fronts, especially in the field of healthcare and in particular medicine.

The last few decades have seen an increasing number of infections get under control.

There is however an increase in the number of non-communicable diseases like DM, HTN, Cardiovascular diseases, strokes to name a few. All of these are eventually associated with co-morbiditiies such as CKD.

Data suggests that around 11-15% of the general population has CKD.

The Problem!!!

Contributors to the problem

Awareness of kidney diseases is relatively low in our community including among us doctors and healthcare workers.

Sr. Creatinine level, though widely advised and easily available, is a poor marker of renal function.

Most patients are asymptomatic to begin with. This is why they do not approach a doctor in the early stages of the disease.

What is Chronic Kidney Disease(CKD)?

CKD is an all inclusive term:The chief criteria are:

Glomerular filtration rate(GFR) < 60 ml/min for > months.

Complains of persistent renal damage by pathological or imaging tests even in presence of a normal GFR.

Why is it CKD and not Chronic Renal Failure (CRF)?

The spectrum of the patient’s condition ranges from being asymptomatic to being dialysis dependent.

The term “kidney” is better understood by the lay people.

As mentioned earlier, Sr. Creatinine is not a reliable marker for assessing renal function; particularly in the elderly.

The gold standard test for this purpose remains GFR.

GFR: The Gold Standard.

Defintion:A kidney function test in which results are determined from the amount of ultrafiltrate formed by plasma flowing through the glomeruli of the kidney. The amount is calculated from inulin and creatinine clearance, serum creatinine, and blood urea nitrogen.

A number of formulae have been developed for GFR estimation. These include. Cockcroft-Gault formula. Schwartz formula Mayo Quadratic formula CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)

formula Modification of Diet in Renal Disease (MDRD) formula

The most commonly employed formula is the Cockcroft-Gault formula:A commonly used surrogate marker for estimate of

creatinine clearance (eCCr) is the Cockcroft-Gault formula, which in turn estimates GFR in ml/min.

(eCCr :- Estimated creatinine clearance rate)

Evolution of CKD

The disease progresses through 5 stages with progressive decline in renal function as assessed by GFR. Out of these: Stages 1 and 2 are asymptomatic. Stages 3 to 5 correspond to CRF ( GFR < 60 ml/min) Stage 5 is also known as End Stage Renal

Disease(ESRD) where the GFR falls to below < 15 ml/min.

At ESRD the treatment modalities available to the patient include DIALYSIS or RENAL TRANSPLANT.

Identifying the vunerable population.

Regular screening for renal function must be done especially for the subset of population which is at risk. This includes: Elderly people, diabetics, hypertensives. Those with malignancy, autoimmune disease. Renal stones Recurrent UTI, family H/O CKD Low birth weight, reduced kidney mass Obese people, smokers. Users of Non Steroidal Anti-inflammatory

Drugs(NSAIDs). Young hypertensives.

Role of the Doctor

A nephrologist has a rather limited role in the early diagnosis of CKD.

A family physician is more substantial in the initial stages. He should develop a high suspicion index for renal disorders amongst his patients and look for decline of renal function. He can do this by: Looking for protienuria atleast annually Sr. Creatinine USG (A+P)- for stones, cysts, hydronephrosis.

Advice on Lifestyle modification

Pt. should target an ideal body weight, exercise regularly, stop smoking, reduce stress.

Diet: diet rich in fruits and vegetables are best for health in presence of normal renal function. In CKD stages 3 to 5 however these can be dangerous

as they increase Sr. Potassium. This can be overcome by leaching of the vegetable.

Curtail salt intake to 3-4 gm/day.Intake-output must be monitored Proteins 0.69gm/kg of high biological value.

Routine chek up for all.

Check up for even the healthy population must be advocated.

Every adult must have atleast a Blood Pressure check annually.

Out of this the at risk population must be identified and screened.

Lab tests:

Urine examination: Routine:Simple dipstick for proteinuria in the clinic Ideal: the Micral test to look for Microalbuminuria

particularly in the diabetic pateint. Microscopy: casts, RBC’s.

• GFR calculation (using Sr. Creatinine)

DM and HTN: Main constituents of the pool.

Optimal control of BSL: Diabetics form 40% of dialysis patients. HbA1c < 7% must be targeted in this population.

Blood pressure control : <130/80 mm of Hg Use the combination of correct drugs Correct usage of renoprotective agents like ACE

Inhibitors and ARB’s Monitoring RFT’s and Sr. Electrolytes while giving

these agents.

Avoiding the pitfalls:

Advise regarding avoidance of usage of NSAIDs on a long term basis even for chronic inflammatory conditions.

COX -2 InhibitorsTreatment of co-morbidities should be

thorough.Since the Risk of coronary events and strokes increases

drugssuch as Statins and low dose aspirin should be

prescribed asneeded.

Interaction between the physician and the nephrologist.

An early referral should be done when the creatinine level is borderline for establishing the etiology and for treating a correctable cause.

Patient should follow up with the family physician regularly.

Parameters such as BP and haemoglobin levels (between 11-12 g/dl) should be monitored.

Avoidance of nephrotoxic drugs.Regular monitoring of renal and other

parameters initially- 3 monthly.Transplant and dialysis education.

Take Home Message

India is increasingly becoming renowned as the Chronic Kidney Disease and Diabetic Capital

An integrated approach in addition to increased patient awareness through education can help tame this modern epidemic.

THANK YOU.