CME : Your SA Journal of CPD - Volume 25, Issue 8, 2007
Volume 25, Issue 8, 2007
Strategies for the early detection and management of chronic kidney diseaseâ??tertiary and primary health care working together : main articleSource: CME : Your SA Journal of CPD 25, pp 360 –365 (2007)More Less
- There is a close relationship between chronic kidney disease (CKD) and cardiovascular disease (CVD) and both are rising worldwide.
- In resource-challenged health systems we have to place a large emphasis on early detection and comprehensive high-quality management of chronic illnesses.
- Most affected people have more than one chronic illness, e.g. hypertension and obesity, justifying integrated rather than disease- specific programmes.
- Non-communicable diseases (NCDs) account for most deaths in South Africa and, together with HIV (a chronic illness), make chronic illnesses a major burden of illness and death in this country.
- Research and subsequent clinical guidelines have significantly improved our focus for detecting, following and managing patients with CKD and CVD.
- A clear, simple and integrated approach to risk factor and chronic disease management needs to be adopted, using chronic illness management models such as the Wagner Chronic Illness Care Model.
- Primary health care clinicians and specialists have to work together as a team to ensure that patients with a significant disease burden are detected and treated.
- An integrated model requires an understanding of existing resources capacity, when patients should be managed in primary care and when they should be referred for specialised care.
Source: CME : Your SA Journal of CPD 25, pp 372 –376 (2007)More Less
- Sub-Saharan Africa is at the epicentre of the HIV pandemic.
- Acute and chronic kidney disease is common in the course of HIV infection.
- There is a huge projected burden of CKD as a result of HIV in sub-Saharan Africa, for which we do not have the resources to cope.
- At present, most people with ESRD and HIV are not offered renal replacement therapy (dialysis and transplantation).
- More emphasis needs to be placed on screening and prevention of CKD in HIV.
- A screening and prevention programme for CKD in HIV needs to be devised and implemented as a matter of urgency.
- Appropriate and well-designed research from the sub-Saharan region needs to be done to determine the effect of interventions on the progression of CKD in HIV.
Author M.R. DavidsSource: CME : Your SA Journal of CPD 25, pp 378 –382 (2007)More Less
- Chronic kidney disease (CKD) is defined as kidney damage or a glomerular filtration rate (GFR) of < 60 ml/min/1.73 m2 for 3 months or more.
- As many as 1 in 10 adults is affected, with diabetic nephropathy, glomerulonephritis and uncontrolled hypertension being the major causes.
- The global burden of CKD is expected to increase in parallel with the increase in diabetes - the developing world bearing the brunt of this epidemic.
- The major consequences of CKD are end-stage renal disease (ESRD) and premature death from cardiovascular disease (CVD).
- A patient with CKD is far more likely to die of CVD than to reach ESRD.
- CKD is a very strong risk factor for CVD, justifying lower targets for blood pressure and lipid control.
- The management of ESRD is extremely costly; therefore the emphasis must be on the early detection and treatment of CKD, which is very effective in preventing progression to ESRD and in decreasing the morbidity and mortality from CVD.
- Management involves maintaining a healthy weight, increasing physical activity, reducing salt intake, smoking cessation, and treating hypertension and hyperlipidaemia, including the use of drugs that block the renin-angiotensin system.
- Effective action is required at national and international levels to combat this global public health problem, and co-operation across disciplines is essential.
Source: CME : Your SA Journal of CPD 25, pp 384 –388 (2007)More Less
- CVD is the leading cause of death in patients with CKD.
- The risk of CVD increases as CKD progresses to ESRD.
- Clinicopathological manifestations of CVD in CKD are:
- accelerated atherosclerosis
- left ventricular hypertrophy
- systolic hypertension.
- 'Uraemia-related' risk factors add to the increased CVD risk.
- Exercise electrocardiography is a suboptimal test for the diagnosis of CVD.
- Coronary angiography is still the gold standard for diagnosis of CAD.
- Achieving targets for risk factors in CKD slows progression of CKD and lowers CVD risk.
Author C.R. SwanepoelSource: CME : Your SA Journal of CPD 25, pp 389 –394 (2007)More Less
- Progression of renal function deterioration occurs in the majority of patients with CKD.
- The progression can be slowed by paying particular attention to blood pressure control and, additionally in diabetic nephropathy, tight control of blood sugar.
- Obesity and smoking are deleterious factors in progression and must be handled from the outset.
- Salt retention is always a problem with the diseased kidney and therefore salt restriction and a diuretic are useful in alleviating fluid retention and controlling the blood pressure.
- ACE-I and / or ARB treatment is essential in any patient with CKD with proteinuria and / or hypertension. They have a positive influence in slowing renal function deterioration.
- NSAIDs inhibit diuretic action.
- Spironolactone is being suggested for use in patients with CKD accomplishing total RAAS block. The evidence of efficacy in slowing progression and reducing proteinuria is encouraging but not substantial. Judgement on the safe use of this agent is still awaited.
- Reduction of phosphate levels is essential for the bone well-being of the patient with CKD. The only way we in SA can achieve this is with the use of calcium carbonate given before meals.
- The new osteodystrophy classification relies on states of bone turnover together with mineralisation status and bone volume.
- Lipid-lowering agents should be prescribed in patients with CKD (insulin-resistant state) although the efficacy in slowing progression has not yet been established. This is particularly pertinent in patients with the nephrotic syndrome.
Author N.D. MadalaSource: CME : Your SA Journal of CPD 25, pp 395 –398 (2007)More Less
- Chronic kidney disease (CKD) patients are at a high risk for acute renal failure.
- Glomerular filtration rate must be estimated in all patients with hypertension, diabetes and other CKD risk factors for diagnosis and staging of CKD.
- Always look for reversible causes in patients presenting with renal failure.
- Correction of hypovolaemia and hypotension restores baseline renal function in prerenal causes.
- Immediate relief of obstruction is critical to prevent further kidney damage in postrenal acute-on-chronic.
- Avoid NSAIDs, nephrotoxic antimicrobials and radiocontrast agents in CKD patients.
- ACE-Is and ARBs must be stopped if serum creatinine increases more than 15% from baseline value within a week of starting treatment.
- Optimal BP control may result in renal recovery in accelerated phase hypertension.
- Urgent referral for renal biopsy is mandatory where recurrence of active lupus nephritis or rapidly progressive glomerulonephritis are suspected.
- Preserving renal function and delaying onset of chronic dialysis is the ultimate goal in the care of CKD patients.
Source: CME : Your SA Journal of CPD 25, pp 401 –402 (2007)More Less
- Metformin-associated lactic acidosis is extremely rare.
- Prospective studies have so far failed to demonstrate that the traditional contraindications increase the risk of this life-threatening complication.
- Case reports have suggested that renal dysfunction may be the strongest association with this disorder.
- A creatinine level greater than 130 mmol/ l in men and 120 mmol/ l in women has been suggested as a contraindication, but an estimation of the creatinine clearance is more meaningful.