Assessment Patient Ckd Hd_arwedi

7/30/2019 Assessment Patient Ckd Hd_arwedi

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ASSESSMENT OF THE PATIENT

WITH CHRONIC KIDNEY DISEASE

Arwedi Arwanto


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HIGHTLIGHTS

Patients with CKD requirecomprehensive assessment

Assessment and management isguided by the stage of CKD


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Assessment and Management

How to assess and manage patients according to the stage ofchronic kidney disease

Stage ofCKD

Based onGFR()

Direct assessment and management to(b)

1. 90

Primary disease, cardiovascular risk

2. 6089 Early hyperparathyroidism, progression of CKD

3. 3059 Anaemia, dyslipidaemia, ECFV

4. 1529 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.


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Initial Assessment

How to initially assess the patientwith 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


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Comprehansive Assessment

How to comprehensively assess the patientwith 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


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Establish the cause

Establish the cause of CKD as manydiagnoses carry additional

implications, including a familial natureand recognized complications.


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Differentiate from acute kidneydisease

Differentiate CKD from acute kidney disease bymeans of renal USG, Hb level and serial assessmentof 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


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Examine urinary sediment

Examine the urinary sediment in afresh 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 ofadvanced renal disease.


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Quantify GFR

Quantify the GFR to assign the stage ofCKD. This is usually done by using the

Cockroft-Gault formula to first determinethe uncorrected creatinine clearance:

Creatinine Clearance (males)(mL/min)

= (14C age) body weight (kg)

0.814 plasma creatinine (mol/L)


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Calculate the rate of progression

Calculate the rate of progression of CKD byserial (quarterly) calculation of GFR.

Look for factors that may accelerate itsprogression and also at how adequate thetreatment is at slowing the progression (e.g. glucose control, blood pressure control,

minimization of proteinuria).


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KIDNEY FUNCTION DECLINE IN CKD

K/DOQI 2004


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YEARS UNTIL KIDNEY FAILUREBASE ON LEVEL OF GFR AND RATES OF GFR DECLINE

K/DOQI 2004


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Quantify urinary protein excretion

Quantify the urinary protein excretionby an initial timed urinary collection

for protein and creatinine, Follow the response to anti-proteinuric

therapy with assessment of serial (e,g.

quarterly) spot urinaryprotein:creatinin ratios oralbumin:creatinine ratios.


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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, lowerlimb vessels

Measure non traditional risk factors


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


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Looks for reversible renaldysfunction

Look for factors causing acute, reversibledeterioration 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


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Assess lifestyle risks

Assess lifestyle factors that mightcontribute to comobidity

Including body habitus (BMI),

Diet,

Smoking,

Exercise


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Complications of the primarydisease

Concider the possibility of complications relevant tothe primary disease, including: Diabetes-macrovaskular & microvaskular disease

Primary & secondary glomerulonephritides-acutedisease 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 (sloughedpapilla), transitional cell carcinoma


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Complications relevant to the stageof 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-dihydroxyhole-

calciferol levels; anemia; fluid overload

Stage 4: abnormal electrolytes-potassium,

bicarbonate, uric acid, magnesiumStage 5: clinical evidence of bleeding diathesis,

serositis, sexual dysfunction, neuropathy,

malnutrition


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RR of death according to Ca x P product inmaintenance haemodialysis


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Cumulative survival according to the self-reported appetite status

In haemodialysis patients


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Assess suitability for dialysis

Sites for dialysis access

Personal coping mechanisms, social

supports, transport and flexibility ofemployment

Hepatitis B and C, HIV, MRSA and VRE

status, and vaccination status


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Asses suitability for transplantation

Potential living donors

Risk of malignancy

Cardiovascular risk

Other significant comorbidity


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Assess medications

Regularly assess the appropriatenessof all medications and commence a

personal medication list for eachpatient.


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Assessment Patient Ckd Hd_arwedi

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