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CKD-Diagnosis

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CKD-Diagnosis

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Chronic Kidney Disease ( CKD ) is an abnormality of kidney function or structure that is present for more than 3 months with implications for health 
( National Clinical Guideline Centre 2014 )

eGFR reflects 
the total filtration
 by all functioning nephrons ,
 as nephrons are damaged or 
destroyed eGFR declines

Markers of kidney disease or damage-Proteinuria Haematuria ( of presumed renal origin ) Structural abnormalities ( eg reflux nephropathy , 
renal dysgenesis , medullary sponge kidney ) A known diagnosis of a genetic kidney disease ( eg PCKD ) Abnormalities detected by examination of renal histology Electrolyte abnormalities due to renal tubular disorders H/O kidney transplantation. Patients with a GFR > 60 should not be classified as having CKD unless they 
have other markers of kidney disease

Risk factors- Hypertension and diabetes ( most imp risk factors ) Insulin resistance , Obesity and metabolic syndrome Family h/o CKD Prior h/o AKI / ARF Urological conditions as
○ reflux nephropathy ○ renal calculi ○ prostatic hypertrophy Reduced kidney mass ( solitary kidney ) Nephrotoxic medications Autoimmune /Systemic conditions ( eg SLE , vasculitis , myeloma ,glomerulonephritis ) Low birth weight Infections eg HIV Sociodemographics eg
old age , male gender , ↓ ed access to healthcare Ethnic – African American , Native American , Hispanic , Asian High dietary protein intake Smoking

Diabetes is the
 most common cause
 of CKD about 40 % of patients with diabetes will develop CKD.

Measuring- Advice not to eat meat for 12 hrs before test Blood should get to the lab within 12 hrs Use correction for people of African-Carribean or African family origin ( multiply eGFR by 1.159 ) Interpret with caution in people with extremes of muscle mass. Proteinuria- Use ACR ( Albumin to creatinine ratio ) to identify and detect proteinuria PCR can be used for quantification and monitoring of high levels of proteinuria eg ACR 70 mg /mmol or more ACR is unaffected by variation in urine concentration ACR result approximates milligrams of albumin excreted in 24 hrs Albuminiuria reflects damage to glomerulus and is an independent risk factor for CKD progression .Haematuria-Evaluate further if 1 + or more Measure renal function and assess proteinuria in all Exclude UTI Consider persistent if two out of three dipstick tests show 1 + or more of blood once UTI has been excluded Look at suspected urological cancer guidance
https://www.a4medicine.co.uk/
suspected-urological-cancer/

eGFR provides and estimate of kidney function Interpret eGFR values of 60 or more with caution as estimates of GFR become less accurate as the true GFR increases Serum creatinine levels alone are insensitive for detecting impaired renal function eGFR of 125 m is the normal value for young adult men and women eGFR not validated in elderly , children or pregnant women , AKI , extremes of body size and in some ethnic groups CKD-EPI ( epidemiology collaboration ) is similar to eGFR but improves the accuracy of estimating GFR particularly in young adults and women

CKD is diagnosed when tests persistently show a reduction in kidney function or the presence of proteinuria For eg diagnose CKD if GFR persistently < 60 for > 3 months and / or
Evidence of kidney damage – eg ACR ratio is persistently > 3 mg/mmol Do not diagnose CKD
○ GFR persistently > 60 and ACR < 3 and no other markers of kidney disease CKD is classified using eGFR and ACR Some patients with reduced GFR do not have proteinuria , radiological abnormalities or other markers to suggest a cause ( particularly elderly )

Increased ACR is associated wuth ↑↑ ed risk of adverse outcomes Decreased GFR is associated with ↑↑ ed risk of adverse outcomes Increased ACR and ↓↓ ed GFR in combination multiply the risk of adverse outcomes Disease progression often associated with
○ high levels albuminuria
○ progressive decrease in GFR
○ poorly controlled BP

References ; Further reading
 Chronic kidney disease in adults : assessment and management NICE Clinical guideline CG 182 July 2014 Chronic Kidney Disease ( CKD ) Clinical Practice Recommendations for Primary Care Physicians and Healthcare Providers A Collaborative Approach Edition 6 Epidemiology and cause of chronic kidney disease Philip D Evans et al Medicine Volume 43 , Issue 8 , August 2015 , Pages 450-453 Making Sense of CKD ; A Concise guide for Managing Chronic Kidney Disease in the Primary Care Setting NKDEP July 2014 Assessment and monitoring of chronic Kidney Disease NICE Pathways Chronic Kidney Disease Not Diabetic- CKS NHS CKD Stages https://renal.org/information-resources/the-uk-eckd-guide/normal-gfr/

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