Role of family physician in prevention and management of different stages of CKD: Dr. Umesh Khanna
M3 India Newsdesk Nov 13, 2018
Dr. Umesh Khanna, a senior Nephrologist provides chief pointers in diagnosis and treatment to primary care physicians who are often the first point of contact for patients with chronic kidney disease.
Chronic Kidney Disease (CKD) is a global pandemic but a highly under-recognised health problem in India. Diabetes and Hypertension are common causes of CKD in the world and are important lifestyle diseases whose prevalence is increasing day by day. If properly targeted, these diseases could be controlled to slow down the growth of CKD in the population.
WHO estimates that by 2025 the prevalence in India will increase to 57.2 million, almost 3 fold higher than that of the US!
At risk groups
- Diabetes affects 3 to 5% of the Indian population (approximately 30 million people). Diabetics are 17 times more likely to develop CKD. Thus, from diabetes alone 10 to 20 million individuals in India will develop CKD.
- The prevalence of hypertension could be anywhere between 15-30% derived from various studies. If 10% of hypertensives develop CKD, then the total figure of CKD patients from diabetes and hypertension alone is staggering.
If we extrapolate the figures from the US population data that 5 to 10% of the general population have CKD then, translated to an Indian population of approximately 1 billion people, 100 million could be suffering from CKD, a mind-boggling figure catapulting CKD to the position of a compelling health problem requiring concerted efforts not only from the nephrology community but also from primary care physicians, governmental agencies, NGOs and common people.
The role of GPs / PCPs in prevention and management of CKD
As the first and prime level of associating with the patient, general practitioners play a very important role in helping with the prevention of kidney disease. Their contribution in this respect would be:
- To recognise the pandemic of CKD and to know that up to 10% of the Indian population could be suffering from CKD
- To know about the new terminology and classification of CKD as explained in other articles in this issue
- To be aware that serum creatinine rises only after 50% of the kidney is damaged and that serum creatinine is an insensitive and inaccurate marker of renal function and laboratories should report eGFR or estimated GFR
- To identify the population at risk and do screening tests for the community and the individual
At risk population comprises of patients suffering from: Diabetes, Hypertension, Kidney stones, High-risk pregnancies, Past history of acute renal failure, Old age, Those habitually on painkillers for backache, arthritis, migraine, Those on Ayurvedic drugs, Those drinking hard water, Those with chronically infected scabies and sore-throats, Those with family history of kidney diseases
Role of GPs in managing “At Risk Population”
Primary care physicians should do the following when dealing with patients who are found to be at high risk of CKD:
- Educate the patient of the risk for developing CKD
- Reinforce the need for periodic health check-ups
- Refer at-risk patients to NGOs like Mumbai Kidney Foundation (MKF), National Kidney Foundation (NKF), and similar organisations who regularly conduct Kidney disease detection camps
What tests are needed?
- Urine routine analysis to pick up macroalbuminuria
- Spot urine albumin/creatinine ratio (to pick up microalbuminuria)
- Serum creatinine or better still, calculated creatinine clearance or estimated GFR (eGFR)
If microalbuminuria or macroalbuminuria is detected, then institute treatment as per the stage of CKD
At risk population & stage I and II: ABC of prevention strategy in Diabetes & Hypertension
- A. HbA1C- keep <7.0
- B. Blood pressure <130/80 mmHg & if possible <125/75 mmHg
- C. Cholesterol- LDL <100 mg/dl
A for HbA1C
HbA1C measures the average blood sugar over 3 months. Patient's FBS should be between 80 to 100 and PLBS <140 mg.
Ways patients can achieve this:
- Dietary modification
- Regular OHA / Insulin
- Exercise
- SMBG (Self Monitoring Blood Glucose)
- Regular follow up
B for Blood pressure
Target BP must be <130/80 and if associated risk factors are present, it should be <125/75 mmHg.
Ways patients can achieve this:
- Salt restriction
- Regular Exercise
- Timely initiated treatment
- Regular monitoring (SMBP)
- Use of ACEIs or ARBs
C for LDL cholesterol <100 <mg/dl
Ways patients can achieve this:
- Yearly checking
- Dietary advice
- Exercise
- Statins & if required fibrates
Drugs of choice for prevention of progression of renal disease are ACE inhibitors/Angiotensin receptor blockers.
Established CKD Stage III onwards
Treat patients in consultation with a Nephrologist.
- Approach to a case of elevated serum creatinine:
- Any patient with a serum creatinine >1.5 in males and >1.3 in females should be put on red alert
- Results should be cross-checked with a different lab
- Causes for false positivity should be ruled out e.g., drugs, dehydration, gastrointestinal bleed
- Serum creatinine clearance should be calculated by Cockroft and Gault formula (eGFR )
Once the creatinine level is confirmed to be elevated, proceed to the next step.
- Differentiate Acute Renal Failure (ARF) from Chronic Renal Failure (CRF)
Definitive Criteria for CRF includes:
- Abnormal urinalysis & creatinine value for >3 months
- Small kidneys on USG
- Evidence of Renal Osteodystrophy
- Biopsy evidence of CRF
- Relative points to differentiate ARF from CRF (points in favor of CRF)
- Anaemia
- Decrease in calcium & increase in phosphorus
- Urea/creatinine ratio >10:1
- Patients very comfortable with the degree of azotemia
- Other end-organ damage, eg. fundus, ECG
- Search for Correctable factor
- Dehydration: Look for evidence of postural hypotension
- Obstruction: Check USG for hydronephrosis
- ACE inhibitors and diuretics in combination or diuretics alone in a situation of volume depletion can worsen the azotemia and hence attain euvolemia
- Patient may be on NSAIDs - omit NSAIDs, Cox-2 inhibitors
- Severe hypertension or hypotension can worsen azotemia, so try to attain normal BP
- Hunt for UTI, fever, or sepsis and try to correct it with non-nephrotoxic drugs
- Treat the underlying disease
- Remove obstruction e.g. stones, prostate, etc.
- Control BP and diabetes
- Prescribe steroids or immunosuppressants for glomerulonephritis
- Advise Angioplasty for Renovascular disease
- Retard progression of kidney disease
Patients should be advised:
- Specific renoprotective therapy with ACE inhibitors eg. Enalapril, Lisinopril, ramipril etc. or Angiotensin receptor blockage eg. Losartan, Valdesartan, Telmisartan, etc.
- Dietary protein restriction to <0.8 g/day
- Lipid-lowering agents- statins or fibrates
- Strict control of diabetes and hypertension
- To avoid smoking
- Obesity treatment
Role of GP in stage V CKD
Explain the treatment options in case of CKD stage V to the patient and prepare him and his family physically, mentally and financially.
The various treatment options are:
- Conservative treatment till the patient reaches the stage of dialysis
- Continuous ambulatory peritoneal dialysis or CAPD
- Haemodialysis
- Kidney transplantation
In the next article, Dr. Umesh Khanna provides tips on Haemodialysis, CAPD, and for the treatment of CRF. Read it here.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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