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Renal Disease in General Practice: Key Insights

Understand renal diseases in primary care with insights on haematuria, proteinuria, and more. Learn about causes, investigations, and management of renal impairments in a clinical setting.

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Renal Disease in General Practice: Key Insights

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  1. RENAL DISEASE – A GENERAL PRACTICE PERSPECTIVE Dr Shareen Hallas

  2. REMEMBER THE KIDNEYS?

  3. …..AND THE NEPHRON?

  4. …AND WHAT GOES ON THERE?

  5. WHAT’S IN THE NEWS? • “Apple Shape” linked to higher risk of kidney disease. (BBC News 12th April 2013)

  6. RECENT RESEARCH • BMJ 2013;346:f324 • Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis • Over 2 million participants • Cohort study • Conclusions Both sexes face increased risk of all-cause mortality, cardiovascular mortality, and end stage renal disease with lower estimated glomerular filtration rates (<45) and higher albuminuria (ACR>30). These findings were robust across a large global consortium

  7. WHAT DO WE SEE IN PRIMARY CARE?

  8. SCENARIO 1 • A 60 year old man presents with urinary frequency and urgency. He is a smoker. He has hypertension and takes amlodipine 5mg. Urinalysis shows blood++. No nitrites or leucocytes • What will you do next?

  9. HAEMATURIA • Visible haematuria • REFER at any age to Urology • 2 week rule if painless at any age • Remember with renal stones up to 20% are negative for haematuria

  10. NON VISIBLE HAEMATURIA • Is it blood? (beetroot, rifampacin etc) • Exclude UTI, menstruation, exercise) • Refer symptomatic non visible haematuria at any age

  11. SYMPTOMATIC NON VISIBLE HAEMATURIA • Check U&E, creat, eGFR, bp, ACR. • Refer if over 40 to UROLOGY 2 weeks • Likely needs referral to urology if symptomatic at any age

  12. ASYMPTOMATIC NON VISIBLE HAEMATURIA • Check 3 urinalysis over a 2/52 period. If 2/3 positive this is a positive result • If over 40 refer to UROLGY • If under 40 refer NEPHROLOGY if: • ACR>30 • eGFR<60ml/min (2 readings, no reversible cause) • BP>140/90 • If these referral criteria are not met, annual follow up as likelihood of serious pathology is 8% and malignancy in 1.5%

  13. REMEMBER • Proteinuria is the best indicator of glomerular disease • Approximately 10% people with non visible haematuria have a urological malignancy. The most common is bladder cancer • Check a urinalysis when looking for causes of iron deficiency anaemia

  14. SCENARIO 2 • A 46 year old woman presents for follow up urinalysis after a recent UTI. No urinary symptoms. NoHx hypertension, diabetes. Not pregnant. No FH renal disease. Meds nil reg, intermittent NSAID for dysmennorhoea. • O/E bp 140/80 no oedema. • Urinalysis protein++. Nil else. • What will you do next?

  15. NSAIDS • Most common cause of drug induced renal damage in general practice • If on long term nsaids monitor renal function 2-3 times per year.

  16. PROTEINURIA • Positive urinalysis in 2 or more urine samples over a 1-2 week period. UTI can cause false positive • Remember ACR has a greater sensitivity than PCR • If ACR >70mg/mmol (PCR >100mg/mmol) REFER NEPHROLOGY • If ACR >30mg/mmol (PCR > 50mg/mmol) WITH NON VISIBLE HAEMATURIA. REFER NEPHROLOGY

  17. OTHER INVESTIGATIONS • U&E, eGFR, BP, Hba1c • Then select ix depending on potential cause • May include; C3, C4, Igs, electrophoresis, RF, ASOT, ANCA, ANA, dsDNA, cholesterol (raised in nephrotic synd)…….. • What about renal ultrasound?

  18. LOTS OF CAUSES OF PROTEINURIA! • Transient proteinuria • Emotional stress. • Exercise. • Fever. • Urinary tract infection. • Orthostatic (postural) proteinuria*. • Seizures. • Persistent proteinuria. • Primary glomerular causes • Focal segmental glomerulonephritis. • IgA nephropathy (ie Berger's disease). • IgM nephropathy. • Membranoproliferative glomerulonephritis. • Membranous nephropathy. • Minimal change disease. • Secondary glomerular causes • Alport's syndrome. • Amyloidosis. • Sarcoidosis. • Drugs (eg non-steroidal anti-inflammatory drugs (NSAIDs), penicillamine,gold, angiotensin-converting enzyme (ACE) inhibitors). • Anderson-Fabry disease. • Sickle cell disease. • Malignancies (eg lymphoma, solid tumours). • Infections (eg HIV, syphilis, hepatitis, post-streptococcal infection). • Tubular causes • Aminoaciduria. • Drugs (eg NSAIDs, antibiotics). • Fanconi's syndrome. • Heavy metal ingestion. • Overflow causes • Haemoglobinuria. • Multiple myeloma. • Myoglobinuria. • Other important causes (likely to have multiple pathologies) • Pre-eclampsia/eclampsia.

  19. NEPHROTIC SYNDROME • Heavy proteinuria. PCR > 200mg/mmol • Hypoalbuminaemia <30g/l • Oedema, particulalry periorbital

  20. MODERATE PROTEINURIA (100-200MG/MMOL) • May be tubular disease eg drug induced interstitial nephritis.

  21. PROTEINURIA WITH NVH MORE LIKELY TO BE: • IgA nephropathy (most common cause of acute glomerulonephritis, 80% in age 16-35), polycystic kidneys, vasculitis, collagen multisystem disease, post infectious glomerulonephritis

  22. WHAT ABOUT PRESCRIBING IN RENAL IMPAIRMENT? • BNF - For many drugs with only minor or no dose-related side-effects very precise modification of the dose regimen is unnecessary and a simple scheme for dose reduction is sufficient. For more toxic drugs with a small safety margin, dose regimens based on GFR should be used • Take care with many antibiotics, histamine H2-receptor antagonists, digoxin, anticonvulsants and NSAIDs, potassium sparing drugs, vit D, antacids (high Na content), ACE (watch out for renal artery stenosis), diuretics. • Care after iodine contrast • If patient on dialysis ask a specialist.

  23. SCENARIO 3 • A 55 year old woman presents after receiving a letter from the practice to come in to discuss he blood tests which show chronic kidney disease stage 3. • She has hypertension controlled with amlodipine 5mg. Bp 140/90. eGFR 50ml/min/1.73m2 • What will you do?

  24. WHAT IS CKD DEFINED AS? • eGFR < 60ml/min/1.73m2 for 3 months

  25. CKD • Stage 1 eGFR >90 with other evidence of kidney damage • Stage 2 eGFR 60-90 with other evidence of kidney damage • Stage 3A eGFR 45-59 • Stage 3B eGFR 30-44 • Stage 4 eGFR 15-29 • Stage5 EGFR <15 • Use suffix p to denote proteinuria • Chronic kidney disease affects 10–16% of the general adult population in Asia, Europe, Australia, and the United States

  26. HOW OFTEN SHALL I MONITOR CKD? • CKD 1 and 2 , yearly • 3A and 3B, 6 monthly • 4, 3 monthly • 5, 6 weekly • According to NICE CG 73 • NB CKD is a part of the QRISK 2 score

  27. REMEMBER • Correct eGFR for ethnicity (African or Caribbean) X 1.21 • New low eGFR repeat within 2 weeks • Measure minimum 3 eGFRs over 90 day period - need at least 2 to diagnose CKD • DO NOT EAT MEAT for 12 hour pre-test for eGFR • Measure ACR • ACE inhibitors can reduce creatinine by up to 20%. If creat inc by >20% or eGFR dec by >15% can be due to renal artery stenosis. • Serum creatinine has limitations - can remain within the normal range despite the loss of over 50% of renal function

  28. CKD 3 • All cause mortality (and CVD mortality) is increased in stage 3 CKD, increase is much greater in stage 3B • Progression of renal disease is rare (4% with esrf in 10 years) • Cholesterol lowering in this group can reduce CV events (SHARP study) • Over 10 years a patient with CKD 3 has a 25% chance of dying from CVD • Need pneumococcal and annual flu immunisations

  29. REMEMBER • Will kidneys fail in your patient’s lifetime, or will they die of something else first?

  30. TIP • CSA CKD explained mattandhazelsmith video youtube

  31. ACR IN DIABETES • Normal is <2.5 in men and <3.5 in women • In diabetes can get an initial increase in eGFR as glycosuria damages the basement membrane. Protein can therefore leak when the eGFR is still normal. • EPO produced round prox tubules – damaged in Dm, hence can get EPO deficiency earlier in diabetic kidney disease.

  32. ACE INHIBITORS • Check u&e 1-2 weeks after starting ACE • If creatanine rises by >20% or eGFR drops by >15% consider renal artery stenosis • Repeat after dose increase • Stop ACE in dehydrating illness • Counsel women of childbearing age

  33. WHEN DO I DO A RENAL ULTRASOUND? • Obstructive symptoms • FH polycystic kidneys • Haematuria, progressive CKD • Stage 4 or 5 CKD

  34. WHEN DO I REFER A PATIENT WITH CKD? • Stage 4 or 5 (check Hb and Ca/PO4) • Proteinuria (ACR >70) • ACR >30 AND haematuria • Rapidly declining eGFR (>5ml/min in one year) • Poorly controlled hypertension despite 4 drugs (aim bp <140/90) • Suspected renal artery stenosis or rare cause CKD

  35. REMEMBER LIFESTYLE • Stop smoking • Reduce salt • Men have bigger kidneys than women • After age 40 renal function decreases by 1ml/min/year

  36. DIALYSIS • Around 40,000 people in the UK are having dialysis or have functioning kidney transplants

  37. DIALYSIS • Usually starts when GFR 10 ml/min ( 15ml/min in diabetes) • Indications: • Presence of clinical features of uraemia (eg, pericarditis, gastritis, hypothermia, fits or encephalopathy). • Fluid retention leading to pulmonary oedema: inability to reduce excess volume with diuretics with urine volume under 200 mL in twelve hours. • Severe hyperkalaemia (potassium above 6.5 mmol/L) unresponsive to medical management. • Serum sodium above 155 mmol/L or below 120 mmol/L. • Severe acid-base disturbance (pH under 7.0) that cannot be controlled by sodium bicarbonate. • Severe renal failure (urea greater than 30 mmol/L, creatinine greater than 500 μmol/L. • Toxicity with drugs that can be dialysed

  38. HAEMODIALYSIS • Arterio-venous fistula formed 3-6 months before starting dialysis • Dialysis 3 times a week, 4 hours each time • Complications: • Access-related: local infection, endocarditis, osteomyelitis, creation of stenosis, thrombosis or aneurysm. • Hypotension (common), cardiac arrhythmias, air embolism. • Nausea and vomiting, headache, cramps. • Fever: infected central lines. • Dialyser reactions: anaphylactic reaction to sterilising agents. • Heparin-induced thrombocytopenia, haemolysis. • Disequilibration syndrome: restlessness, headache, tremors, fits and coma. • Depression.

  39. PERITONEAL DIALYSIS • CAPD involves 4 exchanges of 20 minutes through the day • Can do peritoneal dialysis at night too • Greater flexibility • Contra-indications to peritoneal dialysis • Intra-abdominal adhesions and abdominal wall stoma. • Obesity, intestinal disease, respiratory disease and hernias are relative contra-indications. • Complications of peritoneal dialysis • Peritonitis, sclerosing peritonitis. • Catheter problems: infection, blockage, kinking, leaks or slow drainage. • Constipation, fluid retention, hyperglycaemia, weight gain. • Hernias (incisional, inguinal, umbilical). • Back pain. • Malnutrition. • Depression

  40. RENAL TRANSPLANT • Good survival rates •  1 year and 10 year graft survival rates are 89% and 67% for adult kidneys from 'brain death donors' and 96% and 78% for kidneys from live donors.

  41. SCENARIO 4 • A 20 year old woman presents to you in tears as her mother is going to start dialysis for ESRF due to Polycystic kidney disease. • She wants to know if she has this too, What is her risk? What are you going to do?

  42. ADULT POLYCYSTIC KIDNEY DISEASE • Affects 1 in a 1000 (50% in ESRF by age 60) • Accounts for 10% people on dialysis • Autosomal dominant (but de novo mutation in 5% cases) • Loin pain is the most common symptom (60%) • Hypertension in 10-15% affected children and 50% affected adults • Intracranial berry aneurysms in 6% with no fh and 16% with fh. If FH MRI scan 5 yearly. • Mitral valve prolapse in 25% • When to screen family members? (uss after age 20)

  43. POST STREPTOCOCCAL GLOMERULONEPHRITIS • Mainly in under 5s • 7-14 days after group A B haemolytic strep infection , usually sore throat • Accounts for 90% of acute glomerulophritis • GFR usually returns to normal in 10-14 days • 92%-98% recover fully • Haematuria may persist asymptomatically for 2 years.

  44. HELP FOR YOUR PATIENTS • http://pkdcharity.org.uk/ • http://www.kidneyresearchuk.org/home.php • http://www.gosh.nhs.uk/medical-conditions/ • http://www.britishkidney-pa.co.uk/

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