Chronic Kidney Disease: The Silent Killer

Contact: Audrey Hu Whatsapp/hp: 0086 13880143964 Email: audrey.hu@wecistanche.com

INTRODUCTION

March 9 is observed as World Kidney Day by WHO. This symbolizes victory over communicable diseases like smallpox, plague, polio, etc. because of which people are living much longer than before. This victory has brought new diseases and these are non-communicable and degenerative diseases like diabetes, hypertension1, cardiovascular and cerebrovascular accidents, cancer, and chronic kidney diseases.

Chronic Kidney Disease (CKD) is a global pandemic2 but highly under-recognized health problem in India. CKD ranks 3rd amongst the life-threatening diseases following cancer and cardiac ailments. Every 10th person is suffering from CKD and by this calculation, we are having 100 million people suffering from CKD in India. India cannot afford the treatment of end-stage renal disease and hence it is important for us to understand and manage CKD well. The term “Chronic Renal Failure” has been replaced by “Chronic Kidney Disease,” as the term kidney is more familiar to many people. Additionally, the term ‘Failure’ which suggests a more gloomy picture has been replaced. We all are aware that chronic kidney disease is a progressive disease and patients may present at various stages. The new terminology and staging would bring uniformity in use across the globe and communication would be more easy, meaningful, and better understood.

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Definition

Chronic Kidney Disease (CKD) as defined by the National Kidney Foundation2–and accepted internationally as follows: “The presence of markers of kindy damage for > 3 months as defined by structural or functional abnormalities of the kidney with or without decreased Glomerular Filtration Rate (GFR) manifest by either pathological abnormalities or other markers of kidney damage including abnormalities of the composition of blood or urine and/or abnormalities in imaging tests. Or The presence of GFR < 60 ml/min/1.73 m2 for > 3 months with without other signs of kidney damage as described above”

Stages of Chronic Kidney Disease

Staging CKD helps a lot and makes us understand where exactly the patient stands. It also helps to plan further treatment and predict the outcome. The consequences of undetected CKD are a progressive loss of kidney function leading to kidney failure and the need for dialysis and transplantation which are modalities of treatment. The other important consequence is premature death due to cardiovascular events3,4. The mortality of a patient on dialysis is very high, almost more than 100 times than in the general population.

Recently revealing data have highlighted that even small increases in serum creatinine levels have a huge impact on cardiovascular morality5,6. Also, the cost of managing end-stage kidney disease is escalating worldwide. The economic burden could strain healthcare budgets worldwide and more so in developing countries. Thus, there is a need for early detection and possible prevention (Figs 1 to 3).

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The population at Risk

1. Diabetics7 2. Hypertension 3. Kidney stones 4. High-risk pregnancies 5. Past history of acute renal failure 6. Old age 7. Habitual consumption of “Pain Killers” 8. Patients on ayurvedic drugs 9. Drinking hard water 10. Chronically infected with scabies and sore throats 11. Family history of kidney diseases.

Primary public health preventive measures must, therefore, be aimed at preventing the disease from developing in the “Population at Risk8, (let’s call them to stage ‘O’ for convenience). Public awareness programs must be aimed at identifying stage ‘O’ patients and instituting proper intervention.

Fig. 1: CKD Burden: Increased death

Fig. 2: CKD Burden: Increased CV events

Fig. 3: CKD Burden: Increased hospitalization

Role of Physicians

The role of physicians is enormous and they have to act as leaders. First of all, they must understand and realize the pandemic situation. It is the physicians who will pick up these high-risk patients group and educate them, they should be told about various possibilities and subject them to routine health check-ups. It is ultimately the physician who will order a microalbuminuria test in every diabetic or hypertensive and explain the possibility of reversibility of disease. It is he who has to start Aceinhibitors9 and teach the patient the need for a target BP of 120/80 mm of Hg. Also, educate patients for regular measurement of GFR at an early stage of CKD. So the role of physicians is very important in controlling this pandemic situation, early detection of CKD, and retarding progression of CKD. Also, early referral to a nephrologist by the physician is very important10.

Management of CKD

For the population at risk and stage I and II: ABC of a prevention strategy in diabetes and hypertension: A. HbA1C–Keep < 7.0 B. Blood pressure < 130/80 mm of Hg and more ideal will be 125/75 mm of Hg. C. Cholesterol–LDL < 100 mg/dl

A for HbA1C

• Measure the average blood sugar over 3 months

• Keep FBS between 80-100 and PLBS < 140 mg/dl. Steps to Achieve

• Dietary modification

• Drugs

• Exercise

• Monitor blood sugar

• Follow-up.

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B for Blood Pressure

Target BP must be 130/80 mm of Hg and if proteinuria or risk factors are present then it should be 125/75 mm of Hg.

Steps to Achieve

• Salt restriction

• Regular exercise

• Proper evaluation

• Timely initiated treatment

• Self-monitoring of BP regularly

• Use of Ace inhibitors and ARBS

C for Cholesterol

• LDL cholesterol < 100 mg/dl

• Yearly checking

• Dietary advice

• Exercise

• Statins and others

Management of CKD (Stage III Onwards)

Ideally, it should be done in consultation with nephrologists as multiple steps are to be taken to control the progression of CKD.

1. Any case of mild elevation of Sr Creatinine (In male > 1.5 and in female > 1.3 mg %) should be put on red alert. 2. Adjust the drugs dosages and avoid nephrotoxic medications. 3. Treat additional reversible factors e.g., drug toxicity, dehydrations, avoid pain killers, Bahamas, etc. 4. Calculate the GFR. 5. Treat complications of CKD e.g., anemia, renal osteodystrophy, etc. 6. Preparation for RRT.

While managing CKD, one has to keep in mind to check the progression of CKD. This is very important in our country and all of us have to concentrate on this. Our major goal will be to delay ESRD. This can be achieved by following the below measures: 1. Specific renoprotective therapy with Ace inhibitors or ARBS11 2. Dietary protein restriction to < 0.8 gm/day and of which major is a first-class protein or high biological value protein12. 3. Lipid-lowering agents–statins 4. The strict control of diabetes and hypertension 5. Avoid smoking 6. Avoid further insult to kidneys e.g. dehydration, infection, nephrotoxic drugs, etc. 7. Treat obesity.

In the management of advanced stages of CKD, one has to keep in mind the complications of CKD and its treatment. This will help to preserve other organs in better shape. Following main points to be kept in mind: 1. Anemia correction, which helps to control cardiac function and preserve the feeling of well being13. 2. Correction of volume overload 3. Control of potassium 4. Treatment of renal osteodystrophy.

While treating CKD one has to keep in mind of total rehabilitation of the patient. This will be very important to have successful management of individual patient points of view. It consists of the following points: 1. Self-management education 2. Physical rehabilitation 3. Mental health treatment14 4. Social support15 5. Vocational rehabilitation.

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REFERENCES

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10. Arora P, Obrador GT, Ruthazer R, Krausz AT, Meyer KB, Jenuleson CS, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol 1999;10:1281-6.

11. Wang PH. When should ACE inhibitors be given to normotensive patients with IDDM? Lancet 1997;349:1782-3.

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14. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;2101-7.

15. Christensen AJ, Smith TW, Turner CW, Holman JM, Gregory MC, Rich MA. Family support, physical impairment and adherence in hemodialysis: An investigation of main and buffering effects. J Behav Med 1992;15:313-25.

16. McClellan WM, Knight DF, Karp H, Brown WW. Early detection and treatment of renal disease in hospitalized diabetic and hypertensive patients: Important differences between practice and published guidelines. Am J Kidney Dis 1997;29:268-375.

17. Mathiesen ER, Hommel E, Hansen HP, Smidt UM, Parving H-H. Randomised controlled trial of the long-term efficacy of captopril on the preservation of kidney function in normotensive patients with insulin-dependent diabetes and microalbuminuria. BMJ 1999;319:24-5.

18. Mailloux LU, Levey AS. Hypertension in chronic renal disease. Am J Kidney Dis 1998;32:S120-S141.

19. Parving HH, Andersen AR, Smidt UM. Early aggressive antihypertensive treatment reduces the rate of decline in kidney function in diabetic nephropathy. Lancet 1983;1:1175-9