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Managing chronic kidney disease in primary care

21 Mar 2018
 

Chronic kidney disease (CKD) has a global prevalence of 7–12 percent, with a mortality risk that has increased over the past 25 years – ranking 25th in 1990 to 17th in 2015. While there is no sufficient data reflecting the incidence of CKD in South East Asia (SEA), in Singapore, 2.3 percent of adults aged 18–69 years have been found to have renal impairment (estimated glomerular filtration rate [eGFR] of <60 mL/min/1.73m2).

 

Audrey Abella speaks with Dr Hong Wei Zhen and Dr Priyanka Khatri, Associate Consultants of the Division of Nephrology at National University Hospital, Singapore, on the challenges in diagnosing and managing CKD in the primary care setting.

 

Introduction

CKD entails a reduction in the number of nephrons, causing compensatory hyperfiltration in the rest of the glomeruli. This consequently activates the renin-angiotensin-aldosterone system and increases proteinuria. Over time, this leads to increased inflammation and fibrosis of the glomeruli and tubules, resulting in a progressive decline in the GFR and eventually, kidney failure (Table 1).

 

Table 1: Stages of CKD

Stage

Description

GFR (mL/min/1.73 m2)

1

Kidney damage with normal/ GFR

90

2

Kidney damage with mild GFR

60–89

3

Moderate GFR

30–59

4

Severe ↓ GFR

15–29

5

Kidney failure

<15

 

Given the increasing mortality risk associated with CKD, early detection and management is essential to delay the deterioration of kidney function and reduce overall mortality.

 

Diagnosing CKD

One of the challenges in diagnosing CKD is the lack of obvious symptoms in the early stages. Should there be signs and symptoms, these are usually non-specific.

 

Early diagnosis is crucial, as there are treatments that specifically target the initial stage that can reverse kidney damage or slow down disease progression. Given this, efforts should be geared towards educating and assisting primary care providers for early detection and appropriate management of CKD.

 

To facilitate an early and accurate diagnosis, regular screening is recommended especially among medically compromised patients such as those with type 2 diabetes (T2D), hypertension, established cardiovascular (CV) disease, obesity, or history of kidney failure.

 

CKD diagnosis is not confined to the GFR range. Other markers of kidney damage include haematuria (after exclusion of urological causes), albuminuria, or the presence of structural abnormalities (incidentally caught on ultrasound or CT scans) for ≥3 months.

 

However, most primary care providers lack awareness on the latest guidelines on CKD. Insufficient clinical exposure to CKD patients is a factor that might influence their ability to assess CKD. In light of this, clinicians are encouraged to refer to local and international guidelines* to assist in the detection of potential CKD in their patients.

 

Seeking consult from several doctors could complicate CKD monitoring and management, hence the emphasis is on following up with a single primary care provider.

 

Laboratory tests

Laboratory exams could be costly and could affect patient adherence to follow-ups. Nonetheless, these procedures are imperative to facilitate a proper diagnosis.

 

Measuring eGFR is recommended as adjunct to serum creatinine screening, as normal serum creatinine measurements do not exclude loss of kidney function.

 

Urinalysis (first morning void specimen) is necessary to evaluate for albuminuria, proteinuria, and haematuria, as well as imaging studies to determine structural abnormalities.

 

Dipstick test for determining the presence of protein in urine is no longer recommended, as the sensitivity and specificity of this test is suboptimal.

 

Treating CKD
CKD treatment is not just targeted at CKD itself – rather at managing and optimizing the associated chronic medical conditions and underlying risk factors. Although conditions such as glomerulonephritis warrant specific interventions (ie, immunosuppression), this comprises only a small fraction of CKD in Singapore.

 

T2D management is a key factor in delaying CKD progression, as T2D is the number one cause of CKD not just in Singapore but in SEA. It is important to achieve and maintain an HbA1c target of 7–7.5 percent and a blood pressure (BP) target of <140/90 mm Hg or, if tolerated, <130/85 mm Hg.

 

Reducing CV risk is also important as CKD is an independent risk factor for future CV events. Therefore, smoking cessation, weight reduction in obese patients, optimizing hyperlipidaemia, and encouraging patients to maintain a healthy lifestyle are of paramount importance. 

Dose-optimized angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARB) are the preferred antihypertensive agents for patients with proteinuria and CKD. ACE inhibitor/ARB combination therapy is not recommended, as this may increase the risk of hypotension, syncope, hyperkalaemia, and acute kidney injury (AKI). Moreover, this drug combination does not provide added benefit in retarding CKD progression compared with ACE inhibitor or ARB monotherapy.

 

Prolonged exposure to nephrotoxins like non-steroidal anti-inflammatory drugs should also be avoided as this may lead to AKI.

 

Challenges in treating CKD in Singapore

Compliance is a major issue in the local context, hence the need to emphasize patient education. It is important that clinicians are able to inculcate in patients the value of early intervention and adherence to follow-up to delay disease progression.

 

Majority of the problem lies in the community, and simple measures instituted early can solve the bulk of this problem. The number of CKD patients managed by nephrologists only represents the tip of the iceberg; therefore, screening for diabetes in a high-risk population, aggressive risk factor reduction including stringent glycaemic and BP control, and optimizing ACE inhibitor and ARB use to reduce albuminuria should be actively practiced in the community.

 

Emphasis on obesity

Obesity, another independent CKD risk factor, should also be addressed in light of the prevalence of CKD among young adults today.

Obesity 
is related to a sedentary lifestyle, an unhealthy diet, and lack of exercise. As a result, obese patients carry an increased risk of developing T2D, hypertension, and gout, which increase predisposition to CKD.

 

With the growing prevalence of obesity in Singapore**, increasing public awareness on healthy lifestyle and regular exercise is essential to combat obesity and its associated health risks, which includes CKD.

 

Conclusion

Primary care providers play a very important role in the battle against CKD. Early referral to a nephrologist reduces the rate of progression to end-stage renal disease, and increases the likelihood of timely preparation for renal replacement therapy. Consequently, nephrologists can make certain recommendations to GPs to optimize CKD treatment and management in primary care.

 

Dr Hong Wei Zhen
Dr Hong Wei Zhen

Dr Priyanka Khatri
Dr Priyanka Khatri
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Stephen Padilla, 25 Jul 2019
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