CHRONIC KIDNEY DISEASE

Candra Wibowo
Nephrology Division, Medical School of Trisakti University Jakarta

DEFINITION & CLASSIFICATION

KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification and Stratification
http:/www.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm, accessed Oct 10, 2007

Definition (KDOQI 2002)

Kidney damage 3 mo as defined by structural or

functional abnormalities w/o GFR, manifest by either :

Pathological abnormalities or
Markers of kidney damage, including abnormalities in the
composition of blood or urine, or abnormalities in imaging tests

GFR < 60 mL/min/1.73 m2 for 3 mo, w/o kidney

damage

Classification

Stages of CKD is based on GFR

DEFINING KIDNEY DAMAGE

Pathologic Abnormalities?
By Radiology (USG, CT, MR, etc) e.g.
Multiple cysts consistent with PKD
Extensive scarring
Small kidneys but be careful of the term
medical renal disease.
REMEMBER: Renal masses or cysts that are not
simple should be referred to a Urologist

By Histology ie, renal biopsy

DEFINING KIDNEY DAMAGE

Markers of Kidney Damage?
Proteinuria
Microalbuminuria
Hematuria (especially when seen with
proteinuria)
Isolated hematuria has a long differential:
infection, stone, malignancy, etc.

Casts (especially with cellular elements)

CLASSIFICATION & STAGES OF CKD

KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification and Stratification
http:/www.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm, accessed Oct 10, 2007

GFR
(mL/min/1.73 m2)

With Kidney Damage

With HBP

Without HBP

With HBP

Without HBP

90

HBP

NORMAL

60 89

HBP with
GFR

GFR@

30 59

15 29

< 15
(or dialysis)

HBP : high blood pressure as defined as 140/90 mmHg

@ : may be normal in the elderly or infants

Without Kidney Damage

K/DOQI NKF, 2002

AJKD 2009; vol 20 (XX)

KDIGO Controversies Conference:

Definition, Classification and Prognosis in
CKD, London, October 2009
ACR (mg/g)
<30 (A1)

GFR
Stages,
Description and
Range
(mL/min/
1.73m2)

Normal or
increased

>90

mild

60-89

3a

mildmoderate

45-59

3b

moderatesevere

30-44

severe

15-29

kidney
failure

<15

30-299 (A2)

300 (A3)

The known pts with ESRD

0,2%

Many pts with CKD 1-4

11-16%

ICEBERG PHENOMENONE

Prevalence of GFR Categories in the USA

Stage

Description

GFR
Prevalence Prevalence
(mL/min/1.73m2)

Kidney damage with > 90

normal or GFR

Mild GFR

3
4
5

5.9 million

3.3%

60-89

5.3 million

3.0%

Moderate GFR

30-59

7.6 million

4.3%

Severe GFR
Kidney Failure

15-29

400,000

0.2%

< 15 or dialysis

300,000

0.2%

Coresh, et al, Am J Kidney Dis. 2003; 41: 1-12

The Patient with Early Stage CKD is

5 to 10 times MORE LIKELY to die
from a cardiovascular event than
progress to ESRD.
Foley RN, Murray AM, Li S, Herzog CA, McBean AM, Eggers PW, Collins AJ.
Chronic kidney disease and the risk for cardiovascular disease, renal
replacement, and death in the United States Medicare population, 1998 to 1999.
J Am Soc Nephrol 2005; 16:489-95.

CKD Patients Are More Likely to Die

than to Progress to ESRD
5 year follow-up

GFR 15-29

N=27998

Died
RRT
Event Free
Disenrolled

GFR 30-59
GFR 60-89; + Proteinuria
GFR 60-89, No
Proteinuria
0% 20
%

40
%

60
%

80 100
% %

Keith, et al, Arch Int Med; 2004; 164:659-663

COSTS OF ESRD

Depending on stage (compared to controls) pts

with CKD

Had 1.9 to 2.5 times more prescriptions

Had 1.3 to 1.9 times more outpatient visits
were 1.6 to 2.2 times more likely to have had an
inpatient stay
Had 1.8 to 3.1 more stays than did controls

CKD pts had approximately double the costs of

control pts in this study
Smith DH, et al. J Am Soc Nephrol. 2004; 15: 1300-1306

MORBIDITY & MORTALITY

More than 50% of all death in ESRD pts are due

to CVD
CKD is independently associated with an
increased rate of death from CVD
The presence of CKD is associated with worse
outcomes after ACS & PCI

Go AS, et al. New Engl J Med. 2004; 351 (13): 1296-1305

Muntner P, et al. J Am Soc Nephrol. 2002; 13(3): 745-753
Wright RS, et al. Ann Intern Med. 2002; 137(7): 563-570
Best PJ, et al. J Am Coll Cardiol. 2002; 39(7): 1113-1119

MORBIDITY & MORTALITY

Go AS, et al. New Engl J Med 2004; 351 (13): 1296-1305

CAUSE OF DEATH ON DIALYSIS

QUALITY OF LIFE

Out of working day

2-3 x/week for going to HD center

3 x 1 x 5 hrs/day for exchanging dialysate
1-2 x/month for visiting doctor
3-6 x/year as an inpatient due to ESRDs complications

Associated with ESRDs complications

Anemia
Ca-P disorders
Hypertension
Volume overload
Infection on immunocompromised state
CVD/CHF
CVA
Others

PRIMARY PREVENTION OF CKD

EARLY DETECTION

Screening for CKD risk factors

Determine traditional & CKD-related
CVD risk factors
Reduce CKD risk factors

PRIMARY PREVENTION OF CKD

Adverse outcomes of CKD can often be prevented or
delayed through early detection and treatment.
Earlier stages of CKD can be detected through routine
laboratory measurements.
The presence of CKD should be established, based on
presence of kidney damage and level of kidney function
(GFR), also stage of CKD, irrespective of diagnosis;
according to the K/DOQI CKD classification

EARLY DETECTION :
SCREENING & LOOKING FOR CAUSE OF CKD

Who should be screened for CKD ?

Why should we care?
How do screen for CKD ?
When do evaluate screening for CKD ?

Who should be screened for CKD ?

1. Everyone who gets 40 yrs old
2. Everyone who has CKD risk factors

Traditional risk factors

CKD-related CVD risk factors
Risk factors of CVD

3. Everyone who gets CKD causes

Who should be screened for CKD ?

Potential Risk Factors for Susceptibility to and Initiation of CKD
Clinical Factors
Sociodemographic Factors
Diabetes mellitus
Hypertension
Autoimmune diseases
Urinary tract infections
Urinary stones
Lover urinary tract obstruction
Neoplasia
Family history of CKD
Recovery from AKF
Reduction in kidney mass
Exposure to certain drugs
Obesity
Low birth weight

Older age
Ethnic : Afro-america, Indian, Hispanic,
Asian/Pacific Islander
Exposure to certain chemical/ environmental
conditions
Low income / education

TRADITIONAL & CKD-RELATED FACTOR POTENTIALLY

RELATED TO AN INCREASED RISK FOR CVD
Traditional CVD risk factors
Older age
Male gender
White race
Hypertension
Diabetes Mellitus
Tobacco user
LDL-C
Physical inactivity
Menopause
Psychosocial stress
Family history of CVD
K/DOQI NKF, 2002

CKD-related CVD risk factors

Type of CVD
GFR
Proteinuria
RAA system activity
ECF volume overload
Abnormal Ca, P metabolism
Uremic, dyslipidemia
Anemia
Malnutrition
Infection
Thrombogenic factors
Hyperhomocysteinemia
Oxidative stress
Chronic inflammatory state
Uremic toxin

CAUSES OF CKD

DM
GNC
Hypertension
Glomerulonephritis primer
Chronic UTI
Obstruction (stones, malignancy, vesicouretero valve impaired
metastasis, cicatrix, iatrogenic, etc)
Tubulointerstitial disease
Polycystic disease
Autoimmune disease (APS, lupus, etc)
Chronic poisoning (lead Pb/Cd/Hg, drugs, antibiotic, traditional
medicine, chemotherapeutic, contrast, cell lysis syndrome, etc)
Gout / hyperuricaemia
NSAID
Pre/eclamptia
OTHERS

Cause of Chronic Kidney Disease

%

RSU Prof.Dr. R.D Kandou Manado

2002-2004
New pts with CKD
>13 yr old
N = 192
M= 126 (65.62%)
F = 66 (34.38%)

Candra et al, Medika 2007

WHY SHOULD WE CARE?

The outcomes of pts with reduced GFR are uniformly
poor
Pts with CKD are more likely to die than go onto dialysis
Early recognition of CKD permits intervention to alter the
Natural History of the disease :
Nephroprotection
Cardio-vascular protection

Mortality Increase Exponentially as GFR Decrease

Go et al. NEJM 2004; 351: 1296-1305

Patients with CKD are More Likely to Die than Go onto Dialysis

US Renal Data System. Am J Kidney Dis 2007; 49 (suppl I): S20

Nephroprotective Treatment :
more effective when started earlier

Paul E de Jong, Netherlands 2007

How do screen for CKD?

Blood pressure
Urinalysis
Dipstick for proteinuria, or microalbuminuria
Kidney function test (creatinin, ureum, cystatin C, CCT)
Kidney imaging (USG, IVP, CT, MRI, Renal study)
Kidney biopsy

How do screen for CKD?

All Patients
Measurement of BP
SCr to eGFR
Protein-to-creatinine ratio or alb-to-creatinine ratio in a first-morning or random
untimed spot urine specimen

Selected Patients, Depending on Risk Factors

USG : in pts with symptoms of urinary tract obstruction, infection or stone, or family
history of PKD
Serum electrolytes : Na, K, Cl, HCO3
Urinary concentration or dilution (SG or Osm)
Urinary acidification (pH)

BLOOD PRESSURE
Pts should be seated with their backs supported, arms bared & at heart
level
Refrain from smoking or ingesting caffeine 30 preceding the
measurement
Start after at least 5 of rest
Appropriate cuff size: the bladder within the cuff should encircle at least
80% of the arm
Taken preferably with a mercury sphygmomanometer or calibrated
aneroid manometer or validated electronic device
The 1st appearance of sound (phase 1) is used to define for SBP & the
disappearance of sound (phase 5) is used to define DBP
2 or more readings separated by 2 min should be averaged. If the 1 st
readings differ by more than 5 mm Hg; additional readings should be
obtained and averaged
OR : 1st is discarded to ensure that pts is relaxed, & the mean of 2 nd 3rd
readings is calculated

AMBULATORY BP MONITORING
Useful in pts with apparent drug resistance, hypotensive
symptoms with antihypertensive drugs, episodic
hypertension.
Seldom required & should not be used to delay appropriate
therapy
BP tends to be higher in clinic than outside of the office
(white-coat hypertension)
Ambulatory results are an average of 10/5 mm Hg lower
than office BP
No agreement on upper limit of normal home BP; but
reading of 135/85 or greater should be considered elevated.
Definition HTN 140/90 or greater.
Awake < 135/85 mm Hg and asleep 125/75 mm Hg.
majority; BP falls 10-20% during the night

BLOOD PRESSURE
In mild hypertension : reassessment 3 months later
In moderate hypertension : reassessment 3-4 weeks
later
In severe hypertension (>180/110 mm Hg) :
reassessment 2 weeks later and treatment started if this
level is sustained
Immediate treatment is required in accelerated
hypertension (papilloedema, retinal haemorrhages and
exudates, acute cardiac complication (aortic dissection)

URINALYSIS
Recommended collection of urine sampling :
Mid stream urine
Fresh urine (within 3 h)
At the morning 30-60 min after the 1st mixture

Examination
Macroscopic :

Colour
Smell
Bubble
SG

- Chemist reaction :
pH
protein/albumin
glucose
nitrite

Microscopic :

Cylinder/cast : hyalin, erythrocyte, leukocyte, epithel, broad

Bacteria
Crystals : cystine, tyrosine, leucin, sulfa
Epithel
Erythrocyte/leukocyte

DEFINITION OF PROTEINURIA & ALBUMINURIA

KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification and Stratification
http:/www.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm, accessed Oct 10, 2007

Urine collection
methods
Total
Protein

Albumin

Normal

Micro
albuminuria

Albuminuria or
clinical proteinuria

24 h excretion

< 300 mg/d

NA

> 300 mg/d

Spot urine dipstick

< 30 mg/dl

NA

> 30 mg/dl

Spot urine protein to

creat ratio

< 200 mg/g

NA

> 200 mg/g

24 h excretion

< 30 mg/d

30 300 mg/d

> 300 mg/d

Spot urine alb

specific dipstick

< 3 mg/dl

> 3 mg/dl

NA

Spot urine alb to

creat ratio

< 17 mg/g (m)

< 25 mg/g (w)

17 250 mg/g
25 355 mg/g

> 250 mg/g (m)

> 355 mg/g (w)

Gender specific cut-off values are from a single study. Use of the same cut-off value
leads to higher values of prevalence for women than men. Current recommendation from
ADA do the cut-off values for spo t urine alb-to- creat ratio for microalbuminuria and
albuminuriaas 30 and 300 mg/g respectively w/o regard to gender

K/DOQI NKF, 2002

DEFINITION OF PROTEINURIA & ALBUMINURIA

KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification and Stratification
http:/www.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm, accessed Oct 10, 2007

Category

Abnormal values

Normal
24-h excretion albumin

< 30 mg/d

Microalbuminuria
24-h excretion albumin/creatinine ratio

30-300 mg/d
> 2.5 mg/mmol cr

Clinical (overt) albuminuria

24-h excretion albumin/creatinine ratio

> 300 mg/d

> 3.5 mg/mmol cr

Clinical proteinuria
24-h excretion protein/creatinine ratio

> 300 mg/d

> 13.0 mg/mmol cr

RENAL SURVIVAL AND PROTEINURIA

METHODS OF ESTIMATING GFR

1. Inulin/iothalamate clearance : GOLD STANDARD
2. Creatinine clearance (collect 24 h urine)
U.cr X Vol. urine X 1,73
P.cr
1440
Koef

3. Equations base on SCr

1. Cockcroft-Gault :
2. MDRD

(140 age) x BW
72 x P.cr

186 x [Pcr]-1.154 x [age]-0.203

x [0.742 if female] x [1.212 if AfAm]

Note : women must be corrected by 85%

>18 yrs old uses Schwartz OR Counahan-Barratt

SCr, CrCl & eGFR are not in PERFECT

Serum Creatinine alone CAN NOT be used to accurately
assess level of kidney function.
Serum creatinine is a function of production (muscle
mass) and excretion (both GFR and tubular secretion).
Age, sex, and lean body mass have to be taken into
account.
Estimations of eGFR (MDRD equation) and CrCl
(Cockcroft-Gault equation) were NOT developed in
subjects with normal renal function or normal health.

FACTORS AFFECTING SCr CONCENTRATION

Increase
Kidney disease
Ketoacidosis
Ingestion of cooked meat
Post trauma (mechanic, electric, thermal)
Drugs : Trimethoprim
Cimetidine
Flucytosine
PPI
Ketoconazol
Some cephalosporins

Decrease
Reduced muscle mass
Malnutrition
Elderly age

GFR NORMALLY DECREASE WITH AGE

LESS 60 AFTER 60

A significant proportion of >60 yrs old has eGFR <60 ml/min.

SCr is an Inadequate Screening Test for Renal

Failure in Elderly Patients
At what level of creatinine does a 65 yr old diabetic,
hypertensive woman with BW 50 kg have CKD?
NKDEP conducted a survey with 600 primary care providers.
77% said : creatinine > 1.5 mg/dl
GFR = 37 mL/min/1.73 m2
Ccreat= 30 mL/min
Creatinine > 1.0 mg/dl
GFR = 59 mL/min/1.73 m2

COCKCROFT-GAULT EQUATION
TO PREDICT GFR
Developed to predict creatinine clearance, thus an
overestimate of GFR
Prediction based on age, gender, creatinine and ideal
body weight
ClCr (cc/min) = [140-age] x BW/72 x SCr x [0.85 if female]

Used almost universally as the basis for drug dosing!

MDRD EQUATION TO PREDICT GFR

Prediction based on age, gender, race and
serum creatinine. Developed to follow GFR
as part of the Modification of Diet in Renal
Disease (MDRD) study. Validated.
GFR/1.73m2 = 186 x [Pcr]-1.154 x [age]-0.203 x
[0.742 if female] x [1.212 if AfAm]

http://www.kidney.org/professionals/KDOQI/gfr.cfm

COCKCROFT-GAULT

VS

MDRD

The MDRD equation estimates GFR.

eGFR is given per 1.73m2 BSA

The Cockcroft-Gault equation estimates

CrCl.
CrCl is best used for drug dosing decisions
drug dosing is usually indexed to CrCl.

When do evaluate screening for CKD ?

When negative : (TREAT ON RISK FACTORS)
every 1 yrs for pts with risk factor
every gets systemic disorders

When positive : (MANAGEMENT ON CKD)

Re-evaluate for several times within 1-3 months
Make diagnosis
Do therapeutic

PATIENTS SUFFER FROM KIDNEY DISEASE?

NO

Find & reduce risk factor

PREVENTION

YES

Determine Stage of CKD

Determine underlying cause
Identify risk factors for
progression
Identify comorbidites
MANAGEMENT

STAGES IN PROGESSION OF CKD AND

THERAPEUTIC STATEGIES
COMPLICATION

NORMAL

RISK

Screening
for CKD
risk factor

GFR

Diag & treat,

treat comorbid,
slow progression
CKD risk
reduction,
screening
for CKD

PRIMARY PREVENTION
K/DOQI NKF, 2002

DAMAGE

ESRD

DEATH

RRT by dialysis
or transplant
Estimate
progression,
treat complic,
prepare for RRT

SECONDARY PREVENTION

TERTIARY PREVENTION

EARLY TREATMENT ON RISK FACTORS

Interventions proven to be effective include:
1. Strict glucose control in diabetes;
2. Strict blood pressure control;
3. ACEI and ARBs
Interventions that may be effective, but studies
are inconclusive, include:
1. Dietary protein restriction;
2. Dietary callory restriction;
3. Lipid-lowering therapy;
4. Partial correction of anemia.

EARLY TREATMENT ON RISK FACTORS

Attempts should be made to prevent acute renal failure:

1. Volume depletion;
2. IV contrast;
3. Some antibiotics : aminoglycosides & amphotericin B;
4. NSAIDs, including COX 2 inhibitors;
5. Other drugs: ACEI, ARBs, calcineurin inhibitors
6. Obstruction.

SLOWING PROGRESSION
DO EARLIER GET BETTER

DIABETES MELLITUS
IF,
everybody exercised
few hours a week,
type 2 diabetes would be
virtually nonexistent

DIABETIC EVOLUTION

STRICT GLYCEMIC CONTROL

80% Type I DM with microalbuminuria
develop DN in 10-15years, 50% to ESRD
DCCT, benefit of tight control in reducing
occurrence subclinical and overt DN(40-60%)

20-40% Type II DM with microalbuminuria

develop DN, 20% to ESRD
UKPDS 33, 25% reduction in microvascular
events
Kumamoto
Steno Type 2, 73% reduction in clinical proteinuria

CRITERIA OF DIABETES CONTROL

Good

Moderate Worse

Fasting blood glucose (mg/dL)

80 109

110 125

126

2 h post prandial blood glucose

110 144

145 179

180

A1C (%)

< 6.5

6.5 8

>8

Total cholesterol (mg/dL)

< 200

200 239

240

LDL-C (mg/dL)

< 100

100 129

130

HDL-C (mg/dL)

> 45

Triglyceride (mg/dL)

< 150

150 199

200

IMT (kg/m2)

18.5-22.9

23 25

> 25

Blood pressure (mmHg)

< 130/80

130-140/80-90

> 140/90

Recommended : A1c < 7

ADA, 2002

H
Y
P
E
R
T
E
N
S
I
O
N

CLASSIFICATION OF BOOD PRESSURE

FOR ADUTS AGED 18 YRS OR OLDER
Hypertension is defined as blood pressure 140/90 mmHg
JNC 6 1997, WHO-ISH 1999, ESH/ESC 2003,
ESH/ESC 2007
Category

JNC 7 2002

Systolic

Diastolic

Systolic

Diastolic

Category

Optimal

< 120

< 80

< 120

< 80

Normal

< 130

< 85

High-normal

130 -139

85 89

120 - 139 80 -89

Prehypertension

Borderline hypertens

140 - 149 90 94

140 - 159 90 - 99

Stage I

Grade I (mild)

140 - 159 90 99

Grade 2 (moderate)

160 - 179 100 109

160

100

Stage II

Grade 3 (severe)

180

110

Isolated systolic
hypertension

>140

< 90

>140

< 90

Isolated systolic
hypertension

Subgroup borderline

> 140

< 90

Normal

2007 Guidelines for the management of

arterial hypertension
European Heart Journal (2007) 28, 14621536

The Task Force for the Management of Arterial

Hypertension of the European Society of
Hypertension (ESH) and of the European Society of
Cardiology (ESC)

Denitions & Classication of BP Levels

Category

Systolic

Diastolic

Optimal

<120

and

<80

Normal

120129

and/or

8084

High normal

130139

and/or

8589

Grade 1 hypertension

140159

and/or

9099

Grade 2 hypertension

160179

and/or

100109

Grade 3 hypertension

>180

and/or

>110

Isolated systolic hypertension

>140

and

<90

Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressurevalues in the ranges indicated,
provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and
severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication
of total cardiovascular risk.

TARGET ON BLOOD PRESSURE LEVEL

Chobanian AV, et al. JAMA 2003; 289: 2560-2571

American Diabetes Association. Diabetes Care 2002; 25: 134-147
National Kidney Foundation. Am J Kidn Dis 2002; 39 (suppl 1): S1-S266

Clinical Practice Guidelines for

Management of Hypertension in CKD
Type of Kidney Disease

Blood Pressure
Target
(mm Hg)

Preferred Agents
for CKD, with or
without
Hypertension

Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target

ACE inhibitor
or ARB

Diuretic preferred, then

BB or CCB

None preferred

Diuretic preferred, then

ACE inhibitor, ARB, BB
or CCB

Diabetic Kidney Disease

Nondiabetic Kidney Disease

with Urine Total Protein-toCreatinine Ratio 200 mg/g
Nondiabetic Kidney Disease
with Spot Urine Total Proteinto-Creatinine ratio <200 mg/g
Kidney Disease in Kidney
Transplant Recipient

<130/80

CCB, diuretic, BB, ACE

inhibitor, ARB

TREATMENT OF HYPERTENSION
Life style modification
Not at Goal BP
(<140/90 mmHg for those with DM or CKD)
Initial drug choices
Hypertension without
compelling indications
Stage 1
Thiazide type diuretics
Consider ACE-I, ARB,
BB, CCB or combination

Hypertension with
compelling indications

Stage 2
2 drugs combination
for most

Not at Goal BP

JNC VII. JAMA 2003;289:2560-2572

Optimize dosages or
add additional drugs

Drugs for compelling

indication

INTERVENTIONS TO DELAY PROGRESSION

OF CKD : ACE-I AND ARBs
Mechanisms
Lower systemic blood pressure
Lower glomerular capillary blood pressure and
protein filtration
Reduce AT II mediated cell proliferation and
fibrosis

Should be employed in all proteinuric kidney disease !!!

INTERVENTIONS TO DELAY PROGRESSION

OF CKD : ACE-I AND ARBs
Diabetic Kidney Disease
ACEI or ARB in all diabetic patients with microalbuminuria
ACEI (alt ARB) in Type 1 Diabetics with macroalbuminuria
ARB (alt. ACEI) in Type 2 Diabetics with macroalbuminuria

Nondiabetic Kidney Disease

ACEI/ARB recommended in all proteinuric (>200 mg/g Cr on spot
urine) patients with CKD
May tolerate creatinine rise of 35% above baseline
<130/80 is goal
3 or more drugs may be required! One will probably be a diuretic
(thiazide first, then loop)
ACEI and ARB may be used in combination
KDOQI 2002, 2006
JNC 7, 2003

SUMMARY
As most cases with CKD even though
ESRD are not known by physicians, so
we need active detect subjects at risk in
an early phase.
Such screening is needed as it enables
early prevention not only of progressive
CKD; but also of progressive CVD.
Screening for albuminuria and eGFR is
simple, cheap and important things.

SUMMARY
Screening for albuminuria helps to detect
subjects at risk of progression CKD & CVD; but
also subjects at risk for new DM and new HTN
Albuminuria :
stage 1 & 2 CKD is presented in 5-6% of the general
population
stage 3 is presented in another 4-5% of the general
population

Screening for stage 3 CKD helps to detect

subjects at risk of CVD.

SUMMARY
Screening for albuminuria and early
treatment of those found positive is cost
effective to prevent CKD and also CVD.
Lowering albuminuria helps to prevent
progressive CKD & CVD in general
population.