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Author Topic: Stage 1 CKD??
Tejas
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Post Stage 1 CKD??
on: October 5, 2012, 08:07
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have a quick question for you about this pt.

He is a 70 yr old white make with 20 yr hx DM2 - now in good control. No HTN - BP always good. microalb/Cr ratio always negative. His GFR is over 90. Does he have stage 1 DM renal dz with hyperfiltation? If so should I add a low dose ACE-I or ARB?
Thanks.

Endocrinology Attending

Tejas
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Post Re: Stage 1 CKD??
on: October 5, 2012, 08:18
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Great question.

This answer may not be totally satisfactory because of the limitations in the definitions for Chronic Kidney Disease.

Stage 1, as you know, is poorly defined as:

a) microalbuminuria or proteinuria, or
b) structural disease by imaging, such as ultrasound.

You haven't given me the ultrasound reports because the patient hasn't had one. Thus, with the information you've provided, he does *not* have CKD stage 1. Though this answer is practically laughable because after 20 years of diabetes, one can assume with high certainty that there is probably some damage that has occurred (though not a tremendous amount and perhaps still fully reversible).

Below is a chart that quickly explains the definitions of CKD as per K/DOQI guidelines.

Now, regarding an ACEi or ARB: strictly speaking, this patient does not require such a medication, especially since he is not hypertensive (another indication that the kidney dysfunction is not severe or permanent or even clinically significant). Having written this, however, I would consider starting some form of RAAS blockade because of the 20-year history of diabetes. There is no evidence to support this statement (at least none that I am aware of). Even the AASK trial does not provide an answer to this question.

I hope this helps somewhat.

Tejas Desai

Tejas
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Post Re: Stage 1 CKD??
on: October 5, 2012, 08:50
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Definitions of CKD

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Post Re: Stage 1 CKD??
on: October 5, 2012, 09:03
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I fully agree!
However, I do not just say that the patient is not suffering from kidney disease as I have not seen the histology of the kidney (which it should not do)
I would not put the patient under RASS

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Post Re: Stage 1 CKD??
on: October 8, 2012, 13:23
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I love your website. Thanks for posting my question as a blog.
I am still undecided about this case. I just wonder how often you see any 70 year old man with a GFR over 90? That is why I wondered if it represented hyperfiltation

Endocrinology Attending

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Post Re: Stage 1 CKD??
on: October 8, 2012, 13:27
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Unfortunately I don't see such patients. As a nephrologist such patients never come to my attention, and thus my view is very skewed. I believe he is hyperfiltrating but th eonly way to know for sure is to perform a kidney biopsy. However, the risk-benefit ratio for such a procedure would be unfavorable for the patient.

Tejas Desai

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Post Re: Stage 1 CKD??
on: October 8, 2012, 20:43
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I agree. Just for the heck of it I will ask ask our Chief of Geriatics if he ever sees a GFR in someone over 70.

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