Kidney Disease

Prevention of Urinary Tract Diseases Isabelita M. Samaniego MD

Session Objectives 1. To describe the present health status of kidney problem in the Philippines.  2.To review the common types of kidney diseases.  3. To describe the national objectives for the control and prevention of kidney diseases. 

Situationer 6,500 yearly deaths in the country secondary to various kidney diseases  Renal Diseases threaten to be one of the leading causes of death  Health consequence of chronic kidney disease is renal failure  DOH reported that there are about 6,000 new cases of ESRD a year 

Situationer ESRD –causes are as follows:  Chronic glomerulonephritis (CGN) is the most common (47 percent )  Chronic pyelonephritis (17 percent), diabetes mellitus (13 percent), and hypertensive nephrosclerosis (5 percent) (Kidney center of the Philippines, Medical City 1975-1981 

Situationer  b) c) d)  f) g) h) i)

Dialysis patients: Chronic glomerulonephritis (39 percent) Diabetes mellitus (22 percent) Hypertension (14 percent) (RDR,1998). Other conditions that cause Chronic renal failure vasculitis, interstitial nephritis genetic and congenital disorders polycystic kidney disease.

Situationer ESRD affects persons of all ages  Chronic glomerulonephritis (CGN) usually affects children, adolescent and young adults in their reproductive years  One primary reason for CGN progression is failure to diagnose the disease in its early stage 

Situationer 

b) c) d)

Three interventions have been effective in defined populations: Increase case finding and treatment for CGN Good glycemic control (for patient with diabetes mellitus) Optimum blood pressure control

Situationer Interventions to slow down the ESRD  Simple urinalysis can detect symptoms of urinary tract infection in asymptomatic individuals 

Acute Uncomplicated Cystitis in Women 

 c) d) e) f) g) h)

Definition: Growth of > 100 colony- forming units ( cfu)/ ml of mid stream urine in non pregnant women ( 18-50 yrs old) Symptoms Presented: Dysuria Frequency Urgency Gross hematuria Hypogastric pain Without symptoms of vaginitis , pyelonephritis or risk factors for subacute pyelonephritis or complicated UTI ( Grade A)

Risk Factors for subacute pyelonephritis or complicated UTI         

Hospital Acquired Infection Indwelling Catheter Recent UTI Recent urinary tract instrumentation ( 2 weeks) Functional or anatomic abnormality of the urinary tract Recent antimicrobial use ( 2 weeks) Symptoms > 7 days at presentation DM Immunosuppresion

Treatment & Duration 3 day course of the ff:  TMP/SMX 160/800  Nitrofurantoin 100 mg QID  Norfloxacin 200 mg BID  Cirpofloxacin 250 mg BID  Ofloxacin 200 mg BID  Co amoxyclav 375 mg TID 

Acute uncomplicated Pyelonephritis 

Definition : Fever , chills flank pains, costovertebral angle tenderness , nausea, vomiting, with or without symptoms of lower urinary tract infection in an otherwise healthy female with no clinical or historical evidence or functional or anatomic urologic abnormalities

Acute uncomplicated Pyelonephritis Definition :  Laboratory: pyuria> 5wbc/ hpf in a centrifuge urine 

Acute uncomplicated Pyelonephritis Etiologic diagnosis:  Gram stain ( grade C)  Quantitative C/s ( grade C) 

Acute uncomplicated Pyelonephritis Treatment: Indications for admission:  Inability to maintain oral hydration or medication  Concern about compliance  Uncertainty about the diagnosis  Severe illness with high grade fever  Severe pain  Marked debility  Signs of sepsis

Acute uncomplicated Pyelonephritis Characteristic Pathogens Clinical Situation

Empiric treatment

E. Coli Proteus Mirabilis K Pneumonia

Mild to moderate illness, no nausea, vomitingOPD

Oral: Quinolones, TMP/SMX/ Co amox- 14 days

S. Saprophyticus

Severe illnesshospitalization

Parenteral – Aminoglycoside, quinolones, 3rd gen cephalosporine for 2 days then shift to oral for 14 days

Asymptomatic Bacteriuria Definition : a) presence of > 100,000 cfu/ ml of one or more pathogen on two consecutive midstream urine specimens  B) absence of symptoms attributable to UTI 

Asymptomatic Bacteriuria Risk Groups:  Elderly esp. women  Women with DM  Individuals with long term indwelling catheters  GUT abnormalities  Renal transplant 

Treatment for Asymptomatic Bacteriuria Persistent bacteriuria after catheter removal  Patients who will undergo instrumentation  DM  Abnormal Urinary tract 

UTI in pregnancy 

Asymptomatic Bacteriuria :

A) > 100,000 cfu/ ml with 1 or more organism in two consecutive mid stream urine  B) Absence of symptoms of UTI 

UTI in pregnancy SCREENING:  All pregnant women must be screened  Urinalysis – mid stream  Urine culture / sensitivity 

Acute Cystitis in Pregnancy Definition: urinary frequency, urgency , dysuria , bacteriuria ,gross hematuria but no fever, CVA tenderness  Pyuria of 8 or more pus cells in the urine 

Treatment for UTI in Pregnant women Safe Cephalosporin Co amoxyclav Ampicillin sulbactam

Caution Contraindicated Aminoglycoside Tetracycline TMP/SMX Quinolone TMP/ sulfa – third trimester

Recurrent UTI 

Episodes of acute uncomplicated UTI documented by urine culture occurring more than 2x a year in a non pregnant woman with no urinary tract abnormality

Treatment of Individual Episodes of UTI Grade A: Tx with Co amoxyclav, Cefradine, ciprofloxacin, - 7 days  Grade C = 3 day treatment with antibiotics for simple uncomplicated cystitis.  Intermittent self administered therapy- 4 tablets of TMP/SMX = single dose as soon as the symptoms appear. 

Recommended Prophylaxis Medications

Recommended dose for continuous Prophylaxis

Recommended dose for Post coital Prophylaxis

NitrofurantoinNorfloxacin TMP/smx Ciprofloxacin Ofloxacin

100 mg HS 200 mg HS 40/200mg HS 125 mg/HS

----200 mg HS 40/200mg HS 125 mg/HS 100 mg

Screening Recommendation Gross hematuria during UTI episodes  Obstructive symptoms  Persistent infections  Infections with urea splitting microbes  History of pyelonephritis  Suggestive or urolithiasis  Childhood UTI  Elevated Creatinine 

Choice of Screening Procedure KUB UTZ & plain abdomen  Referral to specialist 

Prophylaxis for Menopausal Women 

Use of estriol cream intravaginal 2x HS for 2 weeks then 2x weekly for 8 months Grade A

Complicated UTI 

Definition- significant bacteriuria in a setting of functional & anatomic abnormalities in the urinary tract.

Types of Complicated UTI Catheter Associated  UTI in diabetics  Long Term > 1 week  Renal transplantation  Anatomic abnormalities  UTI in AIDS  Neutropenic patients 

Antibiotic Regimen     

Oral Cirpofloxacin Nofloxacin Ofloxacin TMP/SMX

    

Dose 250 mg BID 14 d 400 mg BID 14 d 200 mg BID 14 d 160/800 BID 10 days

Antibiotic Regimen       

Parenteral Amoicillin Ceftazidime Ceftraiaxone Cirpofloxacine Imipenem-cilastin Ofloxacin

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Dose

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1 gm q 6 hrs IV gentamicin 3 gm/ kg /day OD IV

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1-2 gms q 8 hrs IV 1-2 gms q 8 hrs IV

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200-400 gms IV q 12 hrs 250-500 mg q 6-8 hrs Iv 200-400 mgs Q 12 hrs IV

UTI in Males Definition : Uncomplicated in Young Males First episode of symptomatic lower UTI in a male (15-40 yrs of age) otherwise healthy sexually active no clinical or historical evidence of structural or functional abnormality. Diagnosis: significant pyuria=> 10 WBC/ mm3 or 5 wbc /HPF 

Diagnostic Work up Urinalysis /urine culture  Imaging proedures 

Treatment TMX/SMX Fluroquinolone  Choice of antibiotic is based on sensitivity patterns 

Prostatitis Acute  Definition: febrile illness with abrupt onset ofn chills, low back & perinial pain , generalized malaise and prostration, irritative voiding symptoms, dysuria, nosturia & frequency 7 urgency. Rectal examination – marked tenderness if the prostate . 

Prostatitis Chronic  Definition:varying degrees of irritative voiding & pain perceived in various sites , suprapubic, perineal, low back, scrotal, penile & inner thighs. 

Diagnosis Expressed prostatic secretions ( EPS)> 10 wbc/ hpf presence of lipid laden macrophages is more prostate specific .  Triple voided urine test- quantitative bacterial colony count of ( EPS) & the next 5-10 ml of urine significantly exceed those of the Urethral & bladder and should be 1 log. 

Treatment Acute: TMP/ SMX=( 160/800 mg)  Fluoroquinolone start while waiting for the result of C/S  TX = 30 days to prevent chronicity  Seriously ill= hospitalized – parenteral ampicillin – aminoglycoside or fluoroquinolone  Refer to urologist 

Treatment        

Chronic :TMP/ SMX=( 160/800 mg) Fluoroquinolone Given for 2-3 months to prevent chronicity Recalcitrant cases- radical TURP Hot sitz bath Antiinflammatory agents Prostatic massage Long term low dose suppressive therapy = TMP/SMX 80/400 mg once daily

Prevention of Catheter Associated UTI Personnel:  Only persons trained in correct aseptic technique of catheter insertion 7 care should handle urinary catheter  Hand washing should be dome immediately before & after insertion 

Prevention of Catheter Associated UTI   

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

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The catheter Limit catheter use to carefully selected patients Should be inserted using aseptic technique & sterile equipment Maintain a sterile , closed catheter system at all times Urine specimen should be obtained aseptically without opening the catheter junction. Maintain unobstructed & adequate urine outflow at all times.

Prevention of Catheter Associated UTI The catheter  Do not change catheters at arbitrary fixed intervals  Remove catheter as soon as possible 

Prevention of Catheter Associated UTI     

Method to prevent endogenous infection –Daily meatal care is not recommended Method to prevent exogenous infection Irrigation of the bladder with antimicrobial agents is not useful Instillation of disinfectants into the bag & the use of antireflux valves & vents are not helpful Segregate infected from uninfected catheterized patients.

Bacteriologic monitoring and treatment of asymptomatic bacteriuria to prevent complications . 2nd prevention 



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Regular bacteriologic monitoring of catheterized patients is not recommended Use of systemic antibiotic prophylaxis in catheterized patient is discouraged. Patients at high risk of complications of catheterassociated bacteriuria , such as renal transplant & granulocytopenic patients may benefit from antibiotic prophylaxis.

Goal



Reduction of Morbidity and Mortality From Kidney Diseases

Health Status Objectives •

Reduce the occurrence of kidney diseases and incidence rate of ESRD to 3,000 cases a year. ( baseline 6, 500 yearly deaths secondary to various kidney diseases, 1998 DOH)

Risk Reduction Objectives •

b) c) d) e) f) g) h) i)

Increase awareness and practice of preventing renal diseases which includes: Adequate water intake, Balanced diet Personal hygiene moderate exercise BP check-up complete immunization management of throat and skin infections regular urinalysis) among high risk groups to 80 percent.

Risk Reduction Objective •

•

Increase awareness of the signs and symptoms of kidney disease (e.g. edema, high BP) to 75 percent. Increase the proportion of school children, adolescent and young adults routinely screened for urinary tract infections, diabetes and kidney disease to 75 percent.

Risk Reduction Objective •

•

Increase the proportion of diabetic patients who receive annual screening tests for microalbuminuria to 70 percent those who receive adequate treatment with ACE-inhibitors and low protein diet for the prevention and control of nephropathy to 50 percent. (Baseline: less than 10 percent are screened for microalbuminuria in 1998: baseline data on adequate treatment is established in 2000)

Risk Reduction Objective 



Increase the proportion of hypertensive individuals screened at the time of initial evaluation for the presence of renal disease (proteinuria, creatinine, BUN) to 80 percent. Increase the proportion of patients with chronic renal disease with optimum blood pressure control of <130/85 to more than 50 percent and yearly monitoring of renal function (proteinuria, hematuria, and serum creatinine) to 60 percent.

Risk Reduction Objective •

Reduce the prevalence of ESRD due to chronic glomerulonephritis to 32 percent (baseline 47 percent), chronic pyelonephritis to 11 percent (baseline 17 percent), diabetes nephropathy to 9 percent (baseline 13 percent) and hypertensive nephrosclerosis to 2 percent (baseline 5 percent) through increased screening, early detection and treatment.

Service and protection Objectives •

•

Increase early referral of abnormality urinary findings to nephrologists for early and adequate management and monitoring to 50 percent. Improve access and median waiting time for renal transplantation.

Service and protection Objectives •

•

Increase organ donation for renal transplantation to 300 donors a year ( Baseline 7 donors in 1993, NKTI) Increase the proportion of primary care providers who routinely counsel their patients about the effects of chronic health conditions (CGN, diabetes, hypertension) on the development and progression of renal disease to 75 percent.

Service and protection Objectives •

Upgrade the capabilities of regional hospitals and facilities that cater to kidney patients for primary, secondary and tertiary care to 90 percent.

Summary 1. Described the present health status of kidney problem in the Philippines.  2.Reviewed the common types of kidney diseases.  3.Described the national objectives for the control and prevention of kidney diseases. 