Diagnostic de l’insuffisance rénale chronique chez l’adulte - Chronic renal failure diagnosis - Guidelines

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Posted on Sep 01 2002 These guidelines about the definition and diagnosis of chronic renal failure (CRF)cover the following issues: Methods used to assess renal function. Normal glomerular filtration rate values, and age-related variation. Definitions of renal disease and renal failure. Diagnosis of renal failure. Organisation of patient follow-up. Situations in which renal failure or renal disease should be looked for. They do not deal with: The management of CRF ans its complications. Progression of CRF. Posted on Sep 01 2002

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                          D IAGNOSIS OF CHRONIC RENAL FAILURE IN ADULTS         September 2002

                     

 

Guidelines Department  

Diagnosis of chronic renal failure in adults

                                      All rights of translation, and lactation and reproduction by any means, are reserved, for all countries. Any reproduction of representation of this work, in whole or in part, by whatever means, made without the permission of ANAES is illegal and constitutes an infringement of copyright. In accordance with the provisions of the Intellectual Property Code, only the following are permitted: 1) reproduction which is strictly for the purpose of the private use of the person making the copy and not intended for collective use, and 2) quotation of short passages which are justified as being for purposes of a scientific nature or for illustration of the work in which they are incorporated.   This document was produced in September 2002. It may be ordered (including carriage) from:   Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES) Service Communication 159, rue Nationale 75640 Paris Cedex 13 France –Tel.: [phone] –Fax: [phone] Ó2002. Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES) ISBN: Price: €  

 

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Diagnosis of chronic renal failure in adults

  These guidelines were produced at the request of theCollège Universitaire des Enseignants en Néphrologie, using the method described in the guide “Clinical Practice Guidelines - Methodology to be used in France, 1999”, published by ANAES. The following learned societies were consulted:   Agence Française de Sécurité Sanitaire des Produits de Santé Association des Diététiciens de Langue Française Association Pédagogique Nationale pour l’Enseignement de la Thérapeutique  Collège National des Enseignants en Néphrologie Collège Universitaire des Enseignants en Néphrologie Société de Formation Thérapeutique du Généraliste Société Française de Biologie Clinique Société Française de Gérontologie Société Française de Médecine Générale Société Francophone de Dialyse Société Nationale Française de Médecine Interne Société Nationale de Médecine Générale Société de Néphrologie.   The work was co-ordinated by Dr. Sabine Laversin under the supervision of Dr. Patrice Dosquet.   Documentary research was carried out by Christine Devaud, with the assistance of Maud Lefèvre.   Secretarial services were provided by Élodie Sallez.   The National Agency for Accreditation and Evaluation in Health would like to thank the members of the Steering Committee, the Working Group, the Peer Review Group and the members of its Scientific Council, who took part in this project.

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Diagnosis of chronic renal failure in adults

S TEERING COMMITTEE  

Dr. Jean-Louis Acquaviva, general practitioner, Le Cannet-des-Maures Dr. Pierre-Louis Caraman, nephrologist, Thionville  Dr. Évelyne Carre, general practitioner, Reims Professor Jacques Chanard, nephrologist, Reims Dr. Raymond Frayssinet, nephrologist, Aix-en- Provence     W ORKING GROUP  

Professor Maurice Laville, nephrologist, Lyon Professor Bruno Moulin, nephrologist, Strasbourg  Professor Pierre Ronco, nephrologist, Paris Professor Armelle Tilly-Gentric, specialist in internal medicine, geriatrician, Brest

Professor Claire Pouteil-Noble, nephrologist, Pierre-Bénite –Chairman of the working group Dr. Catherine Lasseur, nephrologist, Bordeaux –Report coordinator   Dr. Évelyne Carré, general practitioner, Reims Dr. Marc Froissart, nephrologist, Paris Dr. Jean-Pierre Charmes, geriatrician/nephro- Dr. Samy Hadjadj, endocrinologist/diabeto- logist, Limoges logist, Poitiers Dr. Jean-François Dézier, laboratory analyst, Dr. Catherine Paillole, cardiologist, Paris Bain-de-Bretagne Professor Jérôme hrologist, Paris Dr. Éric Drahi, general practitioner, Saint-Jean-Dr. Paul Stroumz   a, R  n os e s p e h r r t, o   l n o e g p ist, Marseille  de-Braye        P EER REVIEW GROUP  

Dr. Jean-Louis Acquaviva, general practitioner, Le Cannet-des-Maures Dr. Norbert Balarac, endocrinologist, Saint- Laurent-du-Var  Dr. Benoît Barrou, urologist, Paris Professor Joël Belmin, specialist in internal medicine, geriatrician, Ivry-sur-Seine Dr. Michel Béruard, specialist in internal medicine, intensivist, Villeurbanne Dr. Pascal Bindi, nephrologist, Verdun Dr. Guillaume Bobrie, nephrologist, Paris Dr. Jean-Louis Bouchet, nephrologist, Bordeaux Dr. Georges Brillet, nephrologist, Chateauroux Professor Bernard Canaud, nephrologist, Montpellier  Dr. Pierre-Louis Caraman, nephrologist, Thionville  Professor Jacques Chanard, nephrologist, Reims Dr. Jean-Pierre Clavel, laboratory analyst, Nogent-sur-Marne 

Professor Christian Combe, nephrologist, Bordeaux  Professor Daniel Cordonnier, nephrologist, Grenoble  Dr. Denis Cuvelier, specialist in internal medicine/nephrologist, Rouvroy Dr. Philippe de Chazournes, general practitioner, Saint-Denis-la-Réunion  Dr. Alexandre Del Corso, laboratory analyst, Paris Dr. Michel Delahousse, nephrologist, Suresnes Dr. Gérard Derrie n, specialist in internal medicine, Arras Professor Patrice Deteix, nephrologist, Clermont- Ferrand Dr. Jean-Marc Dueymes, nephrologist, Brest Dr. François Dumel, general practitioner, Audincourt  Professor Denis Fouque, nephrologist, Lyon Dr. Bruno Fouqueray, nephrologist, Paris

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Diagnosis of chronic renal failure in adults

Dr. Raymond Frayssinet, nephrologist, Aix-en- Provence Professor Michel Godin, nephrologist, Rouen P m r e o d f i e c s i s n o e r /   g R er é i g a i t s r   ic G ia o n n ,  th S i a e i r n , t   - s É pecialist in internal  tienne Professor Nicolas Grenier, radiologist, Bordeaux Dr. Jean-Pierre Grunfeld, nephrologist, Paris Dr. Anne Gruson, ANAES Scientific Council, Paris Professor Serge Halimi, diabetologist, Grenoble Professor Thierry Hannedouche, nephrologist, Strasbourg  Dr. Patrick Herrmann, general practitioner, Ebersheim Dr. Jean-Pierre Hillebrant, urologist, Arras Bernadette Hym, biochemist, Thionville Dr. Gérard Janin, nephrologist, Mâcon, Professor Paul Jungers, nephrologist, Paris Professor Michèle Kessler, nephrologist, Vandoeuvre-lès-Nancy  Dr. Anne Kolko-Labadens, nephrologist, Paris Dr. Jean-Louis Lacombe, nephrologist, Toulouse Dr. Paul Landais, ANAES Scientific Council, Paris Dr. Bruno Lanson, laboratory analyst, Pont- L’Abbé  Dr. Sylvie Lavaud, nephrologist, Reims Professor Maurice Laville, nephrologist, Lyon Dr. Christian Lemaire, nephrologist, Roubaix Dr. Claudie Locquet, general practitioner, Plourivo Professor Denis Lyonnet, radiologist, Lyon Dr. Jacques Maire, specialist in internal medicine, Dijon Dr. Alain Marchal, laboratory analyst, Dole Dr. Jean-Luc Mas, general practitioner, Bourgoin-Jallieu  Professor Françoise Mignon, nephrologist, Paris  

Françoise Moreau, laboratory analyst, Paris Professor Bruno Moulin, nephrologist, Strasbourg  Dr. Josette Pengloan, nephrologist, Tours Dr. Armand Perret-Liaudet, biochemist, Lyon Professor François Piette, specialist in internal medicine/geriatrician, Ivry-sur-Seine Dr. Joseph Pollini, nephrologist, Avignon Professor Jacques Pourrat, nephrologist, Toulouse Dr. Bertrand Prouff, general practitioner, Anglet Dr. Catherine Quere-Maurouard, nephrologist, Alençon Professor Muriel Rainfray, specialist in internal medicine, geriatrician, Pessac Dr. Patrick Rispal, specialist in internal medicine, Agen Professor Pierre Ronco, nephrologist, Paris Dr. Emmanuel Roubertie, general practitioner, expert in bodily injury, Vendôme Professor Jean-Philippe Ryckelynck, nephrologist, Caen Dr. Jean-Marie Schneider, laboratory analyst, La Ciotat Dr. Sophie Seronie -Vivien, laboratory analyst, Toulouse Dr. Roland Servel, general practitioner, Vitry-le- François  Dr. Bénédicte Stengel, epidemiologist, Villejuif Professor Michel Sternberg, biochemist/ n D e r p .  h É ro i l c o   g T ist, Paris  r hervet, nephrologist, Paris Professor Armelle Tilly-Gentric, specialist in internal medicine/geriatrician, Brest Dr. Philippe Vanhille, specialist in internal medicine/nephrologist, Valenciennes Dr. Anne Vassault, laboratory analyst, Paris Dr. Jean-Marie Vetel, geriatrician, Le Mans

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G U

 

IDELINES   

Diagnosis of chronic renal failure in adults

The aim of these guidelines on diagnosing chronic renal failure (CRF) in adults is to help the practitioner recognise early renal failure and so encourage early treatment of patients with pre-end-stage chronic renal failure.   Guidelines are graded A, B or C according to the following system: ∙ A grade A guideline is based on scientific evidence established by trials of a high level of evidence, for example randomised controlled trials of high power and free of major bias, and/or meta-analyses of randomised controlled trials or decision analyses based on properly conducted studies; ∙ A grade B guideline is based on presumption of a scientific foundation derived from studies of an intermediate level of evidence, for example randomised controlled trials of low power, well-conducted non-randomised controlled trials or cohort studies; ∙ is based on studies of a lower level of evidence, forA grade C guideline example case-control studies or case series.  In the absence of scientific evidence, the guidelines are based on agreement among professionals.   Background   Chronic renal failure is a public health problem in France.   ∙  pre-end-stageAlthough there are no accurate figures for the current prevalence of chronic renal failure, the prevalence of end-stage renal disease (ESRD) treated with dialysis has been estimated as 400 per million inhabitants, and its incidence as 100 per million inhabitants. Both prevalence and incidence are rising. Vascular and diabetic renal disease account for 40% of cases of end-stage renal failure;   ∙ The global cost of treating ESRD estimated to be 2% of all health expenditure, is benefitting approximately 0.75‰ of the total French population;

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From 20 to 35% of patients admitted for dialysis were referred to a nephrologist less than 6 months before starting dialysis (grade C). This delay in initiating treatment for renal disease is harmful to the patient. Consequences include a higher rate of emergency first dialysis, more temporary vascular access during the first dialysis session, and a significantly longer initial stay in hospital (grade C). Delay in starting treatment can be explained by a number of factors, such as the generally asymptomatic nature of renal failure, advanced age (grade C), presence of concomitant disease (grade C), and factors related to the doctor and the patient (fear of dialysis, refusal to see a nephrologist, first consultation at advanced stage of renal failure).   These data, together with the current lack of consensus on a definition of pre-end- stage chronic renal failure, have led to the drafting of guidelines on the definition and diagnosis of CRF. These guidelines cover the following issues:

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I.

Diagnosis of chronic renal failure in adults

I Methods used to assess renal function II Normal glomerular filtration rate (GFR) values, and age-related variation III Definitions of renal disease and renal failure IV Diagnosis of renal failure V Organisation of patient follow- up VI Situations in which renal failure or renal disease should be looked for. The y do not deal with: -the management of CRF and its complications; -progression of CRF.     M ETHODS USED TO ASSESS RENAL FUNCTION   Renal function is measured by assessment of glomerular filtration rate (GFR). This may be measured or estimated: - Methods for measuring GFR clearance, isotopic method, iohexol) are (inulin complicated to perform and require special facilities. This limits their use in clinical practice; - Estimating GFR measurement of serum creatinine and the Cockcroft-relies on the   Gault formula (Box 1). In current clinical practice, the Cockcroft-Gault formula should be used to estimate GFR in all patients.    

Box 1. Cockcroft-Gault formula   - with serum creatinine expressed as mg/L:  in men: GFR (ml/min) = [(140-age)] x weight / 7.2 x serum creatinine in mg/L], in women: GFR (ml/min) = [(140-age)] x weight / 7.2 x serum creatinine in mg/L] x 0.85   - with serum creatinine expressed as µmol/l  GFR (ml/min) = [(140-age) x weight / serum creatinine in µmol/l] x k, where k = 1.23 for men, 1.04 for women.   (weight in kg, age in years)

  In adults, normalisation of body surface area (see Annex 1) improves the predictive power of the formula, but the patient's height has to be known.   The power of the Cockcroft-Gault formula in obese patients (BMI > 30 kg/m²) is not known, and it has been not been thoroughly evaluated in the elderly ( > 75 years). Further data, i.e. GFR measurements, are needed to define the threshold of renal failure in these two populations (agreement among professionals).   It is recommended that laboratory analysts should provide an estimation of GFR value using the Cockcroft-Gault formula for every request for serum creatinine. This assumes that they have been sent the patient's age, weight and gender (agreement among professionals).

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Diagnosis of chronic renal failure in adults

  Serum creatinine is an imperfect marker of GFR but has warning value ; 85% of adults with GFR <  60ml3m.7/1in/m 2 have serum creatinine values: > 137 µmol/l (15.4 mg/l) for men >104 µmol/l (11.7 mg/l) for women (grade B).   II. N ORMAL GFR VALUES AND AGE - RELATED VARIATION   There are few data on normal GFR values in the general population, and these are mainly based on estimation rather than measurement of GFR. GFR may be estimated for a subject aged 40 as approximately 120± 15 ml/min/1.73m². Decrease in GFR with age seems to vary between individuals and between populations.   III.   D EFINITIONS OF CHRONIC RENAL DISEASE AND CHRONIC RENAL FAILUR E   CRF is defined as a permanent reduction in glomerular filtration rate. CRF is secondary to renal disease.   The proposed definition implies a treatment strategy according to GF R value and any other indicators of renal impairment that may be present (Box 2 and Annex 2).   Box 2. Definition of markers of renal dysfunction   Microalbuminuria   20-200 µg/min or 30-300 mg/24 hours in type 1 diabetics   or albuminuria/creatinuria ratio > 2 mg/mmol   > 300 mg/24 hours or proteinuria/creatininuria ratio > 200 mg/g   RBC > 10/ 3 or 10 000/ml mm   WBC > 10/mm 3 or 10 000/ml   asymmetric kidney size, irregular margins, small kidneys or large polycystic kidneys, nephrocalcinosis, stones, hydronephrosis    

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Proteinuria  

Abnormal haematuria  

Abnormal leukocyturia  

Abnormal findings on renal ultrasound  

Irrespective of GFR value, if biological markers of renal dysfunction and/or abnormal renal imaging findings (Box 2) persist for more than 3 months, the patient has renal disease which requires an aetiological diagnosis and/or renal monitoring. A GFR value of < 60 ml/min/1.73 m² indisputably renal failure, whether or not is there are any concomitant associated renal markers (biological and/or morphological and/or histological).

Patients with GFR of 60 - 89 ml/min/1.73 m² (N –2SD) -should be regarded as having chronic renal disease if markers of renal dysfunction persist for more than 3 months;

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IV.

Diagnosis of chronic renal failure in adults

-monitoring if there are no markers of renalshould undergo renal function dysfunction as there are insufficient epidemiological data to confirm a diagnosis of renal failure or chronic renal disease.   A classification of severity of renal disease and renal failure is given in Table 1.   Table 1.Proposed classification of chronic renal disease and severity of chronic renal failure   Stage Definition GFR (ml/min/1.73 m 2 )   1 Chronic renal disease*    

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2 Moderate renal failure 30-59 3  15-29Severe renal failure 4 End-stage renal failure †  15 < * biological and/or histological renal abnormalities and/or abnormal renal imaging findings   †  m² independent ofrenal failure is defined as an estimated creatinine clearance of < 15 ml/min/1.73end-stage start of renal replacement therapy (dialysis or transplantation).     The indication for renal replacement therapy (dialysis or transplantation) depends on GFR value and clinical situation. The ANAES 1996 guidelines “Indications de l’épuration extrarénale dans l’insuffisance rénale chronique(Indications for dialysis in chronic renal failure)” state: “dialysis therapy should be started when the first clinical manifestations of end-stage chronic renal failure appear i.e., normally, when creatinine clearance falls below 10 ml/min. Treatment sho uld be started in any patient whose creatinine clearance reaches 5 ml/min”.     D IAGNOSIS OF CHRONIC RENAL FAILURE   The following 3-step procedure is recommended when renal failure is discovered.   (i) Confirm renal failure Renal failure must be confirmed by looking for factors that could modify the serum creatinine concentration, such as interference by other substances, drugs or otherwise, use of drugs affecting tubular secretion of creatinine (cimetidine, trimethoprim) or circumstances of the assay. If any doubt remains, a second estimation of GFR by the Cockcroft–Gault formula is recommended. Serum creatinine should be determined using the same assay method and, if possible, in the same laboratory. If doubts persist, GFR should be measured.

(ii) Eliminate acute renal failure and confirm that disease is chronic If serum creatinine is raised and estimated GFR decreased, the following should be investigated: ∙ functional renal failure, particularly in elderly subjects; ∙  emergency urological and renal workup, including: requiringacute renal failure -obstruction; -drug-related cause (iodinated contrast media, ACE inhibitors, angiotensin II receptor antagonists, nonsteroidal anti- inflammatories, aminosides, etc.);

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Diagnosis of chronic renal failure in adults

-rapidly progressing glomerulonephritis (rapidly progressing renal failure, proteinuria, haematuria, extrarenal signs); -a vascular origin. Factors suggesting that renal failure is chronic are: ∙ Family history of kidney disease, personal history of diabetes, hypertension, recurrent upper urinary tract infections, urological disease, atheromatous disease, chronic use of nephrotoxic drugs; ∙ history of proteinuria, haematuria, raised serum creatinine; ∙ presence of normocytic normochromic non-regenerative anaemia or of hypocalcaemia; ∙ size on imaging (bipolar diameter < 10 cm on renal ultrasound).reduced kidney However, kidney size may not be reduced if the original renal disease was diabetes, amyloidosis, and it may even be increased in the event of polycystic kidney.  Renal failure is classified as chronic when it has been present for at least three months and is not reversible.

(iii) Confirm the aetiological diagnosis The aetiology of renal failure should routinely be investigated, as identification of the cause may lead to specific treatment which will be more likely to be effective the earlier it is started.   Factors guiding the diagnosis will be obtained from history-taking, clinical examination, and imaging and other further investigations. They are given in Table 2.   After this workup, the opinion of a nephrologist should be sought to help decide whether the origin is glomerular, tubular or interstitial, or vascular (Table 3).   The aetiological diagnosis of CRF may require further tests such as urinary protein electrophoresis, urinary protein immunofixation, Doppler ultrasound of the renal arteries, renal biopsy, cystography, intravenous urography, CT scan with or without contrast medium, MRI with or without gadolinium, renal scintigraphy, renal arteriography which should be recommended only as an aid to deciding on treatment (decision on revascularisation). Imaging studies not involving injection of iodinated contrast medium should be preferred. Injection of iodine exposes the patient to the risk of aggravating the renal failure.      

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Diagnosis of chronic renal failure in adults

Table 2.Initial workup after discovery of chronic renal failure   History-taking Clinical examination Look for   Look for      • Family history of renal disease - hypertension, vascular murmur in major • Personal history of arteries, absence of peripheral pulse;   -  diabetes, hypertension, atheromatous disease;-  oedema, kidneys palpable, urological -  recurrent upper urinary tract infections,  (bladder distension, internal obstruction uropathy, stones;  pelvic examination); -  systemic disease or autoimmune disease; -  extrarenal signs of systemic disease. -gout;   - proteinuria, haematuria .   • Chronic or intermittent use of potentially • Urine reagent strip during the nephrotoxic drugs:nonsteroidal anti- consultation to test for:  inflammatories, analgesics, lithium, calcineurin -; iataruahme inhibitors (cyclosporin, tacrolimus), gold salts, - ;aprrinueiot D-penicillamine, certain forms of chemotherapy, - auelirutycok ; certain anti-viral agents, etc. -nitrites, suggesting urine infection • Exposure to toxic substances at work:lead, caused by Gram-negative cadmium.  organisms.     

 

Laboratory tests and imaging studies

Blood biochemistry • Serum protein electrophoresis • Fasting blood glucose:diabetes is defined as fasting blood glucose (after fasting for at least 8 h)³1.26 g/l (7 mmol/l) confirmed by a second test. Urine tests • 24 h proteinuria(combined with determination of 24 h   creatininuria, which validates the quality of the 24-h urine sample) or proteinuria/creatininuria ratio on the urine sample if 24-h collection urine is not possible. • Quantitative urine microscopy and cytology performed on fresh urine:  -to detect and quantify haematuria (red blood cell count per ml); leukocyturia (white blood cell count per ml); -  to look for casts. Imaging • Renal ultrasound: kidney size, asymmetry, irregular margins, large polycystic kidneys, nephrocalcinosis, stones, hydronephrosis, cyst(s), tumour(s). • Bladder ultrasound: abnormalities of the lower urinary tract, post-void residual urine. • Plain abdominal film: stones, arterial calcification.  

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