I wanted to post this article because chronic kidney disease (CKD) is prevalent in patients with CFS/ME and it's essential to have follow-up care to check for abnormalities. This article had the best information I've ever found in one place about what that follow-up care needs to be.
I was looking around the Internet for info on chronic kidney disease, and more specifically, what should be done when the estimated glomerular filtration rate (eGFR) is consistently below 60. (Mine is hovering around 60, but seems to bounce back and forth between 55 and 65, never quite reaching the status of "chronic kidney disease.") This articles speaks directly about what to do when the eGFR is consistently below 60.
The eGFR is calculated from a serum creatinine value. Even though one's creatinine can be in the normal reference range, the gold standard for staging kidney disease is to calculate the eGFR and determine where to go from there. Sometimes the eGFR is already calculated for you on your lab report, and if it's above 60, sometimes it will say just that, "above 60", as in "not to worry, dear."
Here's one online calculator so you can see how it's calculated:
http://www.kidney.org/professionals/KDOQI/gfr_calculator
That should give you some good background for this article, published by the British Columbia Medical Journal in 2008.
http://www.bcmj.org/article/demystifying-chronic-kidney-disease-clinical-caveats-family-physician
Demystifying chronic kidney disease: Clinical caveats for the family physician
I'm going to quote from the middle of the article:
What do I need to pay attention to in patients with CKD?
The following care objectives should be considered for patients with CKD. Clinicians should refer to the official BC guidelines on CKD for more detailed information.[4]
Blood pressure: Blood pressure should be measured at every visit, with a goal of BP <130/80 in all patients with CKD. An angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) are recommended as first-line therapy, and can be combined with close monitoring of serum creatinine and potassium to achieve BP and proteinuria goals.
Most patients with CKD will require more than two drugs to control BP.[10] It is important to be sure that patients are euvolemic, that is, not volume contracted, when started on an ACEI or an ARB.
eGFR: Kidney function should be measured at least every 6 months, with any change in patient status, and with the addition of medications that can affect kidney function. For example, serum creatinine and potassium levels should be measured within 2 weeks after initiation or dose-titration of an ACEI or ARB.
If a rise in serum creatinine of more than 20% or a fall in eGFR of more than 15% is observed, further measurements should be performed within 1 or 2 weeks. Often the kidney function stabilizes; if not, further consultation is warranted.
Of note, acute renal failure precipitated by an ACEI or ARB may indicate underlying renal artery stenosis; this is often accompanied by very good blood pressure control, and in the absence of other renal insults, referral to a specialist should be considered.
ACR: The patient’s albumin/creatinine ratio should be measured every 6 to 12 months with a goal of reducing protein excretion by 50% or more from baseline. While the number is not always consistent, it is the trend that is important.
Cardiovascular disease risk: Assessment for cardiovascular disease risk should be performed in all patients with CKD and managed in accordance with relevant guidelines.[11] Lipid profiles should be measured at least annually, and more often in those on therapy.
In those younger than 70, dyslipidemia should be aggressively treated with a goal of LDL <2.5 mmol/ L, and of TC/HDL <4.0. Currently, evidence for lipid targets is lacking in those older than 70.
In diabetics, measure blood glucose every 3 months with a target of HbA1c ≤7.0%. Be aware that long-acting sulfonyureas may be associated with hypoglycemia in patients with a GFR <60 mL/min. If this occurs, use a short-acting or non-sulfonyurea agent.
Encourage your patients with CKD who smoke to stop, and provide support when they are receptive to this idea. Counsel your CKD patient to maintain a healthy lifestyle, adequate nutrition, and normal BMI.
You should also encourage patient self-management, as patients with kidney disease have better outcomes if they take an active role in their care.
Conditions associated with CKD: Patients should be assessed for anemia, abnormalities of mineral metabolism, and malnutrition. A hematology profile (hemoglobin and transferrin saturation), mineral metabolism parameters (calcium, phosphate, and intact parathyroid hormone), and nutrition profile (albumin) should be measured at least annually, or more frequently with advanced kidney disease.
The goals of therapy for hemoglobin is a normal range for gender (if not on erythropoietin therapy), and 110 g/L to 125 g/L if on erythropoietin therapy. In BC currently, ordering these expensive medications is restricted.
Importantly, the majority of patients with lower eGFR values have a relative iron deficiency leading to anemia, thus it is reasonable to initiate iron therapy if transferrin saturation is less than 20% (e.g., ferrous fumarate up to 900 mg p.o. daily).
It is important to note that ferritin can be misleading; it’s an expensive test and not routinely recommended in CKD patients to assess iron stores. The goals of therapy for mineral metabolism and nutrition are to keep the associated laboratory parameters within a normal range.
Immunizations: Patients with CKD should receive influenza vaccine (annually), and pneumoncoccal vaccine (every decade). If the patient is being considered for dialysis, immunization against hepatitis B is recommended as response to this vaccine is more predictable at a higher level of GFR.[12]
Exposure to nephrotoxic medications: Aminoglycosides, nonsteroidal anti-inflammatories, and COX-2 inhibitors should be avoided in those with CKD Stage 3 or greater. These medications should also be used with extreme caution in patients with Stage 1 or 2 CKD.
