Renal Disease

sec_arr Appendix B:
Medical Evaluation of LEOs with CKD
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Appendix B. Medical Evaluation of LEOs with CKD

History1,27

  •  Prior renal disease 
  • Albuminuria hematuria, proteinuria
  • Genitourinary symptoms
  • Hypertension
  • Diabetes mellitus
  • Renal toxic medications
  • Rheumatological disease
  • Family history of renal disease 

Physical 

  • Blood pressure
  • Pulses
  • Heart murmur
  • Abdominal bruit
  • Peripheral pulses
  • Peripheral neuropathy
  • Arthropathy
  • Peripheral edema

Tests

  • eGFR1, 27, 28
  • Urinalysis
  • Electrolytes (BUN, creatinine)
  • Urine albumin/creatinine (mg/g)
  • Renal/abdominal US (renal/retroperitoneal masses), especially beginning at CKD stage 3.

Medical conditions that might cause a diminution in GFR*: 

  • Diabetes
  • Hypertension
  • Coronary artery disease
  • Peripheral arterial disease
  • Rheumatological disease
  • Personal history of prior renal disease (e.g., hematuria, proteinuria)
  • Renal toxic medications

*Evaluate these conditions per the specific LEO Guidance Chapters.

Stage of CKD 1,27

  • Stage 1 GFR>90 ml/min
  • Stage 2 GFR > 60 ml/min and < 90 ml/min
  • Stage 3 GFR > 30 ml/min and < 60 ml/min
  • Stage 4 GFR > 15 ml/min and < 30 ml/min
  • Stage 5 GFR < 15 ml/min (RRT needed)

Albuminuria

  • Stage 1 – urine albumin/creatinine < 30 mg/g
  • Stage 2 – 30- 299 mg/g
  • Stage 3 – > 299 mg/g

For those who wish to explore further references on the assessment of kidney function,29 derivation of the CKD EPI equation30 and/or an alternate online CKD EPI equation are referenced.31

The US Preventive Services Task Force (USPSTF) has not recommended screening for CKD and/or for bacteriuria in asymptomatic adults.31 However, authors have recommended periodic office dipstick urinalysis testing to detect protein, blood, and glucose.32, 33 For renal disease, patients are staged according to both GFR and degree of proteinuria. Both GFR and proteinuria have prognostic and functional significance.

Cognitive evaluation 

  • Set threshold of concern: 
    • First, determine the level of kidney dysfunction by estimated glomerular filtration rate (eGFR) possibly <60 or <45 ml/min per 1.73 m2,34 and 
    • urinary albumin/creatinine ratio (ACR). ACR of ≥5 mg/g was suggested by Sajjad et al.35 for inclusion of some mild range cognitive changes, but other studies suggest that a higher threshold for ACR such as ≥30 mg/g36 might be more applicable to more significant cognitive risks that might be of concern to you in occupational contexts.
  • Specify cognitive domains and measures: 
    • Studies of cognitive impairment in CKD use coarse cognitive screenings. Resources are available at the evaluators’ discretion, such as the Mini-Mental State Exam (MMSE) or a short variant of the MMSE, and measures with strong demands on verbal memory, basic attention/processing speed, and complex attention/executive functioning.
  • General cognitive functioning (choose 1 from below)
    • Mini-Mental State Exam
    • Montreal Cognitive Assessment (MoCA)
  • Verbal Memory (immediate and delayed recall and delayed recognition trials; choose 1 from below):
    • California Verbal Learning Test-2 (CVLT-2)
    • Wechsler Memory Scales-4 (WMS-4) Word Lists
    • Rey Auditory Verbal Learning Test (RAVLT)
  • Basic attention/processing speed (choose 1 from below):
    • Trail Making Test Part A
    • Digit Span forward
    • Grooved Pegboard Test
    • Purdue Pegboard Test
  • Complex Attention with a stronger executive component (choose 1 from below):
    • Symbol Digit Modalities Test
    • Stroop Color-Word Test
    • Controlled Oral Word Association—animal naming
    • Trail Making Test Part B
    • Digit Span backward
  • Advice to practitioners: 
    • Medical providers evaluating patients with CKD may use a basic cognitive screening such as MMSE or MoCa. Alternatively, a more complex evaluation may be performed by administering one test for each of the four cognitive domains above. Many instruments exist and other measures might be viewable acceptable beyond those specified above.