Chronic Kidney DiseaseChronic Kidney DiseaseJacqueline Annand – CKD NurseJacqueline Annand – CKD Nurse

Mary Simpson – CKD NurseMary Simpson – CKD Nurse

Joyce Mackie – Pre Joyce Mackie – Pre Dialysis/Transplant liaison SisterDialysis/Transplant liaison Sister

Chronic Kidney Disease (CKD), is a progressive loss of renal function over a period of months or years.

Chronic Renal Failure/Established Renal Failure (CRF/ERF) is complete, or almost complete failure of the kidneys to function.

What is CKD?

Stages of CKDStages of CKDStagea GFR

(ml/min/1.73 m2)Description

1 90 Normal or increased GFR, with other evidence of kidney damage

2 60–89 Slight decrease in GFR, with other evidence of kidney damage

3A 45–59 Moderate decrease in GFR, with or without other evidence of kidney damage3B 30–44

4 15–29 Severe decrease in GFR, with or without other evidence of kidney damage

5 < 15 Established renal failure

a Use the suffix (p) to denote the presence of proteinuria when staging CKD (recommendation 1.2.1).

Causes of CKDCauses of CKD

HypertensionHypertension Diabetic nephropathyDiabetic nephropathy GlomerulonephritisGlomerulonephritis Hereditary disease – APKDHereditary disease – APKD Analgesic – nsaidAnalgesic – nsaid Mechanical obstruction – ie prostateMechanical obstruction – ie prostate Ageing processAgeing process

Scope and Range Scope and Range

The Renal Service provides 24hr specialist Renal The Renal Service provides 24hr specialist Renal care to patients from Grampian, Orkney & Shetland.care to patients from Grampian, Orkney & Shetland.

It caters for those suffering from Acute Renal Failure It caters for those suffering from Acute Renal Failure (ARF) and Chronic Renal Failure (CRF), together with (ARF) and Chronic Renal Failure (CRF), together with other nephrological problems, during investigation, other nephrological problems, during investigation, diagnosis, treatment of their condition and offers diagnosis, treatment of their condition and offers specialist palliative care.specialist palliative care.

The main Dialysis Unit and Renal Medical Ward are The main Dialysis Unit and Renal Medical Ward are situated within Aberdeen Royal Infirmary and there situated within Aberdeen Royal Infirmary and there are Satellite Dialysis Units at Elgin, Peterhead, are Satellite Dialysis Units at Elgin, Peterhead, Portsoy & Inverurie. There are also satellite Portsoy & Inverurie. There are also satellite facilities on Orkney & Shetlandfacilities on Orkney & Shetland

Pre-Dialysis & Transplant Clinics are held at within Pre-Dialysis & Transplant Clinics are held at within the main Dialysis Unit & Satellite Units and other the main Dialysis Unit & Satellite Units and other Renal / Nephrology clinics are held at Woolmanhill Renal / Nephrology clinics are held at Woolmanhill

The Renal Transplant Service is provided by NHS The Renal Transplant Service is provided by NHS Lothian. Joint Pre–transplant assessment clinics Lothian. Joint Pre–transplant assessment clinics are held at Aberdeen Royal Infirmary, are held at Aberdeen Royal Infirmary, approximately every 6 weeks in conjunction with approximately every 6 weeks in conjunction with colleagues from NHS Lothian. colleagues from NHS Lothian.

Conservative treatment and support is offered to Conservative treatment and support is offered to

patients, families and carers of those who decide patients, families and carers of those who decide not to undergo Renal Replacement Therapy (RRT).not to undergo Renal Replacement Therapy (RRT).

Local DemographicsLocal Demographics

ARIARI ElginElgin PeterheadPeterhead InverurieInverurie Banff Banff OrkneyOrkney Shetland Shetland Home Home Total 208Total 208

PDPD 36 36 Pre-RRT 106Pre-RRT 106 Transplant 222Transplant 222

Haemodialysis Diabetic

Peritoneal Dialysis Diabetic

Pre Dialysis Diabetic

Transplant Diabetic

CKD Facts & FiguresCKD Facts & Figures

1 in 10 people in the UK have CKD. 1 in 10 people in the UK have CKD. Patients with CKD are more likely to die Patients with CKD are more likely to die than go on to have dialysis.than go on to have dialysis.

Early recognition of CKD permits Early recognition of CKD permits intervention to alter the natural history of intervention to alter the natural history of the disease – nephro-protection, the disease – nephro-protection, cardiovascular protection. cardiovascular protection.

30% of patients with advanced CKD are 30% of patients with advanced CKD are referred late to nephrology services from referred late to nephrology services from primary and secondary care.primary and secondary care.

Referral rate doubled in some areas.Referral rate doubled in some areas.

Why Role Came AboutWhy Role Came About

2006 National Service Framework 2006 National Service Framework – Renal recommended that…– Renal recommended that…

eGFR (eGFR (estimatedestimated glomerular glomerular filtration rate) based on filtration rate) based on serum serum Creatinine level, age, sex, and Creatinine level, age, sex, and

race.race.

…….be the recommended formula .be the recommended formula used to detect CKDused to detect CKD

Job PurposeJob Purpose

To improve outcomes for patients with CKD, To improve outcomes for patients with CKD, by improving service and qualityby improving service and quality

Education of patients re BP/glycaemic Education of patients re BP/glycaemic control, medication compliance, control, medication compliance, supporting lifestyle changessupporting lifestyle changes

To enhance links with primary care in To enhance links with primary care in managing the CKD population in the managing the CKD population in the communitycommunity

Primary care visits, educational Primary care visits, educational sessions, meet the team sessionssessions, meet the team sessions

To provide education to those in primary To provide education to those in primary care who are dealing with this patient groupcare who are dealing with this patient group

GP practice visits, awareneGP practice visits, awareness sessions, ss sessions, contactable resourcecontactable resource

Job PurposeJob Purpose

To support medical personnelTo support medical personnel Back to back clinics with NephrologistsBack to back clinics with Nephrologists

To develop clinical expertiseTo develop clinical expertise Participate in delivery of research and Participate in delivery of research and

evidenced based careevidenced based care To be proactive in developing the roleTo be proactive in developing the role

Teaching/supervising members of MDT Teaching/supervising members of MDT including medical students, pre/post including medical students, pre/post registration nurses with regard to the registration nurses with regard to the complexities of CKD patient complexities of CKD patient managementmanagement

Our BackgroundOur Background

MaryMary 25 yrs renal variety 25 yrs renal variety

of posts from staff of posts from staff nurse, sister, clinic nurse, sister, clinic nurse to research nurse to research nursenurse

7 yrs urology 7 yrs urology researchresearch

CKD NurseCKD Nurse

JacquiJacqui 1 year assessment & 1 year assessment &

rehabilitationrehabilitation 14 years renal 14 years renal

(ward, outpatients (ward, outpatients haemodialysis, haemodialysis, research and research and anaemia)anaemia)

7 months 7 months secondment – clinical secondment – clinical educatoreducator

Here & Now!Here & Now!

Case presentation 1Case presentation 1

78 yr old woman78 yr old woman Hypertensive. Treated with amlodipineHypertensive. Treated with amlodipine BP 160/80BP 160/80 Creatinine 119 (eGFR 42)Creatinine 119 (eGFR 42) Urinalysis: trace of bloodUrinalysis: trace of blood

Clinic reviewClinic review

BP 140/80BP 140/80 Creatinine 170 (eGFR 27)Creatinine 170 (eGFR 27) Ramipril stoppedRamipril stopped 4 weeks later creatinine 127 (eGFR 38)4 weeks later creatinine 127 (eGFR 38)

All patients with CKD should have urinalysis: if proteinuria is detected it should be quantified by PCR. I suspect the patients she refers to "with CKD 4 or 5 who are reviewed at the renal clinic seem to have urinalysis done" are patients with no (or minimal) proteinuria on urinalysis, and hence the consultant does not quantify it at each clinic visit; or they are already maintained on appropriate treatment and the level of proteinuria is stable; or no other intervention is possible and the consultant therefore does not measure it. 

2) Quantifying proteinuria. As we discussed this is 2) Quantifying proteinuria. As we discussed this is not straightforward. Our Lab gives an upper limit not straightforward. Our Lab gives an upper limit for a "normal" PCR of 20mg/mmolcr - other for a "normal" PCR of 20mg/mmolcr - other hospitals may use 30 or 50. Therefore "proteinuria" hospitals may use 30 or 50. Therefore "proteinuria" is any level above an arbitary cut-off. In practice is any level above an arbitary cut-off. In practice the higher it is the more significant, and I am happy the higher it is the more significant, and I am happy to consider >50mg/mmol as "significant".to consider >50mg/mmol as "significant".

All patients with CKD & proteinuria should be All patients with CKD & proteinuria should be consideredconsidered for an ACE-I (but not appropriate for all). for an ACE-I (but not appropriate for all). The key target should be BP reduction.The key target should be BP reduction.

As always the level of proteinuria must be taken in As always the level of proteinuria must be taken in clinical context. I would want to see a 30-year-old clinical context. I would want to see a 30-year-old with a PCR of 80; but would not want to see a 80-with a PCR of 80; but would not want to see a 80-year-old diabetic with a stable PCR of 80, without year-old diabetic with a stable PCR of 80, without other relevant renal problems.other relevant renal problems.

GFR is inversely related to hypertension and cardiovascular risk

Symptoms are unusual until GFR is less than 30mls/min/1.73m2

Complications including renal anaemia and bone disease are unusual until GFR is less than 30 mls/min/1.73m2

Early CKD is very common

Advanced CKD is relatively uncommon

The epidemiology and natural history of CKD is still largely unknown

Some facts regarding CKD