CKDML/LH 17.3.10

Chronic Kidney Disease

• Are we correctly diagnosing CKD?

• Have we the correct patients on our CKD register?

• Are we managing them correctly?

Plan for today

Highlight a few issues around eGFRs

Review NICE and PACE guidance

Discuss how we diagnose and manage CKD

Identify and discuss any uncertain areas

Why introduce CKD QOF indicators?

• End stage renal failure is costly to treat, and its prevalence is increasing

• 30% of patients present late; they have worse outcomes and are more expensive to treat

• It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF

Risks of a low eGFR

Renal

• 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t)

Cardiovascular

• If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event

Possible symptoms (CKD 3 - 5)

• Tiredness

• Anorexia, nausea

• Weight loss

• Dry itchy skin

• Muscle cramps

• Ankle swelling, peri-orbital oedema

• Anaemia

NICE Sept 2008, Clinical Guideline 73

Offer CKD screening to at risk groups

• DM• Hypertensives• CVD• Multisystem diseases

e.g. SLE

• Structural renal tract disease e.g. stones, BPH

• FHx CKD 5 or hereditary kidney disease

• Long term NSAIDS

Testing eGFR

• GFR estimated from serum creatinine and age, using MDRD equation

• If abnormal, repeat the test to confirm

• Multiply eGFR result by 1.212 for African -Caribbean and African patients (Are we recording this correctly?)

eGFR and meat

• NICE specifically advises no meat for 12 hours before eGFR

• Are we doing this?

• How do we record it?

eGFRs and age

• eGFR is not validated in the >75s

(How many patients >75 have we coded with CKD 3?)

• From the age of 40 the eGFR declines by 1ml/min/yr

• NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.

Newly identified CKD

• Stage CKD on eGFR results

• Stage 1 > 90

• Stage 2 60 - 89

• Stage 3A 45 - 59

• Stage 3B 30 - 44

• Stage 4 15 - 29

• Stage 5 <15

eGFRs: ‘normal for age?’

eGFR

> 90 CKD 1

Normal renal function

60-89 CKD 2

45-59 CKD 3A

Impaired renal function

30-44 CKD 3B

15-29 CKD 4

Severely impaired

<15 CKD 5

eGFR /

Age18-29 30-39 40-49 50-59 60-69 70-79 80-89 Age

In yrs

Assess for proteinuria

• NICE advises ACR on first sample of the day (preferably)

• ACR abnormal if >30, in non diabetics• (Repeat to confirm if ACR >30 but <70)

• ACR abnormal if >2.5 in diabetic men

• ACR abnormal if >3.5 in diabetic women

Issues around proteinuria

• NICE also mentions PCRs (mg/mmol)(ACR of 30 = (approx) PCR of 50)

• But in Bradford they report PCIs (mg/mg), which correspond with 24hr urinary protein excretion

• PCR of 50 = PCI of 500 (i.e. divide by 10)

• Leeds/Bfd Biochem are considering changing to PCRs in the future, to fit with NICE

False positives

• Urinary Tract Infection

Do MSU if dipstix +ve for protein

• Menstrual contamination

• Benign orthostatic proteinuria

Assess for progressive CKD

• Check at least 3 eGFRs over at least 90 days

• Defined as a decline in eGFR of

>5 within 1 year, or >10 within 5 years

• Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction,

proteinuria and diabetes

Other baseline tests

For all• Dipstix for haematuria• CVD risk assessment • Consider DEXA scan

CKD 4 and 5• FBC and ferritin• Calcium, phosphate, PTH

Consider renal USS

• If CKD 4 or 5

• Progressive CKD

• Visible or persistent invisible haematuria

• Symptoms of urinary tract obstruction

• FHx polycystic kidney disease and >20yrs of age

Consider referral

• CKD 4 or 5 without diabetes

• ACR >70 in non diabetics

• Proteinuria (ACR>30) with haematuria

• Progressive CKD

• CKD and poorly controlled BP on 4 agents

• Suspected genetic renal disease or renal artery stenosis

Routine management

Lifestyle modification

• Smoking increases risk of progressive CKD

• Lose weight if obese

• Regular exercise

• Reduce salt if hypertensive

Routine management

Monitor eGFR

• CKD 3 6 monthly

• CKD 4 3 monthly

• CKD 5 6 weekly

Routine management

Control BP

• NICE target <140/90

• <130/80 if ACR >70

• <130/80 if diabetic

• QOF <140/85 for all

Routine management

Reduce proteinuria

• ACEIs first line

• ARBs if not tolerated

Routine management

ACEI or ARB:

• Diabetes + ACR (>2.5 men, or 3.5 women) (irrespective of hypertension or CKD stage)

• Non-Diabetic with CKD + HT + ACR >30

• Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)

Routine management

Routine anti-hypertensive treatment

• Non-diabetic + CDK + HT + ACR <30

(See NICE Hypertension guideline 34)

Routine management

CVD risk assessment • treat with a statin if CVD risk >20%

(SystmOne CVD risk calculator does NOT include adjustment for chronic renal disease, but QRISK2 does)

Immunizations• Influenza - annually• Pneumococcal - 5 yearly, due to declining

antibody levels

Routine management

Drugs• Check BNF Appendix 3: Renal Impairment

Test for anaemia• If Hb <11 first consider other causes of anaemia• Determine iron status – if serum ferritin <100

start oral iron• Consider referral for erythropoeisis stimulaing

agents (ESA’s)

Routine management

Manage bone conditions• Ca, PTH and phosphate if CKD 4 or 5• Offer biphosphonates to all “if indicated”• If indicated offer vitamin D supplements:- cholecalciferol or ergocalciferol in CKD3- alfacalcidol or calcitriol in CKD 4 and 5• If on vit D supplements they need to be

monitored

QOF indicators

• CKD1: Register of patients >18 yrs with CKD (stages 3 – 5)

• CKD2: % of pts with BP recorded in last 15 mths• CKD3: % of pts in whom last BP reading, in last

15 mths, is <140/85• CKD5: % of pts with HT + proteinuria on ACEI or

ARB (unless c/i or s/e recorded)• CKD6: % of pts with urine ACR (or PCR) test in

last 15 months

QOF indicators

• CKD points total = 38 points = £££

• CKD1 (reg) = 6 points

• CKD2 (bp) = 6 points

• CKD3 (bp controlled) = 11 points

• CKD5 (acei/arb) = 9 points

• CKD6 (acr) = 6 points