The management of renal problems in primary care

Hugh Gallagher

Consultant Nephrologist

St Helier Hospital

• The “epidemic” of CKD

• What is a typical CKD patient?

• A role for increasing primary care involvement?

• How can we achieve this?

• The “epidemic” of CKD

• What is a typical CKD patient?

• A role for increasing primary care involvement?

• How can we achieve this?

Nephrology workload

• “High” maintenance– Dialysis (HD/PD)– Predialysis– Acute renal failure– Acute transplantation– “Special”, eg vasculitis

• “Low” maintenance– CKD– Long term transplant

follow up– Hypertension– Others

Patient Volumes (1994-2003)

0

50

100

150

200

250

300

350

400

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Txps

CA

PD

HD

0

500

1000

1500

2000

2500

3000

3500

Nep

hrol

ogy

HD TXP CAPD NEPH

“Local health organisations can work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of glomerular filtration rate (eGFR), calculated and reported automatically by all clinical biochemistry laboratories.”

Renal NSF Part 2, Dept of Health, 2004

• MDRD formula– Age– Sex– Creatinine– Ethnicity (black vs. non-black)

• Cockcroft-Gault formula– Age– Sex– Creatinine– Weight

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150 46

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150 46

80 M 60 170

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150 46

80 M 60 170 26

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150 46

80 M 60 170 26

80 F 60 170

Age Sex Weight(kg)

Serumcreatinine(μmol/L)

EstimatedGFR

(ml/min)

60 M 70 150 46

80 M 60 170 26

80 F 60 170 22

K-DOQI Classification of CKD

Stage GFR(ml/min)

Description

1 > 90 1 Kidney damage withnormal or GFR

2 60-89 1 Kidney damage withmild GFR

3 30-59 Moderate GFR4 15-29 Severe GFR5 < 15 Kidney failureChronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

K-DOQI Classification of CKD

Stage GFR(ml/min)

Description Prevalence(%)

1 > 90 1 Kidney damage withnormal or GFR

3.3

2 60-89 1 Kidney damage withmild GFR

3.0

3 30-59 Moderate GFR 4.34 15-29 Severe GFR 0.25 < 15 Kidney failure 0.2Chronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

Prevalence of Unreferred CKD in East Kent

• East Kent population 601,000• Small ethnic population• Study period Oct 2000 - Sept 2002• Using opportunistic serum creatinine

– Monthly screening of Chemical Pathology Database

– Review after two months

• Males serum creatinine 180 mol/L

• Females serum creatinine 135 mol/l

• Approximate to GFR < 30-40ml/min/1.73m2

CKD definition

Prevalence 5554pmpMedian Age 82 (18-103)Median GFR 28.0 (3.6-42.8)41.8% Male17.8% diabetes

CRF PopulationCRF Population

Calculated GFR (mls/min)

40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5

N

umbe

r of

cas

es1600

1400

1200

1000

800

600

400

200

0

Prevalence 0.55%Median Age 82 (18-103)Median GFR 28.0 (3.6-42.8)41.8% Male17.8% diabetes

CKD population

Unreferred CRF population Unreferred CRF population

Median Age 83 (18-103)Median GFR 28.5 (4.1-42.8)39.2% Male17.7% Diabetes

Calculated GFR (mls/min)

40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5

N

umbe

r of

pat

ient

s1400

1200

1000

800

600

400

200

0

Prevalence 0.47%Median Age 83 (18-103)Median GFR 28.5 (4.1-42.8)39.2% Male17.7% Diabetes

Unreferred population

<0.0128.5

(4.1-42.8)

23.4

(4.8-39.8)eGFR (ml/min/1.73m)

<0.0160.843.8Women (%)

<0.0183 (18-103)70 (18-91)Age (yrs)

4708846Prevalence (pmp)

PUnreferredKnown

John et al AJKD 2004;43:825-835DOD/0604-04

Comparison of known and unreferred populations

In real money...

• GP practice 10,000 patients– Stage 3 CKD: 500 patients– Stage 4 CKD: 20 patients– Stage 5 CKD: 20 patients– Unreferred stage 4 and 5: 28 patients

• Renal unit, serving 1.8 million population– Unreferred stage 4 and stage 5: 5,100 patients

• The introduction of eGFR will facilitate early recognition of CKD

• It will also result in increased awareness of advanced CKD previously not recognised as such

• A “coping” strategy needs to be developed before eGFR reporting is introduced

• The “epidemic” of CKD

• What is a typical CKD patient?

• A role for increasing primary care involvement?

• How can we achieve this?

Causes of CKD in the elderly

25%

15%

20%

15%

10%

15%

Diabetes

Hypertension

Aetiology unknow n

Renovascular

Outf low obstruction

Other

Functional consequences of CKD

• Hypertension

• Anaemia

• Disorders of Ca/Pi/PTH metabolism– renal osteodystrophy– vascular calcification

Snapshot of a CKD population in primary care

• GFR estimated on patients from 12 practices in Surrey, Kent and Greater Manchester

• 19% of sample (5% population) stage 3-5 CKD• mean age 74 years (control 57 years)• 75% stage 3-5 (22% control) co-existing

circulatory disease• 25% stage 3-5 (men) prostatic disease• 15% stage 3-5 anaemic by WHO (4% requiring

treatment by European Best Practice guidelines)• 3% recorded as having a renal disease

Comorbidities in CKD

0%

20%

40%

60%

80%

100%

All cardiovascular

disease

Diabetes Ischaemic heart

disease

Heart failure Peripheral vascular

disease

Hypertension

No CKD

Stage 3 CKD

Stage 4 CKD

Stage 5 CKD

• The “epidemic” of CKD

• What is a typical CKD patient?

• A role for increased primary care involvement?

• How can we achieve this?

Most CKD patients are stable

Rate of GFR decline (ml/min/1.73m2/year) <2.0 2.0-2.9 3.0-3.9 4.0-4.9 >5.0 Age (years) <70 (%) 82 4 5 5 5 70-80 (%) 80 5 4 3 7 >80 (%) 77 6 3 4 10 All (%) 79 5 4 4 8

Cardiovascular diseases in CKD

Damage to the heart(Uraemic cardiomyopathy)

Damage to the arteries(Uraemic arteriopathy)

Uraemic Cardiomyopathy

•Thickening of the wall•Dilation of the heart•Myocardial scarring•Calcification•Conduction defects

Uraemic Arteriopathy

•Thickening of the wall•Atherosclerosis•Stiffening of the artery•Calcification

25-34 35-44 45-54 55-64 65-74 75-84 >85

Age

Ann

ual m

orta

lity

(%)

Adapted from Levey AS et al. Am J Kidney Dis 1998; 32: 853-906.

Cardiovascular Mortality Rates are Higher among Dialysis Patients

General population: maleGeneral population: female

Dialysis: maleDialysis: female

10

100

1

0.01

0.1

0.001

Go, A. S. et al. N Engl J Med 2004;351:1296-1305

Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization among 1,120,295 Ambulatory Adults, According to the Estimated GFR

• Most renal patients die of CV causes well before they reach ESRD

• Their management is therefore that of their CV risk

Risk factors

• CVS DISEASE– Hypertension– Dyslipidaemia– Smoking– Obesity– Lack of exercise

• PROGRESSION– Hypertension– Dyslipidaemia– Smoking– Obesity– Lack of exercise

Patient choice…..

“No added value” consultations

• “The BP today was too high at 160/90. I have not made any changes today but suggest you repeat it in 2 weeks….”

• Where are blood tests performed?

• Protocol-based nurse-led clinics

• IT support

• GMS contract

• The “epidemic” of CKD

• What is a typical CKD patient?

• A role for increasing primary care involvement?

• How can we achieve this?

Principles

• Collaborative approach between primary and secondary care

• Concise practice guidelines for referral and management

• Role for practice and community-based specialist nurses

• Support from nephrologists for all stages• Dedicated nephrology care for predialysis and

deteriorating

Dangers

• Late referral• Missing ARF• Undertreatment of renal anaemia and

abnormalities of bone biochemistry• Issues around clinical responsibility• Workload

Short-term goals

• Education• Pilot and issue guidelines for

– management of newly discovered abnormal eGFR in primary care

– management of CKD (including indications for referral) in primary care

• Implement eGFR reporting by St Helier laboratories

• Link the management of CKD to that of CV risk

Longer-term goals

• Specialist nurse-led community based renal clinics

• Protocol-based approach for management of renal anaemia and bone disease in the community

• Renegotiation of GMS contract• Commissioning arrangements

The nephrologist’s view

The GP’s view