CKDChronic Kidney Disease

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CKD-Chronic Kidney Disease

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• Becky Allcock

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What is CKD?

• New term for chronic renal failure
• Classified into 5 stages according to eGFR
• Stage 1- eGFR gt90
• Stage 2- eGFR 60-89
• Stage 3- eGFR 30-59
• Stage 4- eGFR 15-29
• Stage 5- eGFR lt15
• Diagnosis requires abnormalities to be present
  for at least 3 months.
• Its common- 5 have stage 3-5

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Where did all this come from?

• Guidelines published by committee on renal
  disease, RCP, Renal association and RCGP
• Chronic Kidney disease in adultsUK guidelines
  for identification, management and referral March
  2006
• SIGN 97-Feb 2007
• NICE guideline in progress-Due Sept 2008
• QOF points-CKD is one of the new clinical domains

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What is eGFR?

• Estimated glomerular filtration rate
• More sensitive marker of CHRONIC renal impairment
  than creatinine.
• Similar to creatinine clearance

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How do we calculate it?

• Thankfully its done for us in Tayside
• MDRD formula 86 x (Creat / 88.4)-1.154 x
  (Age)-0.203 x (0.742 if female) x (1.210 if
  black).
• On-line calculator www.renal.org
• Lab result is better measure than calculation

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Whats normal?

• Trend over time is useful
• gt90ml/min/1.73m² is normal
• 60-90 does not itself indicate CKD unless
  evidence of kidney damage
• Tayside gives numerical value up to 60
• eGFR lt60 represents CKD
• eGFR decreases with age from 40 by a loss of
  1ml/min/year

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What do we need to do about a low eGFR?

• If unexpected look at historic creatinine
• -if big change or no historic records repeat in 1
  week if well
• -if unwell consider acute renal injury rpt test
  and discuss with specialist
• Check patients blood pressure
• -target BP is 130/85, if there is proteinuria a
  lower target is recommended 120/75
• -QOF target is 140/85
• -Treat with ACEI OR ARB (angiotensin II receptor
  blockers)
• -Check potassium before and after two weeks and
  after dose change
• -If someone is well controlled on other agents
  and no proteinuria do not
• change jut because CKD3
• -If BP gt150/90 and on three antihypertensives
  should be referred to appropriate
• specialist

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What do we need to do about a low eGFR?

• Test for proteinuria
• -urine dip-stick annually, change in BP, oedema
  or systemic disease is an indication for
  dip-stick testing
• -consider infection
• -if positive dip stick send white topped plain
  bottle to lab for total
• proteincreatinine ratio (TPCR)
• -Normal TPCR is lt15mg/mmol
• -gt45mg/mmol is considered proteinuria
• -Check for anaemia Hb lt11g/dl

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What do we need to do about a low eGFR?

• Manage other cardiovascular risk
• Improve control of heart failure and diabetes
• Medication review of drugs which impair renal
  function
• In men consider prostatic disease causing outflow
  obstruction
• Asses stability of disease (by monitoring
  creatinine every 6-12 months)
• Identify those that need referral to nephrology

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Who requires referral to nephrology?

• A Summary-further guidance www.renal.org
• -Those with acute renal failure
• -Those with significant proteinuria (gt1g/day)
  equivalent to protiencreatinine ratio of
  100mg/mmol
• -Microscopic haematuria (may need urology
  referral first)
• -All stage 5 (stage 4 should be discussed)
• -Those with functional consequence of CKD
  eg-anaemia, bone disease, refractory hypertension

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What info is required for referral?

• Dates and results of previous serum creatinine
• Serum potassium
• Haemoglobin
• Past medical history and full drug history
• Blood pressure
• Dipstick result and total proteincreatinine
  ratio if more than trace of protein present
• ?Renal u/s-local policy
• If diabetic HbA1c
• Details of prostate disease
• Some may not be appropriate for referral

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How often to measure eGFR

• Annually in at risk groups
• Stage 1 and 2 (only diagnosed if renal
  impairment)-annually
• Stage 3 6/12 on diagnosis, annually when stable
• Stage 4 3/12 on diagnosis, six monthly when
  stable
• Stage 5 Three monthly

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What QOF points are available?

• Practice needs to produce a register of patients
  over 18 years of age with CKD 3-5. (6 points)
• Percentage of those on the register who have a
  recorded BP in last 15 months (6 points)
• Percentage of patients on the register in whom
  last BP reading in last 15 months is lt140/85 (11
  points)
• Percentage of patients on CKD register who are
  treated with an ACEI or ARB unless
  contraindicated or side effects recorded. (4
  points)

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References

• CKD Frequently asked questions. April 2007
• www.renal.org
• Chronic Kidney disease in adultsUK guidelines
  for identification, management and referral March
  2006
• www.bma.org.uk/ap.nsf/content/gof06
• www.opsi.gov.uk