CKD presentation

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CKD presentation

• 2.12.10

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CKD definition

• Irreversible impairment of kidney function
• How do you accurately assess renal function?
• Serum creatinine
• eGFR(more accurate than Cr)
• Complex meaurements

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Background

• 1 in 10 people in the UK have chronic kidney
  disease (CKD)
• Treatment can prevent or delay the progression
  of CKD and reduce the risk of cardiovascular
  disease.
• CKD is frequently unrecognised, often existing
  with other conditions such as cardiovascular
  disease or diabetes.
• 30 of patients with advanced CKD are referred
  late to nephrology services from primary and
  secondary care.

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CKD stages
Stage Description GFR QOF
1 Normal kidney function but urine findings, structural abnormalities or genetic trait point to kidney disease gt90 No
2 Mildly reduced kidney function, with other findings point to kidney disease 60-89 No
3 Moderately reduced kidney function 45-59 (3a) 30-44 (3b) Yes
4 Severely reduced kidney function 16-29 Yes
5 Very severe, or established kidney failure lt15 Yes
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Prevalence
UK study (Drey et al, AJKD 2003) - 5554 per
million population have CKD stages 3-4 US study
(NHANES AJKD 2003) - 4.5 of adult population
have CKD stages 3-4 2/3 gt 70 years old 1/4
diabetic 3/4 hypertensive
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Prevalence
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Growing problem in UK
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Causes of Severe(4-5) CKD

• 40 Diabetes (mostly type 2)
• 20 Reno-vascular disease
• 20 Hypertension
• 10 Urological problems (inc. congenital
  abnormalities of urinary tract)
• Glomerulo-nephritis vasculitis
• Congenital kidney disease

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Early identification

• Offer testing for CKD where the following risk
  factors are present
• diabetes
• hypertension
• cardiovascular disease
• structural renal tract disease
• renal calculi
• prostatic hypertrophy
• multisystem diseases with potential kidney
  involvement
• opportunistic detection of haematuria or
  proteinuria
• family history of stage 5 CKD or hereditary
  kidney disease

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Who should be tested for CKD?

• At risk individuals
• Diabetes
• HTN
• Cardiovascular (IHD, PVD, CVD, CCF)
• Structural renal tract disease, calculi or
  prostatic hypertrophy
• Multisystem disease with renal impairment
• FHx of CKD5 or hereditary kidney disease
• Opportunistic detection of haematuria or
  proteinuria

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Management of CKD 3-5 patients

• Slow progression
• Hypertension
• Proteinuria
• Manage cardiovascular risk
• Statins, DM control, Smoking
• Manage renal-specific complications/risks
• Anaemia
• Bone disease
• Prepare for renal replacement therapy

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CKD 3 management in primary care

• DM, IHD, Htn
• Risk factor management
• Not much specialist renal medicine involved in
  majority of CKD 3
• Refer if refractory hypertension, complications
  of renal failire, renal artery stenosis etc
• Identify those with progressive CKD and refer

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Identify progressive CKD

• Obtain minimum 3 GFRs over not less than 90 days
• If new finding low GFR, repeat within 2 weeks to
  exclude ARF
• Define progression as GFR fall gt 5 /yr or 10 in 5
  yrs

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ACE inhibitor/ ARBs

• Offer to
• Diabetes and ACR gt 2.5 HTN/CKD
• Non-diabetic with CKD and high BP and ACR 30
  mg/mmol (0.5g/24 hrs)
• Non-diabetic with CKD and ACR gt 70 regardless of
  blood pressure or risk factors
• Titrate to maximum tolerated dose before add in
  second agent

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The metabolic complications of CKD
Uraemia
Hypertriglyceridaemia Hyperphosphataemia Metabolic
acidosis Hyperkalaemia
Ca absorption and lipoprotein activity
reduced Malnutrition, LVH, anaemia
PTH increases at GFR 50-60
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When to refer

• Diagnostic uncertainty
• Rapidly deteriorating renal function. gt5 GFR per
  year or gt10 over 5 years
• Haematoproteinuria (without biopsy diagnosis)
• Poorly controlled BP or proteinuria despite
  angiotensin blockade
• Developing hyperparathyoidism, anaemia or
  difficult to manage CKD complications
• To prepare for dialysis (Stage 4/5 CKD)

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If EGFR lt60

• look at previous results (rate of change)
• review medication
• assess clinically
• urinary symptoms, bladder, BP, heart
• dipstick urine
• blood and protein refer
• protein only greater than refer
• repeat serum creatinine within 5 days if new
  finding
• either enter into a chronic disease management
  program or refer

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EFGR lt30

• refer to nephrology if
• diagnostic uncertainty
• candidate for RRT
• metabolic complications that would respond to
  treatment even if not for RRT
• anaemia
• hypocalcaemia, vitamin D deficient,
  hyperparathyroidism
• hyperkalaemia
• symptom control as part of conservative care
  program

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Blood pressure control

• In people with CKD aim for
• systolic blood pressure below 140 mmHg(target
  range 120139 mmHg)
• diastolic blood pressure below 90 mmHg
• In people with CKD and diabetes - or when ACR ?
  70mg/mmol, aim for
• systolic blood pressure below 130 mmHg(target
  range 120129 mmHg)
• diastolic blood pressure below 80 mmHg

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CVD and CKD

• Risk of CVD is doubled in Stage 3 CKD
• Risk of CVD is doubled with microalbuminuria
• Annual mortality from CVD is increased 10 100
  times with kidney failure (Stage 5 CKD)
• First year CVD mortality x5 greater with Stage 5
  CKD DM (17) than Stage 5 CKD alone (3.5)

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Late referral

• Late referral associated with
• increased age
• more frequent co-morbidity
• diabetes
• renovascular disease
• cardiac failure

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Late referral

• Consequences
• no vascular access
• prolonged hospitalization (40 vs 15 days/year)
• increased mortality

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Proteinuria

• Use albumin creatinine ratio (ACR) (more
  sensitive at low levels)
• ACR in diabetes
• PCR may be used for quanitification and
  monitoring