Chronic Kidney Disease

1
Chronic Kidney Disease

• HOT TOPIC
• FEBRUARY 2007
• Kelly Frullani

2
WHY THIS TOPIC?

• Major workload in practice
• New QOF targets
• Affects large numbers of patients
• ? Exams

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DEFINITION OF CKD

• Kidney damage gt 3months defined by structural
  or functional abnormalities with/without decrease
  in GFR
• Pathological
• Markers of kidney damage (abnormalities in
  blood/urine/imaging)
• GFRlt60 for gt 3months with/without kidney damage

4
NEED FOR GUIDELINES

• Majority with early CKD dont progress to ERF
• Increased risk of CV disease
• Established renal failure rare but expensive
• Numbers receiving renal replacement therapy
  rising 2 of NHS budget
• Majority starting replacement therapy progressed
  from earlier stages of CKD

5
GUIDELINES

• 2004 and 2005 DoH published National Service
  Framework for Renal Services
• CKD in Adults. UK Guidelines for identification,
  management and referral
• Developed by Joint specialist committee on Renal
  Medicine of Royal College Physicians and Renal
  Association March 2006
• ?NICE guideline 2008

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AETIOLOGY

• Most common cause is type 2 diabetes
• Other causes
• Hypertension
• Chronic Glomerulonephritis
• Polycystic Disease
• Pyelonephritis

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PREVALENCE

• 10 of population have CKD
• 5 are in stages 1-2
• 5 are in stage 3-5
• For average GP list size 220 patients with CKD

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CLASSIFICATION

• From US National Kidney Foundation in their
  Kidney Disease Outcomes Quality Initiative
• Stage 1 normal eGFR gt 90 - other evidence of
  CKD
• Stage 2 mild eGFR 60-89 - other evidence of CKD
• Stage 3 moderate eGFR 30-59
• Stage 4 severe eGFR 15-29
• Stage 5 ERF eGFR lt15 or on dialysis
• Other evidence- persistent proteinuria/haematuria/
  microalbuminuria, structural abnormalities on
  USS

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MEASURING GFR

• Assessed by formula based estimation of GFR
• In adults gt18yrs eGFR calculated using the 4
  variable Modification of Diet in renal disease
  (MDRD) equation
• 4 variables- serum creatinine, age, sex, ethnic
  origin
• Equation not validated for use in
• Children lt 18yrs
• Pregnancy
• ARF
• Oedematous states, malnourishment, amputees

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DETECTION OF PROTEINURIA

• Positive Dipstix test (1)- send for UPCR
  culture to exclude UTI
• UPCR45mg/mmol is positive test for protein
• Persistent proteinuria- 2 positive tests
• Proteinuria is single best predictor of disease
  progression
• Reducing urine protein excretion slows
  progressive decline in renal function

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MANAGEMENT

• QOF Targets register of those with stage 3-5
• Need system for recall and audit
• Lifestyle advice
• Smoking cessation, Weight loss, exercise, reduce
  alcohol
• Aspirin- for those with 10yr CV risk of gt20
• Lipid lowering- all with macrovascular disease,
  diabetics and CKD, 10yr CV risk gt20
• Control BP

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BLOOD PRESSURE

• Treatment aims to reduce risk of CV disease and
  risk of progressive loss of kidney function
• Measure at least annually, Conform to BHS
  guidelines
• 140/85 QOF targets and in those without
  proteinuria optimal target of 130/80
• 130/80 with UPCR gt1g-optimal target 125/75
• ACEI/ARB proteinuria, diabetics, heart failure
• Prevent progression from microalbuminuria to
  overt nephropathy in type 12 diabetics
• Can slow progression of non-diabetic nephropathy
• BP gt150/90 despite 3 drugs refer

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STAGE 12

• Annual measurement of BP, urine protein and serum
  creatinine
• Advice on CVS risk factors
• Consider aspirin and lipid lowering
• Antihypertensive therapy

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STAGE 3

• Annual measurment of Hb, Cr, Ca, Phosphate, K
• Six monthly BP checks
• Treat anaemia (Hb lt11) after exclusion of other
  causes
• Renal USS if signs of outflow obstruction
• Immunise against influenza and pneumococcus
• Review medications avoid nephrotoxics
• Consider calcium and vitamin D supplements
  exclude hyperparathyroidism first

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STAGE 45

• Three monthly BP, Hb, Cr, K, phosphate, Ca, PTH,
  GFR, Bicarbonate
• All of stage 3 management
• Dietary assessment
• Immunise against hepatitis B
• Counselling of treatment options
• Provision of vascular or peritoneal access

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REFERRALS

• Immediate
• Suspected acute renal failure
• ARF superimposed on CKD
• Newly detected stage 5
• K gt 7.0
• Malignant Hypertension
• Urgent
• Nephrotic syndrome
• Stage 4 or stable stage 5
• K 6-7

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REFERRALS

• Stage 12
• Isolated proteinuria UPCR gt100mg/mmol
• Protein microscopic haematuria UPCRgt45
• Macroscopic haematuria exclude urological cause
  
• Uncontrolled hypertension BPgt150/90 despite 3
  drugs
• Fall of eGFRgt20 during first 2months after
  starting ACEI/ARB
• Recurrent pulmonary oedema with normal LVF
• Microscopic haematuria without proteinuria
  refer urology unless GFR lt60 refer nephrology

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REFERRALS

• Stage 3
• All of stage 12 criteria
• Progressive fall in GFR
• Proteinura UPCR gt45
• Anaemia
• Persistently abnormal K, phosphate, Ca
• Stage 45
• Immediate or urgent referral
• Consider replacement therapy unless
  co-morbidities

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TRIALS UNDERWAY

• Several trials to examine effect of lipid
  lowering therapy on CV outcomes amongst patients
  with CKD
• SHARP (Study of Heart and Renal Protection Trial)
  aims to randomise 9000 patients with CKD to
  lipid-lowering therapy or placebo not completed
  yet
• Prior to this studys result treat as per
  existing guideline
• British Cardiac Society, British Hyperlipidaemia
  Society, British Hypertensive Society
• Metanalysis in Kidney International 2001- statins
  reduced proteinuria and preserved GFR

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OVERVIEW

• Inclusion of CKD within QOF places emphasis for
  detection and management of early CKD on primary
  care
• Issues for workload and resources needed
• Importance of vascular risk reduction leads to
  improved renal outcomes
• Majority of patients with CKD can be managed
  without referral
• Using register, ensuring long term follow up

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EVIDENCE RESOURCES

• Department of Health. National Service Framework
  for Renal Services Part Two Chronic Kidney
  Disease, Acute Renal Failure and End of Life Care
  2005 www.dh.gov.uk/renal
• Joint Speciality Committee on Renal Disease of
  the Royal College of Physicians of London and the
  Renal Association. CKD in Adults UK Guidelines
  for identification, management and referral March
  2006 www.rcplondon.ac.uk or www.renal.org
• Guidelines for management of hypertension BHS
  2004
• Clinical Review Chronic Renal Disease BMJ 2002
• National Kidney Foundation Kidney Disease
  Outcomes Quality Initiative NKF K/DOQI
  www.kidney.org
• Identification, management and referral of adults
  with CKD concise guidelines. Clinical Medicine
  20055635-642