Chronic kidney disease The primary care perspective

1
Chronic kidney diseaseThe primary care
perspective

• Alistair Chesser
• Consultant Nephrologist
• Barts and The London NHS Trust

2
Areas to be covered

• Why is CKD important?
• Use of eGFR
• Classification of Chronic Kidney Disease
• Management of CKD in primary care
• Referral guidelines for CKD

3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
Association between GFR quartiles and MI/death in
patients undergoing coronary angiogram
7
Mortality with CKD and ESRD

• 20 annual mortality with ESRD
• 20 year old with ESRD same risk as 80 year
  without CKD
• 2 year survival after MI with ESRD is 30
• Increased risk with all stages of CKD

8
(No Transcript)
9
QOF 2006
10
Why CKD is important

• Confers increased cardiovascular risk
• Risk of progression to end-stage renal disease
• Renal NSF
• QOF targets

11
Why use eGFR?
12
(No Transcript)
13
Glomerular Filtration Rate (GFR)

• Isotopic techniques
• Creatinine clearance on 24 hr urine sample
• Estimated glomerular filtration Rate (eGFR)
  (1) Cockroft-Gault equation (2) MDRD equation

14
4 variable MDRD equation
eGFR (ml/min per 1.73m2) 186 x (Creat(mmol/ml)
/ 88.4)-1.154 x
(Age)-0.203 x (0.742 if female) x (1.210 if
black)
Needs Creatinine Age Sex Race
15
(No Transcript)
16
Pitfalls in the use of eGFR
Dear Doctor I would be grateful for your advice
on the management of this 45 year old man who has
a creatinine measured at 186 mmol/l. Urinalysis
is negative for blood and protein and his BP is
normal
17
Pitfalls in the use of eGFR
Dear Doctor I would be grateful for your advice
on the management of This 45 year old man who has
a creatinine measured at 186 mmol/l. Urinalysis
is negative for blood and protein and his BP is
borderline
Wt 156 Kg
eGFR MDRD 36 ml/min
18
Pitfalls in the use of eGFR
Dear Doctor I would be grateful for your advice
on the management of This 45 year old man who has
a creatinine measured at 186 mmol/l. Urinalysis
is negative for blood and protein and his BP is
borderline
Wt 156 Kg
eGFR MDRD 36 ml/min Cockroft Gault 98 ml/min
19
Staging of chronic kidney diseaseK DOQI
guidelines
20
(No Transcript)
21
Stage 5 0.2
Stage 4 0.2
Stage 3 4.3
Stage 2 3.0
Stage 1 3.3
22
Quantifying proteinuria

• There is now good evidence that proteinuria can
  be assessed from a single urine sample
  (preferably an early morning sample), and can
  provide a reliable predictor of a fall in GFR.
• Twenty four hour urine collections are therefore
  unnecessary for this.

Renal NSF
23
Quantifying proteinuria
24
Chronic Kidney Disease (CKD)

• Albuminuria/proteinuria
• Haematuria
• Reduced GFR (raised plasma urea and creatinine)

25
Who is at risk of CKD?
26
(No Transcript)
27
www.rcplondon.ac.uk/pubs/books/CKD
28
(No Transcript)
29
QUALITY REQUIREMENT ONE People at increased risk
of developing or having undiagnosed chronic
kidney disease, especially people with diabetes
or hypertension, are identified, assessed and
their condition managed to preserve their kidney
function. Markers of good practice All people
at increased risk of CKD are identified, and
given appropriate advice, treatment and support
to preserve their kidney function. People
identified as having an increased risk of CKD
have their kidney function assessed and
appropriately monitored, using estimated GFR.
Implementation of the NICE clinical guideline on
the management of Type 1 diabetes.
Implementation of the NICE clinical guidelines on
the management of Type 2 diabetes renal disease
blood glucose blood pressure and blood lipids.
Implementation of the NICE clinical guideline on
the management of hypertension in adults in
primary care.
30
QUALITY REQUIREMENT TWO People with a diagnosis
of chronic kidney disease receive timely,
appropriate and effective investigation,
treatment and follow-up to reduce the risk of
progression and complications. Markers of good
practice All people diagnosed with CKD have
access to care which is sensitive to the
differing needs of culturally diverse groups, to
maximise the benefits of treatment and minimise
the effects of the disease and have a care
plan. Use of the best available evidence to
inform the management of blood pressure,
cardiovascular disease and cardiovascular risk,
and urinary tract obstructions and infections in
people with CKD. In people with diabetes and
CKD, interventions to reduce microvascular
complications, in accordance with the National
Service Framework for Diabetes. Implementation
of the forthcoming NICE guideline on the
treatment of anaemia in CKD. Referral from
primary care to the specialist renal service at
an appropriate stage to optimise outcomes.
31
QOF 2006
32
Who to refer to secondary care

• www.bartsandthelondon.nhs.uk/forgps/ckd

33
Predictors of Progression of CRF

• Severity of renal impairment
• Degree of proteinuria
• Hypertension
• Degree of interstitial scarring
• Cause of renal failure

34
Criteria for referralStages 1-2-3

• Malignant HTN
• Hyperkalaemia (K gt 7 mmol)
• Nephrotic syndrome
• Isolated proteinuria (gt PCR 100 mg/mmol)
• Proteinuria and microscopic haematuria
• Diabetes with proteinuria (PCR gt 100 mg/mmol)
  without DR
• Recurrent pulmonary oedema with normal LV
  function
• Fall of eGFR of gt 15 during first 2 months on
  ACEI/ARB
• Progressive fall in GFR
• Anaemia after exclusion of other causes
• Suspected systemic diseases (e.g. SLE,
  vasculitis, MM)
• Uncontrolled BP e.g. gt 150/90 mm Hg on 3 agents

35
(No Transcript)
36

Fall in
eGFR
gt5 ml in 12
6/12
months
CKD 3
eGFR

PCR or ACR gt100
and PCR

Fall in
eGFR
of gt15 after
starting
ACEi
or ARB
37

• Management in Primary Care
• Patient Information leaflets and advice including
  lifestyle
• information, stopping smoking, exercise, weight
  management
• Perform renal ultrasound only if history
  suggestive of
• urological disease or if ve FH or polycystic
  kidney disease
• Treat hypertension Threshold for Rx 140/90
• Target 130/80 (125/75 if PCR gt100 mg/mmol)
• ACEi or ARB as first line agents
• Suggest patient buys own BP meter
• Treat hyperlipidaemia according to local
  non-renal guidelines
• Aspirin if indicated
• Influenza / pneumococcal vaccination
• Review medications. Avoid NSAIDs

38


RENAL GUIDELINES ADULTS WITH CHRONIC KIDNEY
DISEASE
Chronic Kidney Disease (CKD) is now
staged according to the estimated Glomerular
Filtration rate (eGFR). eGFR is calculated from
the age, sex and serum creatinine measurement by
the chemical pathology laboratory. The normal
range is gt90 ml/min. The stages of CKD are as
follows
Over the age of 40 eGFR normally declines at a
rate of 1ml/min/year
Renal Replacement Therapy
Version 3 March 2006 Adapted and reproduced
with permission from a format developed by the
East Midlands Renal Network
39


RENAL GUIDELINES ADULTS WITH CHRONIC KIDNEY
DISEASE
CKD 1,2 and 3

• Full Biochemical Profile
• U and E
• Albumin
• Calcium, phosphate
• Alkaline phosphatase

• Refer to nephrologist unless clinically
• inappropriate (eg terminal cancer)
• Urgent if Stage 5
• See guidelines on previous sheet
• for information required

CKD 4 and 5
Medicine management FBC full biochemical
profile
PCR/ACR lt 30 mg/mmol
PCR/ACR 30-100 mg/mmol
PCR or ACR gt 100 mg/mmol Microscopic haematuria
ve or -ve
Consider glomerulonephritis especially if
symptoms/signs suggestive of systemic disease
Dipstick -ve haematuria
Dipstick ve haematuria
Dipstick -ve haematuria
Dipstick ve haematuria
Microscopic haematuria defined by 2 positive
test results in a 2 month period, having excluded
UTI
Follow urology guideline (US and IVU for all
cystocopy if age gt 45) Then follow up in primary
care
Discuss with or refer to nephrologist For details
on info required in letter see previous sheet
MANAGE IN PRIMARY CARE
DIAGNOSIS

• Fall in eGFR gt15 ml in 12
• months or 5 ml/year
• over 3 years
• PCR or ACR gt100
• Fall in eGFR of gt15 after
• starting ACEi or ARB

• Management in Primary Care
• Patient Information leaflets and advice including
  lifestyle
• information, stopping smoking, exercise, weight
  management
• Perform renal ulltrasound only if history
  suggestive of
• urological disease or if ve FH or polycystic
  kidney disease
• Treat hypertension Threshold for Rx 140/90
• Target 130/80 (125/75 if PCR gt100 mg/mmol)
• ACEi or ARB as first line agents
• Suggest patient buys own BP meter
• Treat hyperlipidaemia according to local
  non-renal guidelines
• Aspirin if indicated
• Influenza / pneumococcal vaccination
• Review medications. Avoid NSAIDs

Annual eGFR and PCR
CKD 1 or 2

• Fall in eGFR gt5 ml in 12
• months
• PCR or ACR gt100
• Fall in eGFR of gt15 after
• starting ACEi or ARB

6/12 eGFR and PCR
CKD 3
Version 3 March 2006 Adapted and reproduced
with permission from a format developed by the
East Midlands Renal Network
40
Information on referral

• General medical history
• Urinary symptoms
• Medication
• Examination e.g. BP, oedema, bladder
• Urine dipstick for blood and protein
• Urine for PCR if protein presented
• Blood count
• Serum creatinine, urea, Ca, PO4, cholesterol,
  HbA1c (in DM)
• All previous creatinine results with dates
• Results of ultrasound of kidneys if available

41
(No Transcript)
42
Case scenario 2

• 25 year old woman
• History of hypertension, unexplained joint pains,
  hypertension discovered at routine medical
• eGFR 44 ml/min
• PCR 150 mg/mmol
• Refer??

43
Case scenario 3

• 55 year old type 2 diabetic woman
• On insulin. Retinopathy etc
• HbA1c 9.5
• BP control poor (160/90 despite ACE inhibitor)
• PCR 120 mg/mmol, eGFR 44 ml/min
• Refer??

44
Case scenario 1

• 80 year old woman
• Known IHD, CVA, hypertension
• eGFR found to be 44ml/min. No change over
  previous 12 months
• PCR 50 mg/mmol
• BP well controlled
• Refer??

45
Dear Doctor Please could you see this lady with
a reduced eGFR of 44 ml/min. I would be grateful
for your opinion with regard to further
investigation. She suffers with hypertension
and paroxysmal AF, for which she is under Dr
Cardiologist. With many thanks Yours
sincerely A list of current medication is
enclosed
46
Scenario 4

• 55 year old man with CKD Stage 3 (eGFR 44
  ml/min). Hypertension, PCR55 mg/mmol, no
  haematuria, stable renal function
• Ca2 2.21, PO4 1.20
• PTH 15 pmol/l (NR 3.3-7.7)
• Management??

47
PTH in CKD

• Option 1
• Check PTH in all Stage 3 patients
• If raised, check Vit D and treat if low. Recheck
  PTH after 3 months
• If still raised, refer nephrology
• Option 2
• Never check PTH in a Stage 3 patient

48
(No Transcript)
49
(No Transcript)
50
Hypertension
Definition Normotension 120/80
mmHg Prehypertension 120-139/80-89
mmHg Hypertension gt140/90 mm Hg
51
QOF 2006
52
Monitoring indicators and achieving targets in
primary care UK.
53
Dear Doctor Please could you see this 70 year
old lady with a reduced eGFR of 44 ml/min. I
would be grateful for your opinion with regard to
further investigation. She suffers with
hypertension and paroxysmal AF, for which she is
under Dr Kurbaan. With many thanks Yours
sincerely A list of current medication is
enclosed
54
Hillege et al Circulation 2002 106 1777-82
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)