assessment & management of cardiovascular risk …nwrenalaudit.org/downloads/presentaions/ckd cvd...

ASSESSMENT & MANAGEMENT OF

CARDIOVASCULAR RISK FACTORS

IN CHRONIC KIDNEY DISEASE

STAGE III AND IV PATIENTS

Dr Ram Bhat, University Hospital Aintree

Tracey Powell, Manchester Royal Infirmary

Dr. Ajay Dhaygude, Royal Preston Hospital

Overview

� Introduction to Cardio Vascular Disease (CVD) risks in Chronic Kidney Disease (CKD)

� Audit presentation

� Aims, design, methods

� Standards

� Results

� Conclusion

Introduction

45.7%19.9%CKD IV

24.3%1.3 %CKD III

19.5%1.1%CKD II

DeathRRT

Introduction

Local scenario: NEOERICA

� CKD prev. 5- 10 %

� High incidence of anaemia, DM and HT

� Only 20% diabetic CKD patients had BP < 130/80

� CVD prev 50% and increases with age

2.72.94.110Hb < 11

47.171.486.687.8HT %

9.41216.123.0DM %

14.827.142.750.7CVD %

>6045-5930-44

CKD Predicts CVD (Go, et al., NEJM 2004)

CKD predicts CVD

HOORN Study, Henry et al, 2002

Complex interplay

Cardiovascular risk factors

� Traditional

� Age

� Male

� Family history

� Smoking

� Obesity

� Diabetes

� Cholesterol

� Physical inactivity

� Non-traditional

� Proteinuria

� Inflamation

� Anemia

� Volume overload

� PTH / Low Vit D

� Vascular ossification /

complaince

� Lipoprotein (a)

� Homocysteine

Audit of CVD in CKD III and CKD IV patients

AIMS AND OBJECTIVES

� to assess the cardiovascular disease risk factors in patients with chronic

kidney disease stage III and IV (eGFR 15 to 59 mls/min/1.73m2)

� to assess the management of cardiovascular disease risk factors of this

group

PROPOSED HEALTH BENEFITS

� to reduce the risk of cardiovascular morbi-mortality in this group

� to reduce the progression of CKD

Methodology

� Patients: 20 patients with stage IIIA, IIIB and IV CKD from each contributing hospital

� focus on patients

Standards and Guidelines

� Renal Association Standards and Audit Subcommittee. Treatment of adults and children with renal failure: standards and audit measures (10/4/2007). London: Royal College of Physicians 2007

� NICE Clinical Guideline 73. Chronic Kidney Disease - Early Identification and Management of Chronic Kidney Disease in adults in primary and secondary care.

Guidelines

� RA Blood Pressure / Protenuria� Among patients with CKD, blood pressure should be lowered to < 130/80

� ACEI or ARB should form part of antihypertensive treatment of patients with CKD and Urinary protein excretion > 1g/day unless any contraindication

� Patients with diabetes and microalbuminuria should be treated with ACEi/ ARB regardless of initial blood pressure, unless contraindicated

� NICE BP guidelines� NICE Guideline 5.1: We suggest that BP in CKD 1-4 patients should be managed according to NICE guidance:

Guidelines

� Aspirin� NICE Guideline 3.4 - CVD: We suggest that aspirin is indicated for secondary prevention but not primary prevention of vascular disease in renal failure. (2C)

� Statin� NICE Guideline 1.6 - CVD: We recommend that statins (or 3 hydroxy-3methylglutaryl-coenzyme A reductase inhibitors) should be considered for primary prevention in all CKD Stages 1-4 and transplant patients with a 10-year risk of cardiovascular disease, calculated as > 20% according to the Joint British Societies’Guidelines (British Hypertension Society British Cardiac Society2005). (1B)

Guidelines

� Reduction of CV risk:� NICE Guideline 3.1 – CVD: We recommend that CKD stage 1-3 patients with a history of chronic stable angina, acute coronarysyndrome, myocardial infarction, stroke, peripheral vascular disease, or who undergo surgical or angiographic coronary revascularisation, should be prescribed aspirin, an ACE inhibitor, a beta-blocker, and an HMG–CoA reductase inhibitor unless contraindicated as per NICE Guidance. (1B)

RA guidelines

� Diabetes� Diabetic with CKD should achieve good glycemic control defined as HBA1c < 7.5%

� CVD risk

� Patients should have annual formal assessment of their risk factors including measurement of HDL and total cholesterol, BMI, exercise, alcohol and smoking habits as well as interventions to reduce cardiovascular risk (good practice)

� Smoking � Smoking status and action taken should be documented in the patient record at each nephrology clinic visit

� Renal Association Standards

� Serum Calcium� Stage 1 to 4 CKD should be in normal range

� Serum Phosphate� Stage 4 CKD should be in the range 0.9 – 1.5mmol/l

� Serum calcium phosphate product� All CKD should be

Proportion of patients from various units

n = 276

34

69

7

15

71

42

10

18

18

6

94

42

23

2124

1

111

0%

20%

40%

60%

80%

100%

A AP MRI RPH SRH REGION

CKD4

CKD3b

CKD3a

Results – All patients

38 (13.76%)13178Smoker

30.83 ± 7.4731.58 ± 7.4730.9 ± 7.1229.8 ± 7.5BMI

4.53 ± 1.234.32 ± 1.084.40 ± 1.054.94 ± 1.5 *Cholesterol

79.44 ± 11.9979.86 ± 11.9977.55 ± 12.1981.34 ± 11.56Diastolic BP

139 ± 19.69140.86 ± 19.73138.68 ± 19.92138.76 ± 19.28Systolic BP

92 (33.33%)43 (38.73%)36 (38.29%)13 (18.3%)Diabetics

148 : 14650 : 6150 : 4437 : 34Male : Female

56 ± 15.1158 ± 14.9757 ± 12.7254± 13.57Mean Age

2761119471 (25.45%)Number of patients

All patientsCKD 4CKD 3bCKD 3a

•CKD 3a vs CKD 3b (p = 0.044)*•CKD 3a Vs CKD 4 (p = 0.019)*

Results – Age ≤ 65 yrs

35 (16.12%)10178Smoker

30.83 ± 7.4731.58 ± 7.5230.9 ± 7.1229.8 ± 7.53BMI

4.64 ± 1.324.48 ± 1.344.39 ± 1.325.06 ± 1.31Cholesterol

81.06 ± 11.5682.22 ± 12.0178.86 ± 11.7482.43 ± 11.99Diastolic BP

143 ± 18.82141 ± 18.85139.19 ± 19.04137 ± 18.74Systolic BP

70 (32.25%)29 (36.25%)30 (38.96%)11 (18.33%)Diabetics

112 : 10538 : 4244 : 3330 : 30Male : Female

51 ± 11.5949 ± 11.3453 ± 9.150 ± 11.58Mean Age

217807760Number of pts

All patientsCKD 4CKD 3bCKD 3a

Guideline 5.1: We suggest that BP in CKD 1-4 patients should be managed according to NICE guidance:

4513

11

16 7 92

26 12

12

15 7 72

16 1

2

2 122

23 13

17

11

771

86 5

19

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


SBP >130 and DBP >80 SBP >130 and DBP =/

Blood Pressure control by Renal Association standards – Age ≤ 65 yrs

45

8

716

3

79

26

4

3

14

4

51

16

1

2

2 21

23

3

9

10 550

83 5

16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


SBP >130 and DBP >80

SBP >130 and DBP =/

Proteinuria – All patients

41

21

11

11

84

31

11

11

4

57

21

7

11

4

6

49

25

15

45

1

86

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


No results

Category 3: 24 hr 60

Category 1: - 24 hour 0.15gm to 1.0gm or PCR 15 to 100 or ACR 4.5 to 60

Obesity

BMI – Age ≤ 65 yrs

3 3

16

2 18

17

10

1

28

39

3

1

43

7

1

20

28

36

2

47 12

97

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


BMI < 18.5 Normal BMI 18.5 to 24.9 Overweight 25.0 to 29.9

Obese 30.0 to 39.9 Morbidly obese >40.0 No Result

Diabetes – All patients

9

8

2

1

20

27

7

2

36

11

11

12

2

36

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Not recorded / no recent resultsHbA1c outside recommended rangeHbA1c between 6% and 7.5%

Cholesterol

� Guideline 1.7 - CVD: We recommend that a total cholesterol of

Cholesterol – All patients

27

19

6

5 57

59

20

9

14

102

32

33

49

3

117

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Total Cholesterol 4mmol/l Not recorded

Guideline 1.6 - CVD: We recommend that statins (or 3 hydroxy-3methylglutaryl-coenzyme A reductase inhibitors) should be considered for primary prevention in all CKD Stages 1-4 and transplant patients with a 10-year risk of cardiovascular disease, calculated as > 20% according to the Joint British Societies’ Guidelines (British Hypertension Society British Cardiac Society 2005). (1B)

73

29

23

3015

170

44

10

18

197

98

1

7

8

0%

20%

40%

60%

80%

100%


No of patients on statin No. of patients not on statin Not recorded

Smoking – All patients

20

3 58

238

35

15

7

20

1

78

35

20

21

6

82

28

1

15 15

19

78

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


No. of current smokers No. of ex-smokers No who have never smoked Not recorded

Aspirin (Guideline 3.4 - CVD: We suggest that aspirin is indicated for secondary prevention but not primary prevention of vascular disease in renal failure.

(2C))

47 1623 22

8116

68 23

17

2714

3

8

11

149

68

41

13

68

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


No. of patients prescribed anti-platelets No. of patients not prescribed anti-platelets

Not recorded No. of patients prescribed Aspirin

Cardiovascular Risk Factors – All patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of patients with risk

factor (DM, hypertension,

Dyslipidaemia,

Ex/Current smoker)

% of patients with 1 risk

factor

% of patients with 2 risk

factors

%of patients with 3 risk

factors

% of patients with all risk

factors


Manifest cardiovascular disease – All patients

0%

5%

10%

15%

20%

25%

30%

35%

40%

No. of patients

with CVD

MI CABG Angina CVA PVD


Guideline 3.1 - CVD: We recommend that CKD stage 1-3 patients with a history of chronic stable angina, acute coronary syndrome, myocardial infarction, stroke, peripheral vascular disease, or who undergo surgical or angiographic coronary revascularisation, should be prescribed aspirin, an ACE inhibitor, a beta-blocker, and an HMG–CoA reductase inhibitor unless contraindicated as per NICE Guidance. (1B)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of patients with history

CVD (CKD III)

% of patients with CVD

prescribed anti-platelets


prescribed ACE inhibitor


prescribed beta-blocker


prescribed HMG-CoA

reductase inhibitor (statin)


Guideline 3.2 - CVD: We suggest that CKD stage 4/5 patients (including those on dialysis and after transplantation) with a history of chronic stable angina, acute coronary syndrome, myocardial infarction, stroke, peripheral vascular disease, or who undergo surgical or angiographic coronary revascularisation, should be prescribed aspirin, an ACE inhibitor, a beta-blocker, and an HMG–CoA reductase inhibitor unless contraindicated as per NICE Guidance. (2C)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

No. of patients with

history of CVD (CDK IV)


prescribed anti-platelets


prescribed ACE inhibitor


prescribed beta-blocker


prescribed HMG-CoA

reductase inhibitor (statin)


Serum calcium in normal range

70%

80%

90%

100%

A

(2.18 - 2.62)

AP

(2.1 - 2.7)MRI

(2.1 - 2.55)

RPH

(2.15 - 2.55

SRH

(2.1 -2.6)

REGION

Serum Phosphate (CKD 4)

% of CKD4 patients with Serum Phosphate 0.9 - 1.5mmol/L

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Serum calcium phosphate product (CKD 4)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Missing results

Percentage of CKD 4 patients with serum calcium phosphate product (

Serum iPTH: Serum iPTH should be in the normal range for CKD3 and between the top of the normal and twice the normal range for CKD 4 patients

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

A (1.3 - 6.8 ) AP (1.6 - 6.9) MRI (10 - 60) RPH (15 - 65) SRH (15 - 65) REGION

% CKD3 patients with Serum iPTH in normal range

% CKD IV patients with serum iPTH between top of normal and x2 normal range

Management of anaemia

167 10

13

1

47

95

32 36

36

21220

7 2 9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Missing Hb resultPatients with haemoglobin >11g/dlPatients with haemoglobin ≤ 11g/dl

Percentage of patients on binder, alfacalcidol, ESA & Iron

0%

5%

10%

15%

20%

25%

30%

% patients on binder % patients on alfacalcidol % patients on ESA %patients on oral iron % received IV iron in

past 12 months


Conclusions

� Conventional cardiovascular risks remain poorly addressed in a significant proportion of patients with CKD

� Attention given to these factors (especially documentation) during follow up is poor

Recommendations

� Clinic letters to have a separate section noting various cardiovascular risks present in every CKD patient and action taken.

� Multidisciplinary approach to achieve lifestyle changes in patients and improve compliance with advice

� Patient information leaflet explaining the increased risk of cardiovascular morbidity and mortality

� Follow-up of these patients annually to assess cardiovascular outcomes

Contributors

� Audit Lead: � Dr. Ajay Dhaygude

� Data analysis : � Tracey Powell

� Aintree University Hospital� Dr. Rammohan S Bhat

� Dr. Christopher Wong

� Dr. Christopher Goldsmith

� Arrowe Park Hospital� Dr. Anindya Banerjee

� Manchester Royal Infirmary

� Royal Preston Hospital� Dr. Ajay Dhaygude

� Dr. Poonam Batra

� Salford Royal Hospital� Dr. O’Riordan

� Dr. Suham Amin

� Dr. Anu Jayanti

Thank You Questions???

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