chronic kidney disease
TRANSCRIPT
Chronic Kidney Chronic Kidney DiseaseDiseaseHOT TOPICHOT TOPIC
FEBRUARY FEBRUARY 2007 2007
Kelly FrullaniKelly Frullani
WHY THIS TOPIC?WHY THIS TOPIC?
Major workload in practiceMajor workload in practice New QOF targets New QOF targets Affects large numbers of patients Affects large numbers of patients ? Exams? Exams
DEFINITION OF CKDDEFINITION OF CKD
Kidney damage > 3months – defined Kidney damage > 3months – defined by structural or functional by structural or functional abnormalities with/without decrease abnormalities with/without decrease in GFRin GFR
Pathological Pathological Markers of kidney damage (abnormalities in Markers of kidney damage (abnormalities in
blood/urine/imaging)blood/urine/imaging)
GFR<60 for > 3months with/without GFR<60 for > 3months with/without kidney damage kidney damage
NEED FOR GUIDELINESNEED FOR GUIDELINES
Majority with early CKD don’t progress Majority with early CKD don’t progress to ERFto ERF
Increased risk of CV disease Increased risk of CV disease Established renal failure rare but Established renal failure rare but
expensiveexpensive Numbers receiving renal replacement Numbers receiving renal replacement
therapy rising – 2% of NHS budget therapy rising – 2% of NHS budget Majority starting replacement therapy Majority starting replacement therapy
progressed from earlier stages of CKD progressed from earlier stages of CKD
GUIDELINESGUIDELINES
2004 and 2005 DoH published National 2004 and 2005 DoH published National Service Framework for Renal Services Service Framework for Renal Services
CKD in Adults. UK Guidelines for CKD in Adults. UK Guidelines for identification, management and referral identification, management and referral
Developed by Joint specialist committee Developed by Joint specialist committee on Renal Medicine of Royal College on Renal Medicine of Royal College Physicians and Renal Association Physicians and Renal Association March 2006March 2006
?NICE guideline 2008 ?NICE guideline 2008
AETIOLOGYAETIOLOGY
Most common cause is type 2 Most common cause is type 2 diabetes diabetes
Other causes Other causes HypertensionHypertension Chronic GlomerulonephritisChronic Glomerulonephritis Polycystic DiseasePolycystic Disease Pyelonephritis Pyelonephritis
PREVALENCEPREVALENCE
10% of population have CKD 10% of population have CKD 5% are in stages 1-25% are in stages 1-2 5% are in stage 3-5 5% are in stage 3-5
For average GP list size – 220 For average GP list size – 220 patients with CKD patients with CKD
CLASSIFICATIONCLASSIFICATION From US National Kidney Foundation in their From US National Kidney Foundation in their
Kidney Disease Outcomes Quality Initiative Kidney Disease Outcomes Quality Initiative Stage 1 – normal eGFR > 90 - other evidence of Stage 1 – normal eGFR > 90 - other evidence of
CKDCKD Stage 2 – mild eGFR 60-89 - other evidence of CKDStage 2 – mild eGFR 60-89 - other evidence of CKD Stage 3 – moderate eGFR 30-59Stage 3 – moderate eGFR 30-59 Stage 4 – severe eGFR 15-29Stage 4 – severe eGFR 15-29 Stage 5 – ERF eGFR <15 or on dialysis Stage 5 – ERF eGFR <15 or on dialysis Other evidence- persistent proteinuria/haematuria/ Other evidence- persistent proteinuria/haematuria/
microalbuminuria, structural abnormalities on USSmicroalbuminuria, structural abnormalities on USS
MEASURING GFRMEASURING GFR Assessed by formula based estimation of GFRAssessed by formula based estimation of GFR In adults >18yrs eGFR calculated using the 4 In adults >18yrs eGFR calculated using the 4
variable Modification of Diet in renal disease variable Modification of Diet in renal disease (MDRD) equation(MDRD) equation
4 variables- serum creatinine, age, sex, ethnic 4 variables- serum creatinine, age, sex, ethnic origin origin
Equation not validated for use inEquation not validated for use in Children < 18yrsChildren < 18yrs PregnancyPregnancy ARFARF Oedematous states, malnourishment, amputeesOedematous states, malnourishment, amputees
DETECTION OF DETECTION OF PROTEINURIAPROTEINURIA
Positive Dipstix test (≥1+)- send for Positive Dipstix test (≥1+)- send for UPCR + culture to exclude UTIUPCR + culture to exclude UTI
UPCR≥45mg/mmol is positive test for UPCR≥45mg/mmol is positive test for proteinprotein
Persistent proteinuria- ≥2 positive tests Persistent proteinuria- ≥2 positive tests Proteinuria is single best predictor of Proteinuria is single best predictor of
disease progression disease progression Reducing urine protein excretion slows Reducing urine protein excretion slows
progressive decline in renal function progressive decline in renal function
MANAGEMENTMANAGEMENT
QOF Targets – register of those with stage 3-5 QOF Targets – register of those with stage 3-5 Need system for recall and auditNeed system for recall and audit Lifestyle advice Lifestyle advice
Smoking cessation, Weight loss, exercise, Smoking cessation, Weight loss, exercise, reduce alcoholreduce alcohol
Aspirin- for those with 10yr CV risk of >20% Aspirin- for those with 10yr CV risk of >20% Lipid lowering- all with macrovascular disease, Lipid lowering- all with macrovascular disease,
diabetics and CKD, 10yr CV risk >20%diabetics and CKD, 10yr CV risk >20% Control BPControl BP
BLOOD PRESSUREBLOOD PRESSURE Treatment aims to reduce risk of CV disease and Treatment aims to reduce risk of CV disease and
risk of progressive loss of kidney functionrisk of progressive loss of kidney function Measure at least annually, Conform to BHS Measure at least annually, Conform to BHS
guidelines guidelines 140/85 – QOF targets and in those without 140/85 – QOF targets and in those without
proteinuria –optimal target of 130/80proteinuria –optimal target of 130/80 130/80 with UPCR >1g-optimal target 125/75130/80 with UPCR >1g-optimal target 125/75 ACEI/ARB –proteinuria, diabetics, heart failure ACEI/ARB –proteinuria, diabetics, heart failure
Prevent progression from microalbuminuria to overt Prevent progression from microalbuminuria to overt nephropathy in type 1+2 diabetics nephropathy in type 1+2 diabetics
Can slow progression of non-diabetic nephropathy Can slow progression of non-diabetic nephropathy BP >150/90 despite 3 drugs – refer BP >150/90 despite 3 drugs – refer
STAGE 1&2STAGE 1&2
Annual measurement of BP, urine Annual measurement of BP, urine protein and serum creatinine protein and serum creatinine
Advice on CVS risk factors Advice on CVS risk factors Consider aspirin and lipid lowering Consider aspirin and lipid lowering Antihypertensive therapy Antihypertensive therapy
STAGE 3STAGE 3
Annual measurment of Hb, Cr, Ca, Phosphate, Annual measurment of Hb, Cr, Ca, Phosphate, KK
Six monthly BP checksSix monthly BP checks Treat anaemia (Hb <11) after exclusion of Treat anaemia (Hb <11) after exclusion of
other causes other causes Renal USS if signs of outflow obstructionRenal USS if signs of outflow obstruction Immunise against influenza and pneumococcusImmunise against influenza and pneumococcus Review medications – avoid nephrotoxicsReview medications – avoid nephrotoxics Consider calcium and vitamin D supplements – Consider calcium and vitamin D supplements –
exclude hyperparathyroidism first exclude hyperparathyroidism first
STAGE 4&5STAGE 4&5
Three monthly BP, Hb, Cr, K, phosphate, Three monthly BP, Hb, Cr, K, phosphate, Ca, PTH, GFR, Bicarbonate Ca, PTH, GFR, Bicarbonate
All of stage 3 management All of stage 3 management Dietary assessmentDietary assessment Immunise against hepatitis BImmunise against hepatitis B Counselling of treatment optionsCounselling of treatment options Provision of vascular or peritoneal access Provision of vascular or peritoneal access
REFERRALS REFERRALS
Immediate Immediate Suspected acute renal failureSuspected acute renal failure ARF superimposed on CKDARF superimposed on CKD Newly detected stage 5 Newly detected stage 5 K > 7.0K > 7.0 Malignant HypertensionMalignant Hypertension
Urgent Urgent Nephrotic syndromeNephrotic syndrome Stage 4 or stable stage 5 Stage 4 or stable stage 5 K 6-7K 6-7
REFERRALSREFERRALS
Stage 1&2Stage 1&2 Isolated proteinuria –UPCR >100mg/mmolIsolated proteinuria –UPCR >100mg/mmol Protein + microscopic haematuria – UPCR>45Protein + microscopic haematuria – UPCR>45 Macroscopic haematuria – exclude urological Macroscopic haematuria – exclude urological
cause cause Uncontrolled hypertension BP>150/90 despite 3 Uncontrolled hypertension BP>150/90 despite 3
drugsdrugs Fall of eGFR>20% during first 2months after Fall of eGFR>20% during first 2months after
starting ACEI/ARBstarting ACEI/ARB Recurrent pulmonary oedema with normal LVFRecurrent pulmonary oedema with normal LVF Microscopic haematuria without proteinuria – Microscopic haematuria without proteinuria –
refer urology unless GFR <60 refer nephrology refer urology unless GFR <60 refer nephrology
REFERRALSREFERRALS
Stage 3 Stage 3 All of stage 1&2 criteriaAll of stage 1&2 criteria Progressive fall in GFRProgressive fall in GFR Proteinura – UPCR >45Proteinura – UPCR >45 Anaemia Anaemia Persistently abnormal K, phosphate, Ca Persistently abnormal K, phosphate, Ca
Stage 4&5Stage 4&5 Immediate or urgent referral Immediate or urgent referral Consider replacement therapy unless co-Consider replacement therapy unless co-
morbidities morbidities
TRIALS UNDERWAYTRIALS UNDERWAY Several trials to examine effect of lipid lowering Several trials to examine effect of lipid lowering
therapy on CV outcomes amongst patients with therapy on CV outcomes amongst patients with CKD CKD
SHARP (Study of Heart and Renal Protection SHARP (Study of Heart and Renal Protection Trial) – aims to randomise 9000 patients with CKD Trial) – aims to randomise 9000 patients with CKD to lipid-lowering therapy or placebo – not to lipid-lowering therapy or placebo – not completed yetcompleted yet
Prior to this study’s result – treat as per Prior to this study’s result – treat as per existing guideline existing guideline
British Cardiac Society, British Hyperlipidaemia British Cardiac Society, British Hyperlipidaemia Society, British Hypertensive Society Society, British Hypertensive Society
Metanalysis in Kidney International 2001- Metanalysis in Kidney International 2001- statins reduced proteinuria and preserved GFRstatins reduced proteinuria and preserved GFR
OVERVIEWOVERVIEW Inclusion of CKD within QOF places Inclusion of CKD within QOF places
emphasis for detection and management emphasis for detection and management of early CKD on primary careof early CKD on primary care
Issues for workload and resources needed Issues for workload and resources needed Importance of vascular risk reduction – Importance of vascular risk reduction –
leads to improved renal outcomes leads to improved renal outcomes Majority of patients with CKD can be Majority of patients with CKD can be
managed without referral managed without referral Using register, ensuring long term follow Using register, ensuring long term follow
up up
EVIDENCE & EVIDENCE & RESOURCESRESOURCES
Department of Health. National Service Framework for Department of Health. National Service Framework for Renal Services Part Two: Chronic Kidney Disease, Acute Renal Services Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life Care 2005 Renal Failure and End of Life Care 2005 www.dh.gov.uk/renalwww.dh.gov.uk/renal
Joint Speciality Committee on Renal Disease of the Royal Joint Speciality Committee on Renal Disease of the Royal College of Physicians of London and the Renal College of Physicians of London and the Renal Association. CKD in Adults – UK Guidelines for Association. CKD in Adults – UK Guidelines for identification, management and referral March 2006 identification, management and referral March 2006 www.rcplondon.ac.ukwww.rcplondon.ac.uk or or www.renal.orgwww.renal.org
Guidelines for management of hypertension – BHS 2004 Guidelines for management of hypertension – BHS 2004 Clinical Review Chronic Renal Disease – BMJ 2002 Clinical Review Chronic Renal Disease – BMJ 2002 National Kidney Foundation Kidney Disease Outcomes National Kidney Foundation Kidney Disease Outcomes
Quality Initiative NKF K/DOQI Quality Initiative NKF K/DOQI www.kidney.orgwww.kidney.org Identification, management and referral of adults with Identification, management and referral of adults with
CKD: concise guidelines. Clinical Medicine 2005;5:635-CKD: concise guidelines. Clinical Medicine 2005;5:635-642642