Chronic Kidney Disease

Stage 50.2%

Stage 4: 0.2%

Stage 3: 4.3%

Stage 2: 3.0%

Stage 1: 3.3%

Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J

Kidney Dis 2002;41:1-12

CKD stage GFR (ml/min/1.73m2) Description

1 >90 Normal renal function but other evidence of organ

damage*

2 60-89 Mild reduction in renal function with other evidence of organ

damage*

3 30-59 Moderately reduced GFR

4 15-29 Severely reduced GFR

5 <15 End stage, or approaching, end stage

renal failure

* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

Creatinine 120

eGFR 31-40 eGFR 82-106

Copyright ©2006 BMJ Publishing Group Ltd.

Traynor, J. et al. BMJ 2006;333:733-737

Fig 2 Commonly used formulas for estimating renal function. MDRD=modification of diet in renal disease

Association of estimated glomerular filtration rate (GFR) with GFR measured by an isotopic reference method. Below 60 ml/min/1.73 m2 the two methods are tightly

associated, with limited scatter of the points. At higher filtration rates scatter becomes progressively worse, and in kidney donors estimated GFR underestimates renal function

compared with reference measurements. Adapted from Poggio et al.

Giles, P. D et al. BMJ 2007;334:1198-1200

Caveats

• Only an estimate• Inaccurate at extremes of body habitus, pregnant,

amputees• Only validated in Caucasians and Afro-Caribbeans• Underestimates function in kidney donors• MDRD underestimates renal function, C-G

overestimates it• Only valid in steady state

GFR > 60

• Estimated GFR not very accurate

• If GFR > 60, use increase in serum creatinine > 20% as indicator of renal deterioration

Stage 50.2%

Stage 4: 0.2%

Stage 3: 4.3%

Stage 2: 3.0%

Stage 1: 3.3%

Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J

Kidney Dis 2002;41:1-12

2% of NHS budget spent on RRT

CKD stage GFR (ml/min/1.73m2) Description

1 >90 Normal renal function but other evidence of organ

damage*

2 60-89 Mild reduction in renal function with other evidence of organ

damage*

3 30-59 Moderately reduced GFR

4 15-29 Severely reduced GFR

5 <15 End stage, or approaching, end stage

renal failure

* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

Insert p for proteinuria

3a and 3b 45-49 and 30-44

Insert p for proteinuria

3a and 3b 45-49 and 30-44

Insert p for proteinuria

3a and 3b

NICE guidelines Sept 2008

• People who have or are at risk of developing CKD• Those who need intervention to minimise

cardiovascular risk and what that intervention should be

• Those who will develop progressive kidney disease and how they can be managed

• Those who need referral for specialist kidney care

Offer testing for CKD

• Diabetes• HTN• CV disease: IHD, CHF, PVD, CVD• Structural disease, calculi or BPH• Multisystem eg SLE• FHx CKD 5 or hereditary kidney disease• Nephrotoxins (CNIs or ACE inhibitors)• Opportunistic detection of h’turia or p’uria

Proteinuria

• Use albumin: creatinine ratio (ACR) (more sensitive at low levels)

• ACR in diabetes

• PCR may be used for quanitification and monitoring

Don’t offer testing…

• On basis of – Age– Gender– Ethnicity– Obesity without metabolic syndrome, diabetes

or HTN

Who needs a renal ultrasound?

• All people with CKD with– Progressive CKD– Haematuria– Obstructive symptoms– > 20 yrs with FHx polycystic kidneys– CKD 4-5– Prior to biopsy

Who should be referred?

• CKD 4 and 5 (with or without diabetes)• ACR > 70 unless diabetic and already treated• ACR > 30 and haematuria• GFR declining > 5 /yr or 10 in 5 yr• Uncontrolled HTN despite 4 agents• Suspect rare or genetic cause CKD• Suspect renal artery stenosis

Consider discussion with nephrologist by phone or letter if you feel clinic referral may

not be necessary

Single clinic visit with agreed management plan and specified criteria for re-referral may

be all that is necessary

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

Case history

• Mr RB, 69 years old, Type II diabetes

• “Please see this man with CKD 4…”

• PMHx:– DM, ileal conduit and pyelonephritis, dyspepsia

• DHx:– Atenolol, gliclazide, metformin, simvastatin,

lansoprazole, GTN spray

Started lansoprazole

Tubulo-interstitial nephritis

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 > 5 /yr or 10 in 5 yrs

• Extrapolate current rate of decline: will pt need RRT in their life time?

Extrapolate current rate of decline: will pt need RRT in their life time?

1. Will their kidneys fail in their lifetime?

2. Will they die of something else first?

80 yrs old

eGFR 50

No PMHx

BP 120/60

P’uria 0.3g/day

45 yrs old

eGFR 50

Type II diabetes

BP 160/90

P’uria 2.6g/day

RENAL RISK

CKD stage 3a

Manage cardiovascular risk factors

Don’t refer

CKD stage 3p

Progressive

Do refer

In people aged over 70 years, eGFR 45-59, if stable over time and without any other evidence of

kidney damage, unlikely to be associated with CKD related complications

Extrapolate current rate of decline: will pt need RRT in their life time?

1. Will their kidneys fail in their lifetime?

2. Will they die of something else first?

100 patients with eGFR < 60

(Tuesday morning in Outpatients)

Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD

The majority of patients with CKD 1-3 do not progress to ESRF.

Their risk of cardiovascular death is higher than their risk of progression.

O’Hare et al JASN 2007

Optimise risk factors

• Cardiovascular disease

• Proteinuria

• Hypertension

• Diabetes

• Smoking

• Obesity

• Exercise tolerance

ACE inhibitor/ ARBs

• Offer to:– Diabetes and ACR > 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 > 70

regardless of blood pressure or risk factors– Titrate to maximum tolerated dose before add

in second agent

What is an acceptable rise in creatinine?

Loss of nephrons

Hyperfiltration of remaining nephrons

Increased glomerular pressure

Mesangial cell and endothelial cell injury

Mesangial cell proliferation and matrix expansion

Focal sclerosis

Primary renal damage

What is acceptable?

•25% increase eGFR

•30% increase creatinine

•K up to 6.0

Always

•check U and Es 1-2 weeks after starting ACE inhibitor

•Recheck after dose increase

•Advise stopping ACEI with dehydrating illness

•Counsel women of child bearing age

Blood pressure control

• Systolic < 140 (aim 120-139 mm Hg)

• Diastolic < 90 mm Hg

• If diabetes or proteinuria, aim 130/80 mm Hg

What do we do in CKD clinic?

Mr KH

• “Please see this well 73 year old with diabetes..”

• PMHx: DM, IHD, cerebrovascular disease, SCC • DHx: gliclazide, lansoprazole, metformin, quinine,

sildenafil, simvastatin, valsartan, clopidogrel

• BMI 33, BP 132/80• Ur 8.0, Cr 129, PCR 125 mg/l, HbA1C 8.3%

Mr KH (cont’d)

• Address proteinuria– Maximise ACE/ RAS inhibition

Mr KH (cont’d)

• Address proteinuria– Maximise ACE/ RAS inhibition

• Risk factor modification:– Lifestyle– Meticulous BP control– Lipid management– Glycaemic control

Sound familiar?

CKD 3 management in primary care

• Diabetes, ischaemic heart disease, hypertension• 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

Stage 5

Stage 4

Stage 3

Stage 2

Stage 1

PTH increases at GFR 50-60

Ca absorption and lipoprotein activity reduced

Malnutrition, LVH, anaemia

Hypertriglyceridaemia

Hyperphosphataemia

Metabolic acidosis

Hyperkalaemia

Uraemia

The metabolic complications of CKD

“Patients receiving comprehensive care by the renal team have shown:– slower rates of decline in renal function– greater probability of starting dialysis with

higher haemoglobin, better calcium control and permanent access

– a greater likelihood of choosing peritoneal dialysis.”

Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. for the Collaborative Study Group. Renoprotective effect of the angiotensin-receptor

antagonist irbesartan in patients with nephropathy due to type 2 diabetes N Engl J Med 2001. 345:851–860.

Why bother?

• Manage risk factors

• Further investigations (? reversibility)

• Delay progression to ESRF

• Identify and treat complications– Bone– Anaemia– Malnutrition

Stage 50.2%

Stage 4: 0.2%

Stage 3: 4.3%

Stage 2: 3.0%

Stage 1: 3.3%

Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J

Kidney Dis 2002;41:1-12

Primary care

Secondary care

“Since the introduction of eGFR reporting (together with a programme of education in primary care), the proportion of new dialysis patients referred late (defined as within 90 days) has fallen from 38% to 25% (p<0.01).”

BMJ  2007;334:1287 (23 June), doi:10.1136/bmj.39247.723206.3A

Any questions?