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Approach to an abnormal eGFR in primary care. Hugh Gallagher Consultant Nephrologist SW Thames Renal Unit. Changes in the way we measure kidney function eGFR Total protein-creatinine ratio Chronic kidney disease (CKD), classification, clinical features and consequences

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approach to an abnormal egfr in primary care

Approach to an abnormal eGFR in primary care

Hugh Gallagher

Consultant Nephrologist

SW Thames Renal Unit

slide2
Changes in the way we measure kidney function
    • eGFR
    • Total protein-creatinine ratio
  • Chronic kidney disease (CKD), classification, clinical features and consequences
  • Approach to an abnormal eGFR in primary care
  • The management of CKD in primary care
slide3
Changes in the way we measure kidney function
    • eGFR
    • Total protein-creatinine ratio
  • Chronic kidney disease (CKD), classification, clinical features and consequences
  • Approach to an abnormal eGFR in primary care
  • The management of CKD in primary care
slide4
“Local health organisations can work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of glomerular filtration rate (eGFR), calculated and reported automatically by all clinical biochemistry laboratories.”

Renal NSF Part 2, Dept of Health, 2004

the problem with creatinine
The problem with creatinine….
  • Affected by muscle mass (age/sex/weight) so poor surrogate for GFR
  • Insensitive – can lose 50% of renal function before serum creatinine rises
  • Therefore poor marker of early renal disease
slide6
GFR

= Glomerular filtration rate

“Normal” = 80-120 ml/min

Therefore see as “% renal function”

Calculate

1) Actual – iohexol/EDTA clearance

2) Estimated – using formula

formulae in use
Formulae in use
  • *MDRD formula
    • Age
    • Sex
    • Creatinine
    • Ethnicity (black vs. non-black)
  • Cockcroft-Gault formula
    • Age
    • Sex
    • Creatinine
    • Weight
slide9

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

slide10

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

46

slide11

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

46

80

M

60

170

slide12

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

46

80

M

60

170

26

slide13

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

46

80

M

60

170

26

80

F

60

170

slide14

Age

Sex

Weight

Serum

Estimated

(kg)

creatinine

GFR

(

mol/L)

(ml/min)

μ

60

M

70

150

46

80

M

60

170

26

80

F

60

170

22

slide15
The introduction of eGFR will allow early identification of CKD

and

Will result in increased awareness of advanced CKD previously not recognised as such

urine total protein creatinine ratio
Urine total protein:creatinine ratio
  • Replaces timed 24 hour urine collections for protein
  • Random spot urine (preferably early morning, but not essential)
  • Result in mg/mmol (mg of protein per mmol of creatinine)
  • Multiply by 10 = total daily protein excretion in mg
urine total protein creatinine ratio1
Urine total protein:creatinine ratio

Urine protein = 500 mg/l

Urine creatinine = 5 mmol/l

Therefore TPCR = 500/5 = 100 mg/mmol

Therefore daily protein excretion

= 100 x 10

= 1000 mg

= 1 g

not to be confused with
Not to be confused with….

Urine albumin:creatinine ratio

NOT for quantifying urine total protein excretion

BUT simply to diagnose the earliest stage of diabetic nephropathy

Raised ACR = treat with ACEI/ARB (even if normotensive) and address CV risk

slide22
Changes in the way we measure kidney function
    • eGFR
    • Total protein-creatinine ratio
  • Chronic kidney disease (CKD), classification, clinical features and consequences
  • Approach to an abnormal eGFR in primary care
  • The management of CKD in primary care
k doqi classification of ckd
K-DOQI Classification of CKD

Chronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

k doqi classification of ckd1
K-DOQI Classification of CKD

Chronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

in real money
In real money...
  • GP practice 10,000 patients
    • Stage 3 CKD: 500 patients
    • Stage 4 CKD: 20 patients
    • Stage 5 CKD: 20 patients
    • Unreferred stage 4 and 5: 28 patients
  • Renal unit, serving 1.8 million population
    • Unreferred stage 4 and stage 5: 5,100 patients
functional consequences of ckd
Functional consequences of CKD
  • Hypertension (all stages)
  • Anaemia (stage 4-5, earlier in DM)
  • Disorders of Ca/Pi/PTH metabolism (stage 4-5)
    • renal osteodystrophy
    • vascular calcification
snapshot of a ckd population in primary care
Snapshot of a CKD population in primary care
  • GFR estimated on patients from 12 practices in Surrey, Kent and Greater Manchester
  • 19% of sample (5% population) stage 3-5 CKD
  • mean age 74 years (control 57 years)
  • 75% stage 3-5 (22% control) co-existing circulatory disease
  • 25% stage 3-5 (men) prostatic disease
  • 15% stage 3-5 anaemic by WHO (4% requiring treatment by European Best Practice guidelines)
  • 3% recorded as having a renal disease
slide31

Cardiovascular diseases in CKD

Damage to the heart

(Uraemic cardiomyopathy)

Damage to the arteries

(Uraemic arteriopathy)

cardiovascular mortality rates are higher among dialysis patients
Cardiovascular Mortality Rates are Higher among Dialysis Patients

100

10

1

Dialysis: male

Dialysis: female

0.1

General

population: male

0.01

General

population: female

0.001

Adapted from Levey AS et al. Am J Kidney Dis 1998; 32: 853-906.

the kaiser permanante experience
The Kaiser Permanante experience

Derangements in renal function are independently associated with a graded increase in (cardiovascular) risk. This effect is seen even with relatively minor impairments in function.

Go, A. S. et al. N Engl J Med 2004;351:1296-1305

esrd is the tip of an iceberg
ESRD is the tip of an iceberg

DIALYSIS DEPENDENT 0.04%

PROGRESSIVE STAGE 4 CKD 0.05%

STABLE STAGE 4 CKD 0.15%

STAGE 3 CKD 4%

3 key messages
3 Key Messages
  • Most patients with CKD are elderly
  • The majority have stable disease and die of CV causes well before they reach ESRD
  • Their management is therefore that of their CV risk
slide37
Changes in the way we measure kidney function
    • eGFR
    • Total protein-creatinine ratio
  • Chronic kidney disease (CKD), classification, clinical features and consequences
  • Approach to an abnormal eGFR in primary care
  • The management of CKD in primary care
questions to ask with a newly detected abnormal egfr 60 ml min
Questions to ask with a newly detected abnormal eGFR (< 60 ml/min)
  • Is this acute renal failure?
    • Historical records
    • Repeat within 1/52
  • Is it in the context of intercurrent illness?
    • Repeat after illness treated
  • Is there suspicion of obstruction?
    • Renal tract US (not otherwise)
  • Are there abnormalities on urinalysis?
    • Dipstick urine, send simultaneous MSU/TPCR
  • Should the patient be referred?
urinanalysis and the patient with a newly detected abnormal egfr 60 ml min
Urinanalysis and the patient with a newly detected abnormal eGFR (< 60 ml/min)
  • Nephrology referral is indicated in the presence of persistent microscopic haematuria (if age > 45 then urological malignancy should be excluded first)
  • Nephrology referral is also indicated (in the presence or absence of microscopic haematuria) if total protein-creatinine ratio > 100 mg/mmol (1 g proteinuria)
  • Nephrology referral is not required (in the absence of microscopic haematuria) for lower levels of proteinuria, although these patients should be labelled as Stage 3 CKD and entered into appropriate care pathway
should the patient with newly detected egfr 60 ml min be referred
Should the patient with newly detected eGFR < 60 ml/min be referred?
  • Not in the majority of cases
  • ARF
  • Obstruction (urology)
  • Abnormalities on urinalysis
  • For those patients with previously abnormal creatinine/eGFR, treat as CKD
what about referral indication in patients with egfr 60 ml min
What about referral indication in patients with eGFR > 60 ml/min?
  • Proteinuria > 1g/day (TPCR > 100 mg/mmol)
  • Proteinuria > TPCR 45 mg/mmol plus microscopic haematuria
  • Multisystem disease with evidence of kidney damage
  • Accelerated hypertension with evidence of kidney damage
  • Suspicion of renal artery stenosis
  • New diagnosis of APKD
slide42
Changes in the way we measure kidney function
    • eGFR
    • Total protein-creatinine ratio
  • Chronic kidney disease (CKD), classification, clinical features and consequences
  • Approach to an abnormal eGFR in primary care
  • The management of CKD in primary care
general management of ckd
General management of CKD
  • Blood pressure
    • Home meter
    • 140/90 threshold
    • 130/80 target (125/75 if TPCR > 100 mg/mmol)
    • ACEI/ARB if MA/proteinuria/heart failure
    • Refer if >150/90 despite 3 complementary drugs
  • Lipid management
    • JBS guidelines
  • Other
    • Aspirin if 10 year CV risk > 20%
    • Influenza/pneumococcal vaccination
    • Smoking/weight
    • Medication review
specific management of stage 3 ckd
Specific management of Stage 3 CKD
  • Renal US only if:
    • Refractory hypertension
    • Lower tract symptoms
  • 50% dose reduction metformin if eGFR < 45 ml/min
  • Refer if:
    • Progressive (fall in eGFR > 10 % over 1 year)
    • Functional haematological/biochemical consequences:
      • Hb < 11
      • K > 6
      • Ca < 2.1, Pi > 1.5, PTH > 7 pmol/l
    • Poorly controlled hypertension
specific management of stage 4 ckd
Specific management of Stage 4 CKD
  • Discuss with nephrology
  • Renal US
  • Stop metformin
  • Refer if:
    • Diabetic
    • Progressive (fall in eGFR > 15 % over 1 year)
    • eGFR < 20 ml/min
    • Functional haematological/biochemical consequences:
      • Hb < 11
      • K > 6
      • Ca < 2.1, Pi > 1.5, PTH > 11 pmol/l
    • Poorly controlled hypertension
take home messages
Take home messages
  • eGFR as a “% kidney function”
  • 0.5-1%/year lost from 40+
  • Most CKD patients are stable and management is that of CV risk
  • CKD patients that should be referred are those:
    • With progressive disease
    • With advanced disease (Stage 5 +/- Stage 4)
    • With functional consequences of disease
ad