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CKD presentation

CKD presentation. 2.12.10. CKD definition. “Irreversible impairment of kidney function” How do you accurately assess renal function? Serum creatinine eGFR (more accurate than Cr) Complex meaurements. Background. 1 in 10 people in the UK have chronic kidney disease (CKD)

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CKD presentation

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  1. CKD presentation 2.12.10

  2. CKD definition “Irreversible impairment of kidney function” How do you accurately assess renal function? Serum creatinine eGFR(more accurate than Cr) Complex meaurements

  3. Background • 1 in 10 people in the UK have chronic kidney disease (CKD) • Treatment can prevent or delay the progression of CKD and reduce the risk of cardiovascular disease. • CKD is frequently unrecognised, often existing with other conditions such as cardiovascular disease or diabetes. • 30% of patients with advanced CKD are referred late to nephrology services from primary and secondary care.

  4. CKD stages

  5. Prevalence • UK study (Drey et al, AJKD 2003) - 5554 per million population have CKD stages 3-4 • US study (NHANES; AJKD 2003) - 4.5% of adult population have CKD stages 3-4 • 2/3 > 70 years old • 1/4 diabetic • 3/4 hypertensive

  6. Prevalence

  7. Growing problem in UK USRDS, 2000

  8. Causes of Severe(4-5) CKD • 40% Diabetes (mostly type 2) • 20% Reno-vascular disease • 20% Hypertension • 10% Urological problems (inc. congenital abnormalities of urinary tract) • Glomerulo-nephritis & vasculitis • Congenital kidney disease

  9. Early identification • Offer testing for CKD where the following risk factors are present: • diabetes • hypertension • cardiovascular disease • structural renal tract disease • renal calculi • prostatic hypertrophy • multisystem diseases with potential kidney involvement • opportunistic detection of haematuria or proteinuria • family history of stage 5 CKD orhereditary kidney disease

  10. Who should be tested for CKD? At risk individuals • Diabetes • HTN • Cardiovascular (IHD, PVD, CVD, CCF) • Structural renal tract disease, calculi or prostatic hypertrophy • Multisystem disease with renal impairment • FHx of CKD5 or hereditary kidney disease • Opportunistic detection of haematuria or proteinuria

  11. Management of CKD 3-5 patients • Slow progression Hypertension Proteinuria • Manage cardiovascular risk Statins, DM control, Smoking • Manage renal-specific complications/risks Anaemia Bone disease • Prepare for renal replacement therapy

  12. CKD 3 management in primary care • DM, IHD, Htn • 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

  13. 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

  14. 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

  15. The metabolic complications of CKD Uraemia Hypertriglyceridaemia Hyperphosphataemia Metabolic acidosis Hyperkalaemia Ca absorption and lipoprotein activity reduced Malnutrition, LVH, anaemia PTH increases at GFR 50-60

  16. When to refer • Diagnostic uncertainty • Rapidly deteriorating renal function. >5% GFR per year or >10% over 5 years • Haematoproteinuria (without biopsy diagnosis) • Poorly controlled BP or proteinuria despite angiotensin blockade • Developing hyperparathyoidism, anaemia or difficult to manage CKD complications • To prepare for dialysis (Stage 4/5 CKD)

  17. If EGFR <60 • look at previous results (rate of change) • review medication • assess clinically • urinary symptoms, bladder, BP, heart • dipstick urine • blood and protein – refer • protein only – greater than ++ – refer • repeat serum creatinine within 5 days if new finding • either enter into a chronic disease management program or refer

  18. EFGR <30 • refer to nephrology if • diagnostic uncertainty • candidate for RRT • metabolic complications that would respond to treatment even if not for RRT • anaemia • hypocalcaemia, vitamin D deficient, hyperparathyroidism • hyperkalaemia • symptom control as part of conservative care program

  19. Blood pressure control • In people with CKD aim for: systolic blood pressure below 140 mmHg(target range 120–139 mmHg) diastolic blood pressure below 90 mmHg • In people with CKD and diabetes - or when ACR  70mg/mmol, aim for: systolic blood pressure below 130 mmHg(target range 120–129 mmHg) diastolic blood pressure below 80 mmHg

  20. CVD and CKD • Risk of CVD is doubled in Stage 3 CKD • Risk of CVD is doubled with microalbuminuria • Annual mortality from CVD is increased 10 – 100 times with kidney failure (Stage 5 CKD) • First year CVD mortality x5 greater with Stage 5 CKD + DM (17%) than Stage 5 CKD alone (3.5%)

  21. Late referral • Late referral associated with • increased age • more frequent co-morbidity • diabetes • renovascular disease • cardiac failure

  22. Late referral • Consequences • no vascular access • prolonged hospitalization (40 vs 15 days/year) • increased mortality

  23. Proteinuria • Use albumin: creatinine ratio (ACR) (more sensitive at low levels) • ACR in diabetes • PCR may be used for quanitification and monitoring

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