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CKD In Primary Care

CKD In Primary Care. Dr Mohammed Javid. Relevance. End Stage CKD places a very significant burden on patients quality of life. End Stage CKD is very expensive to manage. Deteriorating CKD is an independant risk factor for an increase in mortality from cardiovascular disease.

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CKD In Primary Care

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  1. CKD In Primary Care Dr Mohammed Javid

  2. Relevance • End Stage CKD places a very significant burden on patients quality of life. • End Stage CKD is very expensive to manage. • Deteriorating CKD is an independant risk factor for an increase in mortality from cardiovascular disease. • QOF: CKD = 38 points

  3. Guidelines • National Service Framework 2004 -2005 • NICE guidelines 2008 • PACE local guidelines • QOF

  4. eGFR • CKD classification is based on eGFR • Estimates Glomerular Filtration Rate using serum creatinine and patients Age, Sex, etc • Cockroft-Gault formula • MDRD formula

  5. Creatinine 120 eGFR 31-40 eGFR 82-106

  6. Insert P for proteinuria 3a and 3b 45-49 and 30-44 * Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

  7. Risks of a low eGFR Renal • 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t) Cardiovascular • If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event

  8. 100 patients with eGFR < 60

  9. 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

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

  11. Proteinuria • Indicates poorer renal prognosis • Urine dipstick • Protein : Creatinine ratio PCR • Protein : Creatinine Index PCI • Albumin : Creatinine Ratio ACR • Early morning sample • <5 normal, >30 significant , >70 severe • Check for heamaturia

  12. Progressive CKD • Check at least 3 eGFRs over 90 days • Defined as a decline in eGFR of >5 within 1 year, or >10 within 5 years

  13. Routine management Lifestyle modification • Smoking increases risk of progressive CKD • Lose weight if obese • Regular exercise • Reduce salt if hypertensive

  14. Routine management Monitor eGFR • CKD 3 6 monthly • CKD 4 3 monthly • CKD 5 6 weekly

  15. Routine management Control BP • NICE target <140/90 • <130/80 if ACR >70 • <130/80 if diabetic • QOF <140/85 for all

  16. Routine management ACEI or ARB: • Diabetes + ACR (>30) (irrespective of hypertension or CKD stage) • Non-Diabetic with CKD + HT + ACR >30 • Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)

  17. Routine management Routine anti-hypertensive treatment • Non-diabetic + CDK + HT + ACR <30 (See NICE Hypertension guideline 34)

  18. Routine management CVD risk assessment • treat with a statin if CVD risk >20% (SystmOne CVD risk calculator does NOT include adjustment for chronic renal disease, but QRISK2 does) Immunizations • Influenza - annually • Pneumococcal - 5 yearly, due to declining antibody levels

  19. Routine management Drugs • Check BNF Appendix 3: Renal Impairment Test for anaemia • If Hb <11 first consider other causes of anaemia • Determine iron status – if serum ferritin <100 start oral iron

  20. Consider renal USS • If CKD 4 or 5 • Progressive CKD • Visible or persistent microhaematuria • Symptoms of urinary tract obstruction • FHx polycystic kidney disease and >20yrs of age

  21. Consider referral • CKD 4 or 5 • Proteinuria ACR >70 • Proteinuria ACR>30 with haematuria • Progressive CKD • CKD and poorly controlled BP on 4 agents • Suspected genetic renal disease or renal artery stenosis

  22. QOF indicators • CKD points total = 38 points = £££ • CKD1 (register) = 6 points • CKD2 (bp checked) = 6 points • CKD3 (bp controlled) = 11 points • CKD5 (acei started) = 9 points • CKD6 (acr checked) = 6 points

  23. Take Home Message • CKD is an independant risk factor for cardiovascular mortality which far outweighs the risk of developing end-stage renal disease • CKD 3 is managed in primary care with ACE-i and cardiovascular optimisation. • Monitor eGFR • Blood pressure control with ACE • Check for proteinuria

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