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CKD ML/LH 17.3.10. Chronic Kidney Disease. Are we correctly diagnosing CKD? Have we the correct patients on our CKD register? Are we managing them correctly?. Plan for today. Highlight a few issues around eGFRs Review NICE and PACE guidance Discuss how we diagnose and manage CKD

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chronic kidney disease
Chronic Kidney Disease
  • Are we correctly diagnosing CKD?
  • Have we the correct patients on our CKD register?
  • Are we managing them correctly?
plan for today
Plan for today

Highlight a few issues around eGFRs

Review NICE and PACE guidance

Discuss how we diagnose and manage CKD

Identify and discuss any uncertain areas

why introduce ckd qof indicators
Why introduce CKD QOF indicators?
  • End stage renal failure is costly to treat, and its prevalence is increasing
  • 30% of patients present late; they have worse outcomes and are more expensive to treat
  • It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF
risks of a low egfr
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
possible symptoms ckd 3 5
Possible symptoms (CKD 3 - 5)
  • Tiredness
  • Anorexia, nausea
  • Weight loss
  • Dry itchy skin
  • Muscle cramps
  • Ankle swelling, peri-orbital oedema
  • Anaemia
offer ckd screening to at risk groups
DM

Hypertensives

CVD

Multisystem diseases e.g. SLE

Structural renal tract disease e.g. stones, BPH

FHx CKD 5 or hereditary kidney disease

Long term NSAIDS

Offer CKD screening to at risk groups
testing egfr
Testing eGFR
  • GFR estimated from serum creatinine and age, using MDRD equation
  • If abnormal, repeat the test to confirm
  • Multiply eGFR result by 1.212 for African -Caribbean and African patients

(Are we recording this correctly?)

egfr and meat
eGFR and meat
  • NICE specifically advises no meat for 12 hours before eGFR
  • Are we doing this?
  • How do we record it?
egfrs and age
eGFRs and age
  • eGFR is not validated in the >75s

(How many patients >75 have we coded with CKD 3?)

  • From the age of 40 the eGFR declines by 1ml/min/yr
  • NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.
newly identified ckd
Newly identified CKD
  • Stage CKD on eGFR results
  • Stage 1 > 90
  • Stage 2 60 - 89
  • Stage 3A 45 - 59
  • Stage 3B 30 - 44
  • Stage 4 15 - 29
  • Stage 5 <15
assess for proteinuria
Assess for proteinuria
  • NICE advises ACR on first sample of the day (preferably)
  • ACR abnormal if >30, in non diabetics
  • (Repeat to confirm if ACR >30 but <70)
  • ACR abnormal if >2.5 in diabetic men
  • ACR abnormal if >3.5 in diabetic women
issues around proteinuria
Issues around proteinuria
  • NICE also mentions PCRs (mg/mmol)

(ACR of 30 = (approx) PCR of 50)

  • But in Bradford they report PCIs (mg/mg), which correspond with 24hr urinary protein excretion
  • PCR of 50 = PCI of 500 (i.e. divide by 10)
  • Leeds/Bfd Biochem are considering changing to PCRs in the future, to fit with NICE
false positives
False positives
  • Urinary Tract Infection

Do MSU if dipstix +ve for protein

  • Menstrual contamination
  • Benign orthostatic proteinuria
assess for progressive ckd
Assess for progressive CKD
  • Check at least 3 eGFRs over at least 90 days
  • Defined as a decline in eGFR of

>5 within 1 year, or >10 within 5 years

  • Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction,

proteinuria and diabetes

other baseline tests
Other baseline tests

For all

  • Dipstix for haematuria
  • CVD risk assessment
  • Consider DEXA scan

CKD 4 and 5

  • FBC and ferritin
  • Calcium, phosphate, PTH
consider renal uss
Consider renal USS
  • If CKD 4 or 5
  • Progressive CKD
  • Visible or persistent invisible haematuria
  • Symptoms of urinary tract obstruction
  • FHx polycystic kidney disease and >20yrs of age
consider referral
Consider referral
  • CKD 4 or 5 without diabetes
  • ACR >70 in non diabetics
  • Proteinuria (ACR>30) with haematuria
  • Progressive CKD
  • CKD and poorly controlled BP on 4 agents
  • Suspected genetic renal disease or renal artery stenosis
routine management
Routine management

Lifestyle modification

  • Smoking increases risk of progressive CKD
  • Lose weight if obese
  • Regular exercise
  • Reduce salt if hypertensive
routine management1
Routine management

Monitor eGFR

  • CKD 3 6 monthly
  • CKD 4 3 monthly
  • CKD 5 6 weekly
routine management2
Routine management

Control BP

  • NICE target <140/90
  • <130/80 if ACR >70
  • <130/80 if diabetic
  • QOF <140/85 for all
routine management3
Routine management

Reduce proteinuria

  • ACEIs first line
  • ARBs if not tolerated
routine management4
Routine management

ACEI or ARB:

  • Diabetes + ACR (>2.5 men, or 3.5 women)

(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)
routine management5
Routine management

Routine anti-hypertensive treatment

  • Non-diabetic + CDK + HT + ACR <30

(See NICE Hypertension guideline 34)

routine management6
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
routine management7
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
  • Consider referral for erythropoeisis stimulaing agents (ESA’s)
routine management8
Routine management

Manage bone conditions

  • Ca, PTH and phosphate if CKD 4 or 5
  • Offer biphosphonates to all “if indicated”
  • If indicated offer vitamin D supplements:

- cholecalciferol or ergocalciferol in CKD3

- alfacalcidol or calcitriol in CKD 4 and 5

  • If on vit D supplements they need to be monitored
qof indicators
QOF indicators
  • CKD1: Register of patients >18 yrs with CKD (stages 3 – 5)
  • CKD2: % of pts with BP recorded in last 15 mths
  • CKD3: % of pts in whom last BP reading, in last 15 mths, is <140/85
  • CKD5: % of pts with HT + proteinuria on ACEI or ARB (unless c/i or s/e recorded)
  • CKD6: % of pts with urine ACR (or PCR) test in last 15 months
qof indicators1
QOF indicators
  • CKD points total = 38 points = £££
  • CKD1 (reg) = 6 points
  • CKD2 (bp) = 6 points
  • CKD3 (bp controlled) = 11 points
  • CKD5 (acei/arb) = 9 points
  • CKD6 (acr) = 6 points
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