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Addressing Chronic Kidney Disease: Diagnosis, Management, and Guidelines

The event discusses diagnosing and managing CKD, highlighting issues around eGFRs, NICE and PACE guidance, and uncertainties in treatment. It talks about introducing CKD QOF indicators, risks of a low eGFR, identifying CKD stages, and assessing for proteinuria. The presentation covers the correct eGFR testing procedures, proteinuria measurement, false positives, progressive CKD risk factors, baseline tests, routine management steps, lifestyle modifications, monitoring eGFR, controlling BP, reducing proteinuria, and immunization recommendations for CKD patients. This comprehensive event aims to improve CKD diagnosis and management.

maribeth-madsen
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Addressing Chronic Kidney Disease: Diagnosis, Management, and Guidelines

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Presentation Transcript

  1. CKDML/LH 17.3.10

  2. Chronic Kidney Disease • Are we correctly diagnosing CKD? • Have we the correct patients on our CKD register? • Are we managing them correctly?

  3. 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

  4. 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

  5. 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

  6. Possible symptoms (CKD 3 - 5) • Tiredness • Anorexia, nausea • Weight loss • Dry itchy skin • Muscle cramps • Ankle swelling, peri-orbital oedema • Anaemia

  7. NICESept 2008, Clinical Guideline 73

  8. 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

  9. 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?)

  10. eGFR and meat • NICE specifically advises no meat for 12 hours before eGFR • Are we doing this? • How do we record it?

  11. 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.

  12. 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

  13. eGFRs: ‘normal for age?’

  14. 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

  15. 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

  16. False positives • Urinary Tract Infection Do MSU if dipstix +ve for protein • Menstrual contamination • Benign orthostatic proteinuria

  17. 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

  18. Other baseline tests For all • Dipstix for haematuria • CVD risk assessment • Consider DEXA scan CKD 4 and 5 • FBC and ferritin • Calcium, phosphate, PTH

  19. 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

  20. 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

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

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

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

  24. Routine management Reduce proteinuria • ACEIs first line • ARBs if not tolerated

  25. 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)

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

  27. 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

  28. 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)

  29. 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

  30. 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

  31. 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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