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CKD ML/LH 17.3.10

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

maribeth-madsen
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CKD ML/LH 17.3.10

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  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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