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Cardiovascular Hot topics ‘CKD’

Cardiovascular Hot topics ‘CKD’. Dr Saqib Mahmud MBBS, MD, MRCP(UK), MRCPS(Glasg), MRCGP. CKD. The introduction of routine reporting of eGFR has led to 3 outcomes in primary care; ‘Worried patients, Increased workload & confused clinicians’.BMJ2006

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Cardiovascular Hot topics ‘CKD’

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  1. Cardiovascular Hot topics‘CKD’ Dr Saqib Mahmud MBBS, MD,MRCP(UK), MRCPS(Glasg), MRCGP

  2. CKD • The introduction of routine reporting of eGFR has led to 3 outcomes in primary care; • ‘Worried patients, Increased workload & confused clinicians’.BMJ2006 (Referral rates remain high due to uncertainty how to manage newly diagnosed CKD cases)

  3. Why has CKD been selected as a quality indicator?QOF2 2006 • Patients with CKD have very high rates of vascular disease & require aggressive management of vascular risk factors. (early CKD risk of death from CVD>ESRF)-low GFR predicts CV disease • Its incidence is rising dramatically. (doubled in last 10yrs,5% adult population) • S Cr does not rise until GFR has fallen by 50-70% • Early interventions in CKD improve cardiac & renal outcomes

  4. eGFR-bestestimate of renal function • Based on S Cr, age, sex & ethnic origin. • Does not apply to children, ARF, pregnant women, oedematous & malnourished. • eGFR falls after eating meat, ideally fasting sample or avoid eating cooked meat day before. • CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFR

  5. CKD-classification

  6. Clinical Signs & Symptoms • Tiredness • Anorexia, nausea, vomiting • Generalized pruritis • Nocturia, frequency, oliguria, haematuria • Frothy urine • Loin pain • Pallor, peripheral & pulmonary oedema • Pleural effusion & SOB • leuconychia

  7. QOF 2006 – CKD register • CKD1- register of pts>18 with CKD3-5 • CKD2-(90%) on register with record of BP in last 15/12 • CKD3-(70%) on register with BP<140/85 • CKD4-(80%) patients on ACEI/A2RB-or CI • Worth 27pts=£3,364/-

  8. Conditions with risk of developing CKD • Hypertension • Diabetes • Heart failure • Vascular disease • Urinary outflow obstruction • Multi-system diseases eg;RA, SLE,vasculitis • APKD or reflux nephropathy • Long term Drugs-lithium, cyclosporin,NSAIDs,mesalazine

  9. Monitoring renal function • Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, microalbuminuria, haematuria without urological cause or known polycystic kidney disease or GN. (Annual U & Es) • Stage 3  6/12 • Stages 4 & 53/12

  10. Urine tests • Dipstick urinalysis for protein, • If +ve  msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45) • In diabetics, dipstick negativeACR for microalbuminuria (+>2.5mg/mmol-males,>3.5 in women)

  11. Management – is easy • ‘CKD rarely means dialysis’ • Monitor renal function closely- assess rate of change • Tight BP control with preferential use of ACEI or A2RB • Pay close attention to CV risk

  12. New patient with eGFR<60 • Review previous results ?rate of deterioration • Review medication ?nephrotoxicity • Check BP, urine, full clinical assessment eg ?palpable bladder • Repeat U&E within 5/7 (?rapid progression) • Referral criteria- renal function stable monitor • Stage 4(if stable, monitor) & 5 should be referred • Stage 3 if deteriorating function

  13. Long term management to delay progression and reduce CV events • Life style advise smoking cessation, wt reduction, exercise, low protein diet • Aspirins & statins if CVD risk 15-20% • (evidence is that all CKD patients are high risk) • Strict BP control-QOF2 target <140/85, but renal guidelines best practice target is 130/80 -UK CKD&JBS2 guidelines. • Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBs • Aspirin->BP<150/90, target TC<4,LDL<2

  14. Additional management-CKD3 Renal USS if LUTS, refractory HTN, unexpected fall in GFR Immunise-influenza, pneumococcus, Hep B in CKD4&5 If HB<11-exclude other causes, refer for ESA, iv Fe

  15. Renal osteodystrophy • Renal failure failure of Vit D hydroxylation secondary hyperparathyroidism • increased # risk due to faulty bone remodelling & lowered BMD. • Check PTH levels, if low check 25-hydroxy Vit D levels • Rx- ergo or colecalciferol with calcium/bisphosphonates

  16. Bone disease in CKD • Recent Irish study found 76% of osteoporosis cases in CKD patients • Patients with CKD 4&5 had significantly lower BMD at hip & spine + high bone turnover • 2 fold increased risk of vertebral fractures • Statins - known to have beneficial effect in prevention of osteoporosis as well as decreased incidence of sepsis in CKD!

  17. ACEI / A2RB-Rxor the cause • ACEI/A2RBs improve outcomes but in some patients can be nephrotoxic • A slight reduction in GFR (<15%) or increase in creatinine is a normal haemodynamic response to ACE inhibition & is normally not an indication to stop Rx unless creatinine rises by >30% • Heart failure-rise in CR upto 50% baseline or 200umol/l is acceptable-(NICE)

  18. Renal artery stenosis • GFR- difference b/w flow of blood into glomeruli via afferent arteriole & flow out via efferent arteriole • This is not dependent on AT II normally but kidneys can increase GFR by local production of AT II which vasoconstricts efferent arteriole • In RAS-GFR is dependent on AT II mediated efferent arteriole vasoconstriction

  19. Renin- Angiotensin system

  20. RAS-cont • RAS is likely if rise in S Cr in absence of significant drop in BP • ‘Flash pulmonary oedema’-bilateral RAS predisposes to episodic catastrophic pulmonary oedema-often misdiagnosed as LVF until ACEI Rx causes rapid rise in S Cr • Renal function usually reverts to baseline on stopping ACEI • Small kidneys in Renal USS-strong indicator

  21. RAS-cont

  22. Rx in RAS • Ca channel blockers (dihydropyridines)-Rx of choice in RAS • Also indicated when ACE Is are not tolerated • Targeting BP lowering aggressive is more important than choice of Rx- ALHAT study

  23. Prescribing in CKD • Avoid NSAIDs, codeine • Withold ACEIs in hypovolaemic states-gastroenteritis etc • Antibiotics, digoxin, metformin etc – • ‘use with caution’ • (reduce dose or frequency)

  24. What about elderly patients with low eGFR- how should we manage them? • The guideline makes no age distinctions • BMJ2006;it is ageist not to Rx CKD just because someone is elderly. • BJGP editorial Dec2006;elderly with CKD still benefit from CV risk factor intervention and strict BP control in elderly slows rate of renal decline • Use clinical judgement & patient circumstances

  25. Key points….. • CKD patients have high risks of CV events & so CVD prevention should be fundamental to the management of CKD • Risk of ESRF is very low(ckd3-1.1%:24.3% CV death-5yr) • Best practice target BP is 130/80 with preferential use of ACEI / A2RB • Consider aspirin and statins • Life style advise & low protein diet • Consider Bisphosphonates & Ca for CKD assoc bone disease • ACEIs not necessary for all CKD pts

  26. Thank you-questions??? ‘The enemy of good is better’

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