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Renal Blood Tests

Renal Blood Tests. What do they mean, where to go for what to do. What we will cover. Who to screen What do the results mean How to categorise / classify management monitoring. Chronic Kidney disease (CKD). Screening for CKD – Risk factors Age <60 years

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Renal Blood Tests

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  1. Renal Blood Tests What do they mean, where to go for what to do

  2. What we will cover • Who to screen • What do the results mean • How to categorise / classify • management • monitoring

  3. Chronic Kidney disease (CKD) • Screening for CKD – Risk factors • Age <60 years • Diabetes, cardiovascular disease, urological disease • Family history of kidney disease • hypertension • Smoking • Obesity • Ethnicity – Maori, Pacific, indo Asian (same as CVRA cohort) • Nephrotoxic drugs • Albumin creatinine ratio (aCR), Estimated Glomerular Filtration Rate (e-GFR) and MSU

  4. ProtienuriaFactors Affecting Urinary Protein Excretion • Increases Protein Excretion • Strenuous exercise • Poorly controlled DM • Heart failure • UTI • Acute febrile illness • Uncontrolled hypertension • Haematuria • Menstruation • Pregnancy • Decreases Protein Excretion: • ACEi/ARB • NSAIDs

  5. Management of microalbuminuriaMen = ACR >2.5mg/mmol and <25mg/mmol*Women = ACR >3.5mg/mmol and <35mg/mmol* • Low salt diet • Smoking cessation • Target BP < 130/80 mmhg • Use ACEi/ARB • HbA1c < 55 mmol/mol • Statin • Aspirin * Clinical Pathways can differ from Primary Care Handbook

  6. Goals of Management of CKDMen = urine ACR > 25 mg/mmol or eGFR< 45 ml/min/1.73m2Women = > 35 mg/mmol or eGFR< 45 ml/min/1.73m2 • Investigations to exclude treatable disease • Reduce progression of kidney disease • Reduce CVD risk • Early detection and management of complications • Avoidance of nephrotoxic medications or volume depletion • Adjustment of medication doses to levels appropriate for kidney function • Appropriate referral to a nephrologist when indicated * Clinical Pathways can differ from Primary Care Handbook

  7. Monitoring of CKD • Clinical assessment: • blood pressure • weight • Laboratory assessment: • urine ACR • biochemical profile including urea, creatinine and electrolytes • eGFR • HbA1c (for people with diabetes) • fasting lipids • full blood count • calcium and phosphate • parathyroid hormone (6-12 monthly if eGFR < 45 mL/min/1.73m2)

  8. Blood Pressure Reduction • CKD can cause and aggravate hypertension which can contribute to the progression of CKD • Reducing blood pressure to below threshold levels is one of the most important goals in the management of CKD • Target BP < 140/90 mmHg if no proteinuria present and less aggressive target in elderly • ACE inhibitor or ARB is recommended as first line therapy • Monitoring of creatinine and potassium 5-10 days after starting an ACE inhibitor or ARB and after each dose increment • Combined therapy of ACE inhibitor and ARB is not recommended • Maximum tolerated doses of ACE inhibitor or ARB are recommended • Hypertension may be difficult to control and multiple (3-4) medications are frequently required Note: ACE inhibitors and ARBs can cause a reversible reduction in GFR when treatment is initiated. If the reduction is less than 25% and stabilises within two months of starting therapy, the ACE inhibitor or ARB should be continued. If the reduction in GFR exceeds 25% below the baseline value, the medication should be ceased and consideration should be given to referral to a nephrologist for bilateral renal artery stenosis

  9. Glycaemic Control • Target HbA1c < 55 mmol/mol • For people with diabetes, blood glucose control significantly reduces the risk of developing CKD, and in those with CKD reduces the rate of progression • Metformin - max dose 2 g/day when eGFR< 45 and stop when eGFR< 30 Please note the increasing risk of hypoglycaemic events in stage 4/5 CKD. There is potential increased effect of medicines as renal function deteriorates so consideration and caution is required

  10. Lipid Lowering Treatments • TC:HDL ratio < 4 • Lipid-lowering treatment should be considered where appropriate for CVD risk reduction • Care of increasing risk of side-effects, especially rhabdomyolysis

  11. Lifestyle Modification • Cessation of smoking • weight reduction • low-salt diet • physical activity • moderate alcohol consumption are successful in reducing overall CVD risk

  12. Absolute Cardiovascular Risk Assessment • Patients with moderate or severe CKD (urine ACR > 25 mg/mmolin males or > 35 mg/mmol in females or eGFR < 45 mL/min/1.73m2) are the highest risk of a cardiovascular event. They do not need to be assessed by the cardiovascular risk tool • For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions (for all patients) and pharmacological interventions (where indicated) • Consider commencing aspirin for those at high CVD risk (orange/red risk), those with CKD 3b (eGFR< 45) and/or proteinuria with a PCR > 50 (ACR > 30) and/or/especially those who have had a myocardial event. See CKD Management in General Practice by Kidney Health Australia/ANZSN/RACGP

  13. Commonly prescribed drugs that may need to be reduced in dose or ceased in CKD • Antivirals • Benzodiazepines • Colchicine • Dabigatran • Digoxin • Exenatide • Fenofibrate • Gabapentin • Insulin • Lithium • Metformin (max dose 2 g/day eGFR 30-45 ml/min/1.73 m2 and stop if eGFR < 30 ml/min/1.73 m2) • Opioid analgesics • Saxagliptin • Sitagliptin • Sotalol • Spironolactone • Sulphonylureas (all) • Vildagliptin

  14. Commonly prescribed drugs that can adversely affect kidney function in CKD: • NSAIDS and COX-2 inhibitors • Beware the 'triple whammy' of NSAID/COX-2 inhibitor, ACE inhibitor and diuretic (low dose aspirin is okay) which can result in a potentially serious interaction, especially if volume-depleted or CKD is present. Ensure individuals on blood pressure medication are aware of the need to discuss appropriate pain relief medication with a General Practitioner or pharmacist. • Radiographic contrast agents • Aminoglycosides • Lithium • Calcineurin inhibitors

  15. What do you know? • Who to screen • What do the results mean • How to categorise / classify • management • monitoring

  16. Indications for Referral to a Nephrologist • Referral to a specialist renal service or nephrologist is recommended: • if eGFR < 30 mL/min/1.73m2 • persistent significant albuminuria (urine ACR > 70 mg/mmol) • a consistent decline in eGFR from a baseline of < 60 mL/min/1.73m2 (a decline > 5 mL/min/1.73m2 over a six month period which is confirmed on at least three separate readings) • glomerular haematuria with macroalbuminuria • CKD and hypertension that is difficult to get to target despite at least three anti-hypertensive agents. • Anyone with an acute presentation and signs of acute nephritis (oliguria, haematuria, acute hypertension and oedema) should be regarded as a medical emergency and should be referred without delay. • Also take into account the individual's wishes and comorbidities when considering referral. • Referral is not necessary if: • stable eGFR ≥ 30 mL/min/1.73m2 • urine ACR < 30 mg/mmol (with no haematuria) • controlled blood pressure. • The decision to refer or not must always be individualised. Particularly in younger individuals the indications for referral may be less stringent.

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