Chronic Kidney Disease

1. Chronic Kidney Disease HOT TOPIC FEBRUARY 2007 Kelly Frullani

2. WHY THIS TOPIC? Major workload in practice New QOF targets Affects large numbers of patients ? Exams

3. DEFINITION OF CKD Kidney damage > 3months – defined by structural or functional abnormalities with/without decrease in GFR Pathological Markers of kidney damage (abnormalities in blood/urine/imaging) GFR<60 for > 3months with/without kidney damage

4. NEED FOR GUIDELINES Majority with early CKD don’t progress to ERF Increased risk of CV disease Established renal failure rare but expensive Numbers receiving renal replacement therapy rising – 2% of NHS budget Majority starting replacement therapy progressed from earlier stages of CKD

5. GUIDELINES 2004 and 2005 DoH published National Service Framework for Renal Services CKD in Adults. UK Guidelines for identification, management and referral Developed by Joint specialist committee on Renal Medicine of Royal College Physicians and Renal Association March 2006 ?NICE guideline 2008

6. AETIOLOGY Most common cause is type 2 diabetes Other causes Hypertension Chronic Glomerulonephritis Polycystic Disease Pyelonephritis

7. PREVALENCE 10% of population have CKD 5% are in stages 1-2 5% are in stage 3-5 For average GP list size – 220 patients with CKD

8. CLASSIFICATION From US National Kidney Foundation in their Kidney Disease Outcomes Quality Initiative Stage 1 – normal eGFR > 90 - other evidence of CKD Stage 2 – mild eGFR 60-89 - other evidence of CKD Stage 3 – moderate eGFR 30-59 Stage 4 – severe eGFR 15-29 Stage 5 – ERF eGFR <15 or on dialysis Other evidence- persistent proteinuria/haematuria/ microalbuminuria, structural abnormalities on USS

9. MEASURING GFR Assessed by formula based estimation of GFR In adults >18yrs eGFR calculated using the 4 variable Modification of Diet in renal disease (MDRD) equation 4 variables- serum creatinine, age, sex, ethnic origin Equation not validated for use in Children < 18yrs Pregnancy ARF Oedematous states, malnourishment, amputees

10. DETECTION OF PROTEINURIA Positive Dipstix test (=1+)- send for UPCR + culture to exclude UTI UPCR=45mg/mmol is positive test for protein Persistent proteinuria- =2 positive tests Proteinuria is single best predictor of disease progression Reducing urine protein excretion slows progressive decline in renal function

11. MANAGEMENT QOF Targets – register of those with stage 3-5 Need system for recall and audit Lifestyle advice Smoking cessation, Weight loss, exercise, reduce alcohol Aspirin- for those with 10yr CV risk of >20% Lipid lowering- all with macrovascular disease, diabetics and CKD, 10yr CV risk >20% Control BP

12. BLOOD PRESSURE Treatment aims to reduce risk of CV disease and risk of progressive loss of kidney function Measure at least annually, Conform to BHS guidelines 140/85 – QOF targets and in those without proteinuria –optimal target of 130/80 130/80 with UPCR >1g-optimal target 125/75 ACEI/ARB –proteinuria, diabetics, heart failure Prevent progression from microalbuminuria to overt nephropathy in type 1+2 diabetics Can slow progression of non-diabetic nephropathy BP >150/90 despite 3 drugs – refer

13. STAGE 1&2 Annual measurement of BP, urine protein and serum creatinine Advice on CVS risk factors Consider aspirin and lipid lowering Antihypertensive therapy

14. STAGE 3 Annual measurment of Hb, Cr, Ca, Phosphate, K Six monthly BP checks Treat anaemia (Hb <11) after exclusion of other causes Renal USS if signs of outflow obstruction Immunise against influenza and pneumococcus Review medications – avoid nephrotoxics Consider calcium and vitamin D supplements – exclude hyperparathyroidism first

15. STAGE 4&5 Three monthly BP, Hb, Cr, K, phosphate, Ca, PTH, GFR, Bicarbonate All of stage 3 management Dietary assessment Immunise against hepatitis B Counselling of treatment options Provision of vascular or peritoneal access

16. REFERRALS Immediate Suspected acute renal failure ARF superimposed on CKD Newly detected stage 5 K > 7.0 Malignant Hypertension Urgent Nephrotic syndrome Stage 4 or stable stage 5 K 6-7

17. REFERRALS Stage 1&2 Isolated proteinuria –UPCR >100mg/mmol Protein + microscopic haematuria – UPCR>45 Macroscopic haematuria – exclude urological cause Uncontrolled hypertension BP>150/90 despite 3 drugs Fall of eGFR>20% during first 2months after starting ACEI/ARB Recurrent pulmonary oedema with normal LVF Microscopic haematuria without proteinuria – refer urology unless GFR <60 refer nephrology

18. REFERRALS Stage 3 All of stage 1&2 criteria Progressive fall in GFR Proteinura – UPCR >45 Anaemia Persistently abnormal K, phosphate, Ca Stage 4&5 Immediate or urgent referral Consider replacement therapy unless co-morbidities

19. TRIALS UNDERWAY Several trials to examine effect of lipid lowering therapy on CV outcomes amongst patients with CKD SHARP (Study of Heart and Renal Protection Trial) – aims to randomise 9000 patients with CKD to lipid-lowering therapy or placebo – not completed yet Prior to this study’s result – treat as per existing guideline British Cardiac Society, British Hyperlipidaemia Society, British Hypertensive Society Metanalysis in Kidney International 2001- statins reduced proteinuria and preserved GFR

20. OVERVIEW Inclusion of CKD within QOF places emphasis for detection and management of early CKD on primary care Issues for workload and resources needed Importance of vascular risk reduction – leads to improved renal outcomes Majority of patients with CKD can be managed without referral Using register, ensuring long term follow up

21. EVIDENCE & RESOURCES Department of Health. National Service Framework for Renal Services Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life Care 2005 www.dh.gov.uk/renal Joint Speciality Committee on Renal Disease of the Royal College of Physicians of London and the Renal Association. CKD in Adults – UK Guidelines for identification, management and referral March 2006 www.rcplondon.ac.uk or www.renal.org Guidelines for management of hypertension – BHS 2004 Clinical Review Chronic Renal Disease – BMJ 2002 National Kidney Foundation Kidney Disease Outcomes Quality Initiative NKF K/DOQI www.kidney.org Identification, management and referral of adults with CKD: concise guidelines. Clinical Medicine 2005;5:635-642