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  • NOTES FOR PRESENTERS: Key points to raise: The graph above illustrates a rise in recorded prevalence of CKD stages 3–5 arising from the inclusion of a CKD indicator set within the primary care quality and outcomes framework from April 2006. In preparation for the inclusion of CKD within the QOF, from April 2005 laboratories began to provide estimated glomerular filtration rates (eGFR) (an indication of CKD) alongside routine serum creatinine testing results. The five-stage classification system for CKD was introduced into the UK in 2001. In the year to March 2007 approximately 1.5 million people in England were diagnosed with CKD (Department of Health 2007). It is estimated that there are approximately 2 million unrecorded cases of CKD in England (Information Centre analysis of a sample of anonymised GP patient records using IMS Disease Analyzer). Additional information: Between April 2001 and 2004 facilities for identifying CKD using eGFR were not freely available. Related NICE guidance includes: Type 2 diabetes: the management of type 2 diabetes (update). NICE clinical guideline 66 (2008). Anaemia management in people with chronic kidney disease. NICE clinical guideline 39 (2006). Hypertension: management of hypertension in adults in primary care. NICE clinical guideline 34 (partial update of NICE clinical guideline 18) (2006). This guidance sits within the following policy context: Department of Health (2007) Vascular disease – briefing pack for strategic health authorities Department of Health (2007) The national service framework for renal services: second progress report Department of Health (2006) Supporting people with long-term conditions to self-care: a guide to developing local strategies and good practice Department of Health (2005) Renal services information strategy: supporting part two of the national service framework for renal services Department of Health (2005) National service framework for renal services - Part two: chronic kidney disease, acute renal failure and end of life care Department of Health (2005) Supporting people with long term conditions: an NHS and social care model to support local innovation and integration Department of Health (2001) National service framework for diabetes: standards

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  • 1. Global Kidney Academy CKD Micro-Lecture Epidemiology, Screening and Guidelines Professor Meguid El Nahas, PhD, FRCP Sheffield Kidney Institute UK
  • 2. Global ESRD Lysaght , J Am Soc Nephrol, 2002 1990 2003 2010 426,000 1,000,000 2,000,000
  • 3. USRDS Incident counts & adjusted rates, by age
  • 4. USRDS Incident counts & adjusted rates, by primary diagnosis Incident ESRD patients; rates adjusted for age, gender, & race.
  • 5. ESRD 0.1% Undetected CKD: 10-15%?!
  • 6. eGFR
    • MDRD 4 variables formula:
    • eGFRml/min/1.73m 2 =
    • 175 x{[sCr / 88.4] -1.154 }x age (years) -.203 x 0.742 if F x1.21 B
  • 7. K/DOQI
    • CKD Classification
    • Stage Description GFR
    • 1 Kidney damage/normal GFR* >90ml/min
    • 2 Mild renal insufficiency 89-60
    • 3 Moderate renal insufficiency 59-30
    • 4 Severe renal insufficiency 29-15
    • 5 Kidney Failure <15
  • 8. * Evidence of chronic kidney damage includes: persistent microalbuminuria or proteinuria, haematuria, structural abnormalities, biopsy proven glomerulonephritis. eGFR < 15 Stage 5 eGFR 15 – 29 Stage 4 eGFR 45-59 eGFR 30-44 Stage 3a Stage 3b eGFR 60 – 90 With other evidence of kidney damage* Stage 2 Normal eGFR (>90) With other evidence of kidney damage* Stage 1 Description (eGFR ml/min/1.73m 2 ) CKD Stage NICE Stages of CKD
  • 9. Growth in recognition of Chronic kidney disease UK CKD KDOQI
  • 10. Albuminuria & Age MONICA NHANESIII 14,622 19% 32.7% 15% Garg et al, 2002
  • 11. eGFR
    • MDRD 4 variables formula:
    • eGFRml/min/1.73m 2 =
    • 175 x{[sCr / 88.4] -1.154 }x age (years) -.203 x 0.742 if F x1.21 B
  • 12. MDRD & GC Poggio et al, 2005
  • 13. CKD and the ageing Population
  • 14. CKD CVD
  • 15. Hillege et al, 2002 Arnlov et al, 2005 Microalbuminuria and Survival
  • 16. CKD and CVD Risk HOORN Study, Henry et al, 2002 Pooled Analysis, Weiner et al, 2004 eGFR<60 eGFR>60
  • 17.
    • Screening At-risk Population
    • Diabetics
    • Hypertensives
    • CVD
    • Relatives of CKD5
    • Systemic vasculitis
    • Recurrent UTIs, and urological problems
    • Chronic NSAIDs
  • 18. NSAIDs, COX2s and radiocontrast agents Avoid Standard CV risk reduction measures, including salt restriction Lifestyle Refer to national guidelines sCholesterol ACEi/ ARBs Lowest achievable Proteinuria Start with ACEI or ARBs if proteinuria or DM microalbuminuria - caution in the elderly and those with atherosclerosis. Monitor eGFR within 1-2 weeks of initiation, review if eGFR decreases by ≥15%, stop at ≥25%. 130/80 mmHg or 125/75 in DM and those with proteinuria. BP Agent used Target Parameter CKD management guidelines
  • 19. Evolution
  • 20. NSAIDs, COX2s and radiocontrast agents Avoid Standard CV risk reduction measures, including salt restriction Lifestyle Refer to national guidelines sCholesterol ACEi/ ARBs Lowest achievable <1g/24h Proteinuria Start with ACEI or ARBs if proteinuria >1g/24h or DM 130/80 mmHg or 125/75 in DM and those with proteinuria BP Agent used Target Parameter CKD management guidelines
  • 21. Locatelli et al 1996
  • 22.  
  • 23.  
  • 24.  
  • 25. Immunize: influenza & pneumococcus vaccination (CKD stages 4-5) Chest infections Hepatitis B Infections Adequate calorie & normal protein intake Undernutrition Sodium bicarbonate Venous Bicarbonate > 22 mmol/l Acidosis Calcium carbonate / alfacalcidol Phosphate binders Ca: 2.2-2.35 mmol/l PO4 <1.7 mmol/l Renal osteodystrophy (Stages 4& 5 only) Replace deficiencies Erythropoietin in CKD stage 4-5 Hb 10.5-12.5 g/dl Anaemia Management Target Complication CKD (Stages 3-5) management of complications
  • 26. CKD CVD MINIMIZE