Chronic Kidney Disease HOT TOPIC   FEBRUARY 2007  Kelly Frullani
WHY THIS TOPIC? <ul><li>Major workload in practice </li></ul><ul><li>New QOF targets  </li></ul><ul><li>Affects large numb...
DEFINITION OF CKD <ul><li>Kidney damage > 3months – defined by structural or functional abnormalities with/without decreas...
NEED FOR GUIDELINES <ul><li>Majority with early CKD don’t progress to ERF </li></ul><ul><li>Increased risk of CV disease  ...
GUIDELINES <ul><li>2004 and 2005 DoH published National Service Framework for Renal Services  </li></ul><ul><li>CKD in Adu...
AETIOLOGY <ul><li>Most common cause is type 2 diabetes  </li></ul><ul><li>Other causes  </li></ul><ul><ul><li>Hypertension...
PREVALENCE <ul><li>10% of population have CKD  </li></ul><ul><ul><li>5% are in stages 1-2 </li></ul></ul><ul><ul><li>5% ar...
CLASSIFICATION <ul><li>From US National Kidney Foundation in their Kidney Disease Outcomes Quality Initiative  </li></ul><...
MEASURING GFR <ul><li>Assessed by formula based estimation of GFR </li></ul><ul><li>In adults >18yrs eGFR calculated using...
DETECTION OF PROTEINURIA <ul><li>Positive Dipstix test (≥1+)- send for UPCR + culture to exclude UTI </li></ul><ul><li>UPC...
MANAGEMENT <ul><li>QOF Targets – register of those with stage 3-5  </li></ul><ul><li>Need system for recall and audit </li...
BLOOD PRESSURE <ul><li>Treatment aims to reduce risk of CV disease and risk of progressive loss of kidney function </li></...
STAGE 1&2 <ul><li>Annual measurement of BP, urine protein and serum creatinine  </li></ul><ul><li>Advice on CVS risk facto...
STAGE 3 <ul><li>Annual measurment of Hb, Cr, Ca, Phosphate, K </li></ul><ul><li>Six monthly BP checks </li></ul><ul><li>Tr...
STAGE 4&5 <ul><li>Three monthly BP, Hb, Cr, K, phosphate, Ca, PTH, GFR, Bicarbonate  </li></ul><ul><li>All of stage 3 mana...
REFERRALS  <ul><li>Immediate  </li></ul><ul><ul><ul><li>Suspected acute renal failure </li></ul></ul></ul><ul><ul><ul><li>...
REFERRALS <ul><li>Stage 1&2 </li></ul><ul><ul><ul><li>Isolated proteinuria –UPCR >100mg/mmol </li></ul></ul></ul><ul><ul><...
REFERRALS <ul><li>Stage 3  </li></ul><ul><ul><ul><li>All of stage 1&2 criteria </li></ul></ul></ul><ul><ul><ul><li>Progres...
TRIALS UNDERWAY <ul><li>Several trials to examine effect of lipid lowering therapy on CV outcomes amongst patients with CK...
OVERVIEW <ul><li>Inclusion of CKD within QOF places emphasis for detection and management of early CKD on primary care </l...
EVIDENCE & RESOURCES <ul><li>Department of Health. National Service Framework for Renal Services Part Two: Chronic Kidney ...
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Chronic Kidney Disease

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Chronic Kidney Disease

  1. 1. Chronic Kidney Disease HOT TOPIC FEBRUARY 2007 Kelly Frullani
  2. 2. WHY THIS TOPIC? <ul><li>Major workload in practice </li></ul><ul><li>New QOF targets </li></ul><ul><li>Affects large numbers of patients </li></ul><ul><li>? Exams </li></ul>
  3. 3. DEFINITION OF CKD <ul><li>Kidney damage > 3months – defined by structural or functional abnormalities with/without decrease in GFR </li></ul><ul><ul><ul><li>Pathological </li></ul></ul></ul><ul><ul><ul><li>Markers of kidney damage (abnormalities in blood/urine/imaging) </li></ul></ul></ul><ul><li>GFR<60 for > 3months with/without kidney damage </li></ul>
  4. 4. NEED FOR GUIDELINES <ul><li>Majority with early CKD don’t progress to ERF </li></ul><ul><li>Increased risk of CV disease </li></ul><ul><li>Established renal failure rare but expensive </li></ul><ul><li>Numbers receiving renal replacement therapy rising – 2% of NHS budget </li></ul><ul><li>Majority starting replacement therapy progressed from earlier stages of CKD </li></ul>
  5. 5. GUIDELINES <ul><li>2004 and 2005 DoH published National Service Framework for Renal Services </li></ul><ul><li>CKD in Adults. UK Guidelines for identification, management and referral </li></ul><ul><li>Developed by Joint specialist committee on Renal Medicine of Royal College Physicians and Renal Association March 2006 </li></ul><ul><li>?NICE guideline 2008 </li></ul>
  6. 6. AETIOLOGY <ul><li>Most common cause is type 2 diabetes </li></ul><ul><li>Other causes </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Chronic Glomerulonephritis </li></ul></ul><ul><ul><li>Polycystic Disease </li></ul></ul><ul><ul><li>Pyelonephritis </li></ul></ul>
  7. 7. PREVALENCE <ul><li>10% of population have CKD </li></ul><ul><ul><li>5% are in stages 1-2 </li></ul></ul><ul><ul><li>5% are in stage 3-5 </li></ul></ul><ul><li>For average GP list size – 220 patients with CKD </li></ul>
  8. 8. CLASSIFICATION <ul><li>From US National Kidney Foundation in their Kidney Disease Outcomes Quality Initiative </li></ul><ul><li>Stage 1 – normal eGFR > 90 - other evidence of CKD </li></ul><ul><li>Stage 2 – mild eGFR 60-89 - other evidence of CKD </li></ul><ul><li>Stage 3 – moderate eGFR 30-59 </li></ul><ul><li>Stage 4 – severe eGFR 15-29 </li></ul><ul><li>Stage 5 – ERF eGFR <15 or on dialysis </li></ul><ul><li>Other evidence- persistent proteinuria/haematuria/ microalbuminuria, structural abnormalities on USS </li></ul>
  9. 9. MEASURING GFR <ul><li>Assessed by formula based estimation of GFR </li></ul><ul><li>In adults >18yrs eGFR calculated using the 4 variable Modification of Diet in renal disease (MDRD) equation </li></ul><ul><li>4 variables- serum creatinine, age, sex, ethnic origin </li></ul><ul><li>Equation not validated for use in </li></ul><ul><ul><li>Children < 18yrs </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>ARF </li></ul></ul><ul><ul><li>Oedematous states, malnourishment, amputees </li></ul></ul>
  10. 10. DETECTION OF PROTEINURIA <ul><li>Positive Dipstix test (≥1+)- send for UPCR + culture to exclude UTI </li></ul><ul><li>UPCR≥45mg/mmol is positive test for protein </li></ul><ul><li>Persistent proteinuria- ≥2 positive tests </li></ul><ul><li>Proteinuria is single best predictor of disease progression </li></ul><ul><li>Reducing urine protein excretion slows progressive decline in renal function </li></ul>
  11. 11. MANAGEMENT <ul><li>QOF Targets – register of those with stage 3-5 </li></ul><ul><li>Need system for recall and audit </li></ul><ul><li>Lifestyle advice </li></ul><ul><ul><li>Smoking cessation, Weight loss, exercise, reduce alcohol </li></ul></ul><ul><li>Aspirin- for those with 10yr CV risk of >20% </li></ul><ul><li>Lipid lowering- all with macrovascular disease, diabetics and CKD, 10yr CV risk >20% </li></ul><ul><li>Control BP </li></ul>
  12. 12. BLOOD PRESSURE <ul><li>Treatment aims to reduce risk of CV disease and risk of progressive loss of kidney function </li></ul><ul><li>Measure at least annually, Conform to BHS guidelines </li></ul><ul><li>140/85 – QOF targets and in those without proteinuria –optimal target of 130/80 </li></ul><ul><li>130/80 with UPCR >1g-optimal target 125/75 </li></ul><ul><li>ACEI/ARB –proteinuria, diabetics, heart failure </li></ul><ul><ul><li>Prevent progression from microalbuminuria to overt nephropathy in type 1+2 diabetics </li></ul></ul><ul><ul><li>Can slow progression of non-diabetic nephropathy </li></ul></ul><ul><li>BP >150/90 despite 3 drugs – refer </li></ul>
  13. 13. STAGE 1&2 <ul><li>Annual measurement of BP, urine protein and serum creatinine </li></ul><ul><li>Advice on CVS risk factors </li></ul><ul><li>Consider aspirin and lipid lowering </li></ul><ul><li>Antihypertensive therapy </li></ul>
  14. 14. STAGE 3 <ul><li>Annual measurment of Hb, Cr, Ca, Phosphate, K </li></ul><ul><li>Six monthly BP checks </li></ul><ul><li>Treat anaemia (Hb <11) after exclusion of other causes </li></ul><ul><li>Renal USS if signs of outflow obstruction </li></ul><ul><li>Immunise against influenza and pneumococcus </li></ul><ul><li>Review medications – avoid nephrotoxics </li></ul><ul><li>Consider calcium and vitamin D supplements – exclude hyperparathyroidism first </li></ul>
  15. 15. STAGE 4&5 <ul><li>Three monthly BP, Hb, Cr, K, phosphate, Ca, PTH, GFR, Bicarbonate </li></ul><ul><li>All of stage 3 management </li></ul><ul><li>Dietary assessment </li></ul><ul><li>Immunise against hepatitis B </li></ul><ul><li>Counselling of treatment options </li></ul><ul><li>Provision of vascular or peritoneal access </li></ul>
  16. 16. REFERRALS <ul><li>Immediate </li></ul><ul><ul><ul><li>Suspected acute renal failure </li></ul></ul></ul><ul><ul><ul><li>ARF superimposed on CKD </li></ul></ul></ul><ul><ul><ul><li>Newly detected stage 5 </li></ul></ul></ul><ul><ul><ul><li>K > 7.0 </li></ul></ul></ul><ul><ul><ul><li>Malignant Hypertension </li></ul></ul></ul><ul><li>Urgent </li></ul><ul><ul><ul><li>Nephrotic syndrome </li></ul></ul></ul><ul><ul><ul><li>Stage 4 or stable stage 5 </li></ul></ul></ul><ul><ul><ul><li>K 6-7 </li></ul></ul></ul>
  17. 17. REFERRALS <ul><li>Stage 1&2 </li></ul><ul><ul><ul><li>Isolated proteinuria –UPCR >100mg/mmol </li></ul></ul></ul><ul><ul><ul><li>Protein + microscopic haematuria – UPCR>45 </li></ul></ul></ul><ul><ul><ul><li>Macroscopic haematuria – exclude urological cause </li></ul></ul></ul><ul><ul><ul><li>Uncontrolled hypertension BP>150/90 despite 3 drugs </li></ul></ul></ul><ul><ul><ul><li>Fall of eGFR>20% during first 2months after starting ACEI/ARB </li></ul></ul></ul><ul><ul><ul><li>Recurrent pulmonary oedema with normal LVF </li></ul></ul></ul><ul><ul><ul><li>Microscopic haematuria without proteinuria – refer urology unless GFR <60 refer nephrology </li></ul></ul></ul>
  18. 18. REFERRALS <ul><li>Stage 3 </li></ul><ul><ul><ul><li>All of stage 1&2 criteria </li></ul></ul></ul><ul><ul><ul><li>Progressive fall in GFR </li></ul></ul></ul><ul><ul><ul><li>Proteinura – UPCR >45 </li></ul></ul></ul><ul><ul><ul><li>Anaemia </li></ul></ul></ul><ul><ul><ul><li>Persistently abnormal K, phosphate, Ca </li></ul></ul></ul><ul><li>Stage 4&5 </li></ul><ul><ul><ul><li>Immediate or urgent referral </li></ul></ul></ul><ul><ul><ul><li>Consider replacement therapy unless co-morbidities </li></ul></ul></ul>
  19. 19. TRIALS UNDERWAY <ul><li>Several trials to examine effect of lipid lowering therapy on CV outcomes amongst patients with CKD </li></ul><ul><ul><ul><li>SHARP (Study of Heart and Renal Protection Trial) – aims to randomise 9000 patients with CKD to lipid-lowering therapy or placebo – not completed yet </li></ul></ul></ul><ul><li>Prior to this study’s result – treat as per existing guideline </li></ul><ul><ul><ul><li>British Cardiac Society, British Hyperlipidaemia Society, British Hypertensive Society </li></ul></ul></ul><ul><li>Metanalysis in Kidney International 2001- statins reduced proteinuria and preserved GFR </li></ul>
  20. 20. OVERVIEW <ul><li>Inclusion of CKD within QOF places emphasis for detection and management of early CKD on primary care </li></ul><ul><li>Issues for workload and resources needed </li></ul><ul><li>Importance of vascular risk reduction – leads to improved renal outcomes </li></ul><ul><li>Majority of patients with CKD can be managed without referral </li></ul><ul><li>Using register, ensuring long term follow up </li></ul>
  21. 21. EVIDENCE & RESOURCES <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Guidelines for management of hypertension – BHS 2004 </li></ul><ul><li>Clinical Review Chronic Renal Disease – BMJ 2002 </li></ul><ul><li>National Kidney Foundation Kidney Disease Outcomes Quality Initiative NKF K/DOQI www.kidney.org </li></ul><ul><li>Identification, management and referral of adults with CKD: concise guidelines. Clinical Medicine 2005;5:635-642 </li></ul>

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