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Detection, monitoring and referral of chronic kidney disease Canadian Society of Nephrology  Implementation Committee 2007
Key messages <ul><li>Who to test for chronic kidney disease </li></ul><ul><li>What tests to order </li></ul><ul><li>What t...
<ul><li>Identify patients in your practice at high risk for Chronic Kidney Disease   </li></ul><ul><li>Patients with hyper...
What is Chronic Kidney Disease <ul><li>The presence of Kidney Damage or an eGFR < 60 ml/min/1.73m 2   and </li></ul><ul><l...
Who should be tested for CKD? <ul><li>CSN endorses a case finding approach  </li></ul><ul><li>to testing for CKD, which sh...
Who should be tested for CKD? <ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with hypertension </li></...
Clinical case <ul><li>Joe is a 68 year old welder </li></ul><ul><li>Past Medical History: appendectomy age 15, hypertensio...
<ul><li>Joe should be screened for CKD because he has several risk factors. </li></ul><ul><ul><li>Can you name them? </li>...
Which test would you choose to  assess Joe’s renal function?  <ul><li>Serum creatinine  </li></ul><ul><li>24 hour urine co...
Joe’s labs <ul><li>Na 138 mmol/L  </li></ul><ul><li>K 4.5 mmol/L </li></ul><ul><li>Cl 103 mmol/L  </li></ul><ul><li>HCO3 2...
<ul><li>Joe’s serum creatinine is in the normal range, doesn’t that mean his kidney function is also normal? </li></ul>
Assessing Joe’s renal function using eGFR <ul><li>54 ml/min / 1.73m 2 </li></ul><ul><li>(Stage 3 CKD) </li></ul><ul><li>Cl...
Why use eGFR? <ul><li>It gives the health care practitioner  </li></ul><ul><li>a different sense as to a patient’s level o...
Measuring renal function: what’s eGFR?
GFR <ul><li>Glomerular filtration rate  ( GFR ): </li></ul><ul><li>is the volume of fluid filtered from the </li></ul><ul>...
Methods to assess GFR <ul><li>Serum urea </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Serum cystatin C </li></ul><...
The perfect marker <ul><li>Endogenous </li></ul><ul><li>Freely filtered </li></ul><ul><li>Not secreted or reabsorbed </li>...
Problems with creatinine Stevens L et al, NEJM 2006; 354:2473-2483
Problems with timed collections <ul><li>Cumbersome </li></ul><ul><li>Prone to error </li></ul><ul><li>No longer recommende...
Problems with other methods <ul><li>Cystatin </li></ul><ul><li>Inulin </li></ul><ul><li>Nuclear medicine (iothalamate, EDT...
Creatinine based approximations <ul><li>1)  Cockcroft-Gault equation </li></ul><ul><li>CrCl (ml/min)=  (140-age) x actual ...
eGFR equation provisos <ul><li>eGFR calculations may be less reliable in: </li></ul><ul><ul><li>individuals with near norm...
Estimate of Glomerular Filtration Rate (eGFR) <ul><li>It is not recommended that clinicians rely on serum creatinine measu...
Developed by the BC Medical Services Commission, Guidelines and  Protocols group
Developed by the BC Medical Services  Commission, Guidelines and  Protocols group
Is it just about GFR? <ul><li>Should also assess urine protein losses </li></ul><ul><ul><li>24 hour urines are no longer r...
What do those values mean? Alarm values to refer Microalbuminuria (ie in diabetics) ~30 mg day (albumin) N/A >3 ~900 mg/da...
Who should be tested for CKD? <ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with hypertension </li></...
What tests to order? <ul><li>Assess kidney function with </li></ul><ul><ul><li>eGFR </li></ul></ul><ul><ul><ul><li>As repo...
What to do with the results <ul><li>Now that I know Joe’s GFR is not normal what should I do? </li></ul>
What to do with the results <ul><li>Is one eGFR measurement enough? </li></ul><ul><li>Consider reversible factors </li></u...
Natural history of elevated creatinine levels <ul><li>1434 patients in a family medicine practice </li></ul><ul><li>57 pat...
Is one eGFR measurement enough? <ul><li>Decisions about investigation, treatment or referral should not be made based on a...
For patients with a new finding of an  eGFR between 30-60ml/min/1.73m 2 CSN recommends that clinicians determine  the stab...
Consider reversible factors <ul><li>Intercurrent illness  </li></ul><ul><li>Volume depletion  </li></ul><ul><li>Medication...
Back to Joe <ul><li>You measure Joe’s eGFR in 2 weeks and then again in 3 months and it is unchanged </li></ul><ul><li>You...
Conclusions about Joe <ul><li>Given the stability of these we can conclude that he has stable CKD. </li></ul><ul><li>It is...
CSN recommends that most patients with  non-progressive CKD can be managed by  non-nephrologists without referral.  The re...
CKD is common
Estimated prevalence of CKD in  Canadians  ≥  20 years old   <ul><li>Stage 1 CKD > 90 ml/min  792,000 </li></ul><ul><li>St...
Other common conditions also managed by primary care physicians CKD is a  common  general health problem 8-10 % worldwide ...
Estimated prevalence of CKD in  Canadians  ≥  20 years old   <ul><li>Stage 1 CKD > 90 ml/min  792,000 </li></ul><ul><li>St...
<ul><li>If many patients with CKD do not progress to end stage renal failure why then as a primary care physician should I...
ESRD is not the problem <ul><li>Patients with CKD have high rates of  cardiovascular disease   </li></ul><ul><li>and many ...
Go,A et al. NEJM 2004;351:1291-1305
Quick Tips on Management of CKD <ul><li>Implement measures to slow rate of CKD progression </li></ul><ul><li>Treat to targ...
Joe: three years later  <ul><li>You have continued to follow his eGFR and notice that it is now 42 ml/min/1.73m 2 </li></u...
Who should be referred to a Nephrologist? <ul><li>Patients with acute renal failure </li></ul><ul><li>Patients with eGFR <...
Violet <ul><li>78 year old female </li></ul><ul><li>longstanding patient of a colleague’s – followed for her hypertension ...
Using an “eGFR approach” 35 30 27 24 eGFR (ml/min/1.73m 2 ) 138 156 168 184 Serum Cr (µmol/L) 5 yrs ago 2 yrs ago 1 yr ago...
This woman’s renal disease may have been underdiagnosed Using eGFR may have given a more accurate measure of her renal fun...
Linda <ul><li>54 yo female comes for routine annual physical  </li></ul><ul><ul><li>no problems identified </li></ul></ul>...
<ul><li>Identify patients in your practice at high risk for Chronic Kidney Disease   </li></ul><ul><li>Patients with hyper...
Linda: continued <ul><li>Evaluation of her urine shows no significant amount of proteinuria (ACR <40mg/mmol) and no hematu...
Dave <ul><li>81 year old man, new to your practice </li></ul><ul><ul><li>ASHD, stent placed 2 years ago </li></ul></ul><ul...
Dave <ul><li>Old labs from previous MD show Cr 150-180 umol/L over last 3 years </li></ul><ul><li>What would you do? </li>...
Summary <ul><li>Who should be tested for CKD? </li></ul><ul><ul><li>Patients with diabetes mellitus </li></ul></ul><ul><ul...
Summary <ul><li>What tests should be ordered? </li></ul><ul><ul><li>eGFR to assess kidney function  </li></ul></ul><ul><ul...
Acknowledgements <ul><li>Financial support for the development and distribution of these educational materials was provide...
Quick Tips on Referral and Management of Chronic Kidney Disease <ul><li>Most patients with non-progressive CKD can be mana...
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Detection, Monitoring and Referral of CKD Slide Kit

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  • This slide kit was developed for Primary Care givers by the Canadian Society of Nephrology Implementation Committee. A new position paper on the care and referral of adult patients with reduced kidney function was published on the CSN website in September of 2006 and the Society felt it was best if a document/presentation kit were to be prepared to complement this document dealing specifically with the issue of estimated GFR (eGFR) as it may be a new approach to following renal function to some clinicians. These recommendations address those at risk for chronic kidney disease and are not meant to consider all potential reasons to refer to nephrology (eg. hematuria).
  • These are the three key points that we hope clinicians will remember. - use case-finding approach to CKD in high-risk individuals - test using eGFR (kidney function) and assessment of urine protein (kidney damage) to identify individuals with CKD as well as the subgroup at risk of progressive disease - abnormal findings need serial monitoring as many will improve on repeat testing and serial monitoring helps to identify those with progressive renal disease
  • Kidney Damage is defined well in the Document on Identification, Evaluation and Management of Patients with Chronic Kidney Disease as pathologic abnormalities or markers of damage, including abnormalities in blood, urine or imaging tests studies* To be clear, the type of patient that is referred to is one where the renal function is stable and there is no significant amount of proteinuria present. Chronic kidney disease can be present in patients who have eGFRs over 60ml/min but who have abnormalities of urinalysis such as persistent proteinuria or hematuria. These patients should be referred to a Nephrologist There is no expectation of any Primary Care Physician to manage kidney disease that is progressive or with other complicating elements such as significant proteinuria.
  • Illustrating the power of eGFR using clinical cases
  • Could discuss SCORED study (Arch Int Med Feb 2007; 167:374-381)– Here Joe has a history of hypertension as well as DM. SCORED also considered age as a risk factor
  • Each item in this list has elements that preclude them from being dependably used and easily accessed in the day to day clinical assessment of patient renal function in a reliable and accurate manner. Commonly voiced concerns about 24hr urine collections include 1) instructions are routinely misunderstood leading to inaccurate collections and unreliable inaccurate results 2) Patients find it difficult to commit to an entire day’s worth of “testing” 3) routine under or over collections etc Nuclear medicine tests are not practical nor cost effective ways in which to follow renal function Serum Creatinine and urea measurements alone often are misinterpreted by health care professionals, the most common of which is that despite a value being in the “normal range” it reflects a GFR that is significantly reduced for that patient’s age , gender and body mass. This will be explored more in the presentation.
  • Upper limit of Cr in this lab is 130umol/L
  • This highlights some of the problems with eGFR in that the CG equation is recognized for overestimating renal function. The MDRD equation has been validated for use in the CKD population but it is not as easy to use and not everyone has access to a computer in their clinic area. The point is made however that despite either equation’s pitfalls the patient is better served by having their eGFR calculated and then repeated in a serial fashion to determine if it is changing. Stable chronically reduced eGFR with minimal proteinuria does not necessarily need to be seen by a nephrologist. The presenter can mention that this corresponds to Stage 3 CKD and that the staging system for CKD will be covered a little later on in the presentation
  • The advantage of these equations over serum creatinine measurements alone is that the latter are recognized as being poor indicators of early CKD.
  • There is a great article in BMJ October 2006 that reviews all these methods How to measure renal function in clinic practice. Traylor, Mactier, Geddes and Fox, BMJ 2006; 333: 733-737
  • Can use this slide to point out importance of adjusting for race in African Americans. These are the two main methods whereby an eGFR is generated by the lab. The CSN endorses the use of standardized methods to measure serum creatinine. Creatinine is measured in different ways in labs across Canada. It would be reasonable for the clinician to familiarize themselves with the methods employed in their local lab. Not all labs in Canada generate an eGFR value along with the serum creatinine. Pioneers in the area such as BC and Alberta have this but other areas do not have eGFR reporting at this time. Moreover, one lab may use the CG formula and another the MDRD equation. Again, the clinician is advised to familiarize themselves with the methods employed in their local lab. Both formulae have been validated in various populations with moderate to severe impairment of GFR; however they may be less reliable in patients with near normal (&gt;60ml/min/1.73m2) GFR or in patients with markedly abnormal body composition (eg extreme obesity, cachexia, paralysis, amputations) There remain controversies as to the applicability of these equations to various ethnic groups, the very elderly and to the non-referred populations with modest decreases in renal function which are summarized on the next slide.
  • Remind them of adjusting MDRD for african-american race
  • Can simplify it to explain that eGFR measures renal function (clearance) while proteinuria/albuminuria identifies renal injury and is associated with prognosis
  • These examples were chosen since they are the numbers that people may already be familiar with and include values that should trigger referral to Nephrology. Can also use this slide to re-emphasize that microalbuminuria in diabetics shows evidence of renal injury despite preserved renal function. Demonstrates why need to look at function (eGFR) as well as injury (protein)
  • Summing up what we’ve covered so far
  • Summing up what we’ve covered so far
  • This article was referenced because it is a primary care population in the Canadian setting. Other examples could be used. More than half of those with initially elevated Cr levels saw them return to normal (including 50% of those with initial Cr &gt;300) Only 7 patients progressed to a higher level over 4-5 years of followup In all 1434 patients average age was 63, 18% were diabetic, 47% were hypertensive, only 4% were referred to Neph
  • These are statements from the position paper
  • There will always be cases that do not fit with these recommendations (for example in a 35 year old otherwise well individual a finding of an eGFR below 60 would probably lead to repeat testing sooner than 2-4 weeks). Primary care givers are still asked to use their clinical judgement
  • May also mention fibrates, different forms of NSAIDs (suppositories, creams)
  • Need to address two questions - why look for CKD if most will not be progressive - who does need referral to Nephrology
  • This reference is an excellent one for Primary Care Physicians on CKD. It also outlined the scope of the problem when it extrapolated figures from US data (which was taken from K/DOQI) and gave an idea of the numbers of Canadians who had CKD and expressed these according to their stage of CKD This slide also introduces the idea of the various stages of CKD
  • References for these figures are CVD: http://www.cdc.gov/diabetes/statistics/cvd/fig5.htm DM: http://www.cdc.gov/diabetes/faq/research.htm BP: Hajjar, Kotchen and Kotchen. Annual Rev Public Health 2006; 27:465-90
  • Aim of slide is to demonstrate that although CKD is common (approx 1 in 10 adults) ESRD is not common
  • Risk of cardiovascular death is 100 X the risk of progressing to ESRD
  • This study shows nicely why we must pay attention to those patients with CKD. In addition to their renal disease they are at significantly greater risk for health complications related to cardiovascular disease. This study published in the NEJM in 2004 looked at 1,120,295 adults (55% were female) where a serum creatinine had been measured between 1996 and 2000 who had no history of been treated with dialysis or renal transplant. They examined the multivariate association between the estimated GFR (eGFR) and the risks of death, risk of cardiovascular event and hospitalizations. They found an independent, graded association was observed between a reduced eGFR and the risk of death, cardiovascular events and hospitalizations in a large community based population
  • Full guidelines on the management of CKD will be soon forthcoming from the CSN. In the mean time these “Quick Tips” are part of the CSN position paper on the Care and Referral of Adult Patients with Reduced Renal Function. This is an abbreviated version that fits on the algorithm. A full version is available as a one page handout (see CSN website for both algorithm and handout)
  • This example illustrates the value of eGFR as opposed to Cr for assessment of renal function as well as the value of serial monitoring
  • The presenter should use this table to illustrate how the patient’s renal function was never normal in the first place and that it may have been underestimated all along in her management The presenter should also point out that the serial measurement of the value shows that her renal function is in decline
  • May also chose to discuss that her nausea and lethargy may signal decreased oral intake and her eGFR may be acutely low due to volume depletion
  • This example illustrates the importance of proteinuria in the diagnosis of CKD 90% confidence intervals on this eGFR calculation range from 42-78
  • Here the presenter could emphasize (again) the importance of serial monitoring of the eGFR and of proteinuria. Patients who have eGFR &gt;60ml/min but no proteinuria or hematuria do not have renal disease. Serial monitoring of these patients and the important parameters of eGFR, BP and proteinuria allow for disease progression to be picked up using easy to do and relatively inexpensive means. Also emphasizes the importance of significant proteinuria in identifying patients more likely to develop progressive CKD Proteinuria is a surrogate marker of renal disease
  • This example is used to demonstrate the role primary care docs have in following CKD that is non-progressive
  • Stable CKD, follow serially Achieve BP &lt;130/80 CV risk reduction – LDL at high risk level Watch for renally excreted medications – adjust doses (metformin, glyburide, digoxin etc.) or avoid Would not need Nephro
  • This slide is obviously too hard to read but serves as a reminder to show participants the one page handout which features this information on one side as well as a summary of the key messages from this slide set The CSN Guidelines committee is producing a document regarding the management of patients with CKD which will provide more detailed and evidenced based information (expected winter 2007)
  • Transcript of "Detection, Monitoring and Referral of CKD Slide Kit"

    1. 1. Detection, monitoring and referral of chronic kidney disease Canadian Society of Nephrology Implementation Committee 2007
    2. 2. Key messages <ul><li>Who to test for chronic kidney disease </li></ul><ul><li>What tests to order </li></ul><ul><li>What to do with the results </li></ul>
    3. 3. <ul><li>Identify patients in your practice at high risk for Chronic Kidney Disease </li></ul><ul><li>Patients with hypertension </li></ul><ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with atherosclerotic coronary, </li></ul><ul><li>cerebral or peripheral vascular disease </li></ul><ul><li>- Patients with heart failure </li></ul><ul><li>Patients with unexplained anemia </li></ul><ul><li>Patients with a family history of end stage renal disease </li></ul><ul><li>First nations peoples </li></ul>eGFR <30 eGFR 30-60 eGFR >60 <ul><li>Consider reversible factors: </li></ul><ul><li>Medication - Volume depletion </li></ul><ul><li>Intercurrent illness - Obstruction </li></ul><ul><li>Repeat tests in 2 - 4 weeks </li></ul>Individualized follow up and treatment CKD is diagnosed in this group only if other renal abnormalities are present (i.e. proteinuria, hematuria, anatomical) eGFR <30 eGFR 30-60 Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction eGFR < 30 or progressive decline in eGFR or persistent significant proteinuria or inability to attain treatment targets Stable eGFR 30-60 and no significant proteinuria
    4. 4. What is Chronic Kidney Disease <ul><li>The presence of Kidney Damage or an eGFR < 60 ml/min/1.73m 2 and </li></ul><ul><li>Present for ≥ 3 months and </li></ul><ul><li>Not treated with dialysis or transplant </li></ul>The diagnosis of CKD is only present in patients with eGFR ≥60ml/min if other abnormalities (i.e. proteinuria, hematuria, anatomical) are also present.
    5. 5. Who should be tested for CKD? <ul><li>CSN endorses a case finding approach </li></ul><ul><li>to testing for CKD, which should be </li></ul><ul><li>focused on high-risk groups. </li></ul><ul><li>CSN does not endorse </li></ul><ul><li>mass population screening for CKD </li></ul><ul><li>with either serum creatinine based tests or with urine dipstick testing. </li></ul>
    6. 6. Who should be tested for CKD? <ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with hypertension </li></ul><ul><li>Patients with heart failure </li></ul><ul><li>Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease </li></ul><ul><li>Patients with unexplained anemia </li></ul><ul><li>Patients with a family history of ESRD </li></ul><ul><li>First nations peoples </li></ul>
    7. 7. Clinical case <ul><li>Joe is a 68 year old welder </li></ul><ul><li>Past Medical History: appendectomy age 15, hypertension x 4 years, elevated cholesterol x 1 year, Type 2 DM x 1 year </li></ul><ul><li>Smoker- 1 pack a day since age 21 </li></ul><ul><li>Etoh- a case of beer on the weekend </li></ul><ul><li>Allergy- none known </li></ul><ul><li>Family History- father MI age 50, mother HTN age 48 </li></ul><ul><li>Medications- hydrochlorothiazide 25 mg po od, amlodipine 5mg po od, metformin 1000 mg po bid </li></ul><ul><li>Weight 75 kg </li></ul><ul><li>BP 149/84 mmHg </li></ul>
    8. 8. <ul><li>Joe should be screened for CKD because he has several risk factors. </li></ul><ul><ul><li>Can you name them? </li></ul></ul>
    9. 9. Which test would you choose to assess Joe’s renal function? <ul><li>Serum creatinine </li></ul><ul><li>24 hour urine collection </li></ul><ul><li>Nuclear medicine scan </li></ul><ul><li>eGFR </li></ul>
    10. 10. Joe’s labs <ul><li>Na 138 mmol/L </li></ul><ul><li>K 4.5 mmol/L </li></ul><ul><li>Cl 103 mmol/L </li></ul><ul><li>HCO3 23 mmol/L </li></ul><ul><li>Glucose (R) 6.4 mmol/L </li></ul><ul><li>Urea 10.1 mmol/L </li></ul><ul><li>Creatinine 123 µ mol/L </li></ul><ul><li>CBC normal </li></ul><ul><li>HgB A1C 5.6% </li></ul><ul><li>Ca ++ 2.46 mmol/L </li></ul><ul><li>PO4 = 1.10 mmol/L </li></ul><ul><li>Albumin 38 g/L </li></ul><ul><li>TC 7.60 mmol/L </li></ul><ul><li>TG 2.06 mmol/L </li></ul><ul><li>LDL(C) 5.43 mmol/L </li></ul><ul><li>HDL(C) 1.23 mmol/L </li></ul>
    11. 11. <ul><li>Joe’s serum creatinine is in the normal range, doesn’t that mean his kidney function is also normal? </li></ul>
    12. 12. Assessing Joe’s renal function using eGFR <ul><li>54 ml/min / 1.73m 2 </li></ul><ul><li>(Stage 3 CKD) </li></ul><ul><li>Clearly, Joe’s renal function is not normal </li></ul><ul><li>despite a normal serum creatinine </li></ul>http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm
    13. 13. Why use eGFR? <ul><li>It gives the health care practitioner </li></ul><ul><li>a different sense as to a patient’s level of </li></ul><ul><li>renal function that they may not have </li></ul><ul><li>appreciated by using simple serum </li></ul><ul><li>creatinine measurements. </li></ul>
    14. 14. Measuring renal function: what’s eGFR?
    15. 15. GFR <ul><li>Glomerular filtration rate ( GFR ): </li></ul><ul><li>is the volume of fluid filtered from the </li></ul><ul><li>renal glomerular capillaries into the </li></ul><ul><li>Bowman’s space per unit time. </li></ul><ul><li>Normal for a 20 year old is ~ 120ml/min </li></ul>
    16. 16. Methods to assess GFR <ul><li>Serum urea </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Serum cystatin C </li></ul><ul><li>Timed urine collections </li></ul><ul><ul><li>Creatinine clearance </li></ul></ul><ul><ul><li>Inulin clearance </li></ul></ul><ul><li>Calculated GFR calculations </li></ul><ul><ul><li>based on serum creatinine </li></ul></ul><ul><ul><li>many formulas including Cockcroft Gault and MDRD </li></ul></ul><ul><li>Nuclear medicine methods </li></ul>
    17. 17. The perfect marker <ul><li>Endogenous </li></ul><ul><li>Freely filtered </li></ul><ul><li>Not secreted or reabsorbed </li></ul><ul><li>Inexpensive to measure </li></ul>doesn’t exist !
    18. 18. Problems with creatinine Stevens L et al, NEJM 2006; 354:2473-2483
    19. 19. Problems with timed collections <ul><li>Cumbersome </li></ul><ul><li>Prone to error </li></ul><ul><li>No longer recommended in most situations </li></ul>
    20. 20. Problems with other methods <ul><li>Cystatin </li></ul><ul><li>Inulin </li></ul><ul><li>Nuclear medicine (iothalamate, EDTA etc) </li></ul><ul><li>Complex </li></ul><ul><li>Time-consuming </li></ul><ul><li>Expensive </li></ul><ul><li>Not practical for serial monitoring </li></ul>
    21. 21. Creatinine based approximations <ul><li>1) Cockcroft-Gault equation </li></ul><ul><li>CrCl (ml/min)= (140-age) x actual weight (kg) x 1.2 (if male) SCreat (µmol/L) </li></ul><ul><li>2) MDRD ( Modification of Diet in Renal Disease) </li></ul><ul><li>6 variable or abbreviated version </li></ul><ul><li>GFR(ml/min/1.73m2)=170 (PCr) -0.999 x (Age) -0.176 x (0.762 if female) x (1.21 if African American) x (serum urea) -0.170 x (Albumin) +0.318 </li></ul>Weight probably not available for lab to calculate Lab has patient age and gender – can do abbreviated version
    22. 22. eGFR equation provisos <ul><li>eGFR calculations may be less reliable in: </li></ul><ul><ul><li>individuals with near normal GFR (>60 ml/min/1.73m 2 ) </li></ul></ul><ul><ul><li>individuals with markedly abnormal body composition </li></ul></ul><ul><ul><ul><li>extreme obesity </li></ul></ul></ul><ul><ul><ul><li>cachexia </li></ul></ul></ul><ul><ul><ul><li>paralysis </li></ul></ul></ul><ul><ul><ul><li>amputations </li></ul></ul></ul><ul><li>Controversies exist as to the applicability of these formulae to various ethnic groups and the very elderly </li></ul>
    23. 23. Estimate of Glomerular Filtration Rate (eGFR) <ul><li>It is not recommended that clinicians rely on serum creatinine measurements alone when assessing kidney function. </li></ul><ul><li>CSN calls for the reporting of kidney function as an estimate of glomerular function rate (eGFR) using equations and standardized creatinine measurements </li></ul><ul><li>If neither eGFR reporting, nor calculators are available to a physician, tables based on serum creatinine and other variables are available to provide approximations of eGFR. </li></ul>
    24. 24. Developed by the BC Medical Services Commission, Guidelines and Protocols group
    25. 25. Developed by the BC Medical Services Commission, Guidelines and Protocols group
    26. 26. Is it just about GFR? <ul><li>Should also assess urine protein losses </li></ul><ul><ul><li>24 hour urines are no longer recommended </li></ul></ul><ul><ul><ul><li>For same reasons as with GFR </li></ul></ul></ul><ul><ul><li>Urine dipsticks are affected by hydration status </li></ul></ul><ul><ul><li>Quantify protein excretion with random urine for: </li></ul></ul><ul><ul><ul><li>Urine albumin to creatinine ratio or </li></ul></ul></ul><ul><ul><ul><li>Urine protein to creatinine ratio </li></ul></ul></ul>
    27. 27. What do those values mean? Alarm values to refer Microalbuminuria (ie in diabetics) ~30 mg day (albumin) N/A >3 ~900 mg/day (protein) >100 >60 ~ 500 mg/day (protein) <60 <40 24 hour urine PCR (mg/mmol) ACR (mg/mmol)
    28. 28. Who should be tested for CKD? <ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with hypertension </li></ul><ul><li>Patients with heart failure </li></ul><ul><li>Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease </li></ul><ul><li>Patients with unexplained anemia </li></ul><ul><li>Patients with a family history of ESRD </li></ul><ul><li>First nations peoples </li></ul>
    29. 29. What tests to order? <ul><li>Assess kidney function with </li></ul><ul><ul><li>eGFR </li></ul></ul><ul><ul><ul><li>As reported by lab </li></ul></ul></ul><ul><ul><ul><li>As calculated using equations (and PDA!) </li></ul></ul></ul><ul><ul><ul><li>As estimated by tables </li></ul></ul></ul><ul><ul><li>Quantification of protein with random urine samples </li></ul></ul><ul><ul><ul><li>Urine albumin to creatinine or </li></ul></ul></ul><ul><ul><ul><li>Urine protein to creatinine </li></ul></ul></ul>
    30. 30. What to do with the results <ul><li>Now that I know Joe’s GFR is not normal what should I do? </li></ul>
    31. 31. What to do with the results <ul><li>Is one eGFR measurement enough? </li></ul><ul><li>Consider reversible factors </li></ul><ul><li>Assess risk of progressive renal disease </li></ul><ul><ul><li>who needs referral to Nephrology </li></ul></ul>
    32. 32. Natural history of elevated creatinine levels <ul><li>1434 patients in a family medicine practice </li></ul><ul><li>57 patients had an elevated initial serum Cr levels (>130umol/L) and subsequent Cr levels within 4-5 years of follow-up </li></ul>Marcotte and Godwin, Canadian Family Physician 2006;52:1264-1265,e1-5 0 1 2 3 >300 0 1 3 3 201-300 2 5 12 26 131-200 >300 201-300 131-200 <130 Latest serum creatinine (umol/L) Initial serum Cr
    33. 33. Is one eGFR measurement enough? <ul><li>Decisions about investigation, treatment or referral should not be made based on a single isolated test of kidney function </li></ul><ul><li>In a primary care setting, many patients will show improvement or normalization of kidney function upon repeat testing. </li></ul><ul><li>The diagnosis of CKD is based on serial measurements of kidney function and it is not possible to diagnose CKD on the basis of a single serum creatinine concentration transformed through equations. </li></ul>
    34. 34. For patients with a new finding of an eGFR between 30-60ml/min/1.73m 2 CSN recommends that clinicians determine the stability of the patient’s eGFR Repeat test within 2-4 weeks, and then in 3-6 months
    35. 35. Consider reversible factors <ul><li>Intercurrent illness </li></ul><ul><li>Volume depletion </li></ul><ul><li>Medications </li></ul><ul><ul><li>NSAIDs, aminoglycosides, IV contrast dye </li></ul></ul><ul><li>Obstruction </li></ul><ul><li>An abdominal ultrasound may be indicated at eGFRs <60ml/min/1.73m 2 </li></ul>
    36. 36. Back to Joe <ul><li>You measure Joe’s eGFR in 2 weeks and then again in 3 months and it is unchanged </li></ul><ul><li>You order an ultrasound and it is normal </li></ul><ul><li>His urinalysis is normal </li></ul>
    37. 37. Conclusions about Joe <ul><li>Given the stability of these we can conclude that he has stable CKD. </li></ul><ul><li>It is important to continue to serially follow his renal function. </li></ul><ul><li>Serial measurement is a cornerstone of chronic kidney disease management. </li></ul>
    38. 38. CSN recommends that most patients with non-progressive CKD can be managed by non-nephrologists without referral. The recognition that many patients with an eGFR between 30 and 60 ml/min/1.73m 2 do not have a high risk of progressive kidney disease is important.
    39. 39. CKD is common
    40. 40. Estimated prevalence of CKD in Canadians ≥ 20 years old <ul><li>Stage 1 CKD > 90 ml/min 792,000 </li></ul><ul><li>Stage 2 CKD 60 – 89 ml/min 720,000 </li></ul><ul><li>Stage 3 CKD 30 – 59ml/min 1,032,000 </li></ul><ul><li>Stage 4 CKD 15 – 29 ml/min 48,000 </li></ul><ul><li>Stage 5 CKD < 15 ml/min 24,000 </li></ul>Stigant, C, et al. CMAJ 2003;168:1553-60 . Numbers are estimates based on an extrapolation of US data
    41. 41. Other common conditions also managed by primary care physicians CKD is a common general health problem 8-10 % worldwide Type 2 DM 28% Hypertension 1/20 (Thyroid Fdn of Canada) Thyroid disease 38.7% in diabetic men 30.7 % in diabetic women CVD
    42. 42. Estimated prevalence of CKD in Canadians ≥ 20 years old <ul><li>Stage 1 CKD > 90 ml/min 792,000 </li></ul><ul><li>Stage 2 CKD 60 – 89 ml/min 720,000 </li></ul><ul><li>Stage 3 CKD 30 – 59ml/min 1,032,000 </li></ul><ul><li>Stage 4 CKD 15 – 29 ml/min 48,000 </li></ul><ul><li>Stage 5 CKD < 15 ml/min 24,000 </li></ul>Stigant, C, et al. CMAJ 2003;168:1553-60 . ESRD is not common
    43. 43. <ul><li>If many patients with CKD do not progress to end stage renal failure why then as a primary care physician should I even be looking for them using eGFR? </li></ul>
    44. 44. ESRD is not the problem <ul><li>Patients with CKD have high rates of cardiovascular disease </li></ul><ul><li>and many patients die before progressing to end stage renal failure thus it is important to screen for CKD. </li></ul>
    45. 45. Go,A et al. NEJM 2004;351:1291-1305
    46. 46. Quick Tips on Management of CKD <ul><li>Implement measures to slow rate of CKD progression </li></ul><ul><li>Treat to target BP <130/80; most will need 3 or more meds, diuretics and salt restriction are very useful </li></ul><ul><li>Target urine ACR <40 or PCR <60. ACEI and/or ARB are first line therapies for albuminuria or proteinuria </li></ul><ul><li>Control blood sugar in diabetes, target HbA1C <7% </li></ul><ul><li>Implement measures to modify CV risk factors </li></ul><ul><li>Follow guidelines as per groups at highest risk for CV disease </li></ul><ul><li>Minimize further kidney injury </li></ul><ul><li>If possible, avoid nephrotoxins such as NSAIDs, aminoglycosides, IV and intra-arterial contrast etc </li></ul><ul><li>If contrast is necessary, consider prophylactic measures (if eGFR <60) </li></ul><ul><li>Remember to adjust dosages of renally excreted medications </li></ul>
    47. 47. Joe: three years later <ul><li>You have continued to follow his eGFR and notice that it is now 42 ml/min/1.73m 2 </li></ul><ul><li>All clinical targets (BP, HBA1C, cholesterol) are stable </li></ul><ul><li>No intercurrent illnesses </li></ul><ul><li>His CKD is no longer stable </li></ul>Refer to Nephrology
    48. 48. Who should be referred to a Nephrologist? <ul><li>Patients with acute renal failure </li></ul><ul><li>Patients with eGFR <30ml/min/1.73m 2 </li></ul><ul><li>Patients with progressive loss of renal function </li></ul><ul><li>Persistent significant proteinuria (present on 2 out of 3 samples) </li></ul><ul><ul><li>on dipstick or </li></ul></ul><ul><ul><li>quantified PCR >100mg/mmol or </li></ul></ul><ul><ul><li>quantified ACR >60 mg/mmol. </li></ul></ul><ul><li>Inability to achieve treatment targets or other difficulties in the management of the CKD patient </li></ul>
    49. 49. Violet <ul><li>78 year old female </li></ul><ul><li>longstanding patient of a colleague’s – followed for her hypertension and “mild” renal failure </li></ul><ul><li>You are on call and see her because she is c/o nausea and lethargy </li></ul>138 156 168 184 Serum Creat (µmol/l) 5 yrs ago 2 yrs ago 1 yr ago today Date
    50. 50. Using an “eGFR approach” 35 30 27 24 eGFR (ml/min/1.73m 2 ) 138 156 168 184 Serum Cr (µmol/L) 5 yrs ago 2 yrs ago 1 yr ago today Date
    51. 51. This woman’s renal disease may have been underdiagnosed Using eGFR may have given a more accurate measure of her renal function Serial measurement of eGFR is a powerful tool for the clinician Nephrology referral is recommended for this patient
    52. 52. Linda <ul><li>54 yo female comes for routine annual physical </li></ul><ul><ul><li>no problems identified </li></ul></ul><ul><ul><li>normal physical examination </li></ul></ul><ul><ul><li>family history of ESRD </li></ul></ul><ul><li>All her labs are normal – serum creatinine is 90 µmol/l </li></ul><ul><li>Lab automatically reports an eGFR of 60 ml/min/1.73m 2 </li></ul><ul><li>What do you do with this eGFR value? </li></ul><ul><li>Should she be referred to a Nephrologist? </li></ul>
    53. 53. <ul><li>Identify patients in your practice at high risk for Chronic Kidney Disease </li></ul><ul><li>Patients with hypertension </li></ul><ul><li>Patients with diabetes mellitus </li></ul><ul><li>Patients with atherosclerotic coronary, </li></ul><ul><li>cerebral or peripheral vascular disease </li></ul><ul><li>- Patients with heart failure </li></ul><ul><li>Patients with unexplained anemia </li></ul><ul><li>Patients with a family history of end stage renal disease </li></ul><ul><li>First nations peoples </li></ul>eGFR <30 eGFR 30-60 eGFR >60 <ul><li>Consider reversible factors: </li></ul><ul><li>Medication - Volume depletion </li></ul><ul><li>Intercurrent illness - Obstruction </li></ul><ul><li>Repeat tests in 2 - 4 weeks </li></ul>Individualized follow up and treatment CKD is diagnosed in this group only if other renal abnormalities are present (i.e. proteinuria, hematuria, anatomical) eGFR <30 eGFR 30-60 Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction eGFR < 30 or progressive decline in eGFR or persistent significant proteinuria or inability to attain treatment targets Stable eGFR 30-60 and no significant proteinuria
    54. 54. Linda: continued <ul><li>Evaluation of her urine shows no significant amount of proteinuria (ACR <40mg/mmol) and no hematuria </li></ul><ul><li>She is followed annually </li></ul><ul><li>Two years later </li></ul><ul><ul><li>same eGFR </li></ul></ul><ul><ul><li>blood pressure is 146/94 </li></ul></ul><ul><ul><li>persistent proteinuria with ACR > 60mg/mmol </li></ul></ul><ul><li>Progressive CKD = referral to Nephrology </li></ul>
    55. 55. Dave <ul><li>81 year old man, new to your practice </li></ul><ul><ul><li>ASHD, stent placed 2 years ago </li></ul></ul><ul><ul><li>PSA >100 led to biopsy and diagnosis of prostate cancer, being treated with hormone therapy alone </li></ul></ul><ul><ul><li>On atorvastatin 40 mg, aspirin 81 mg, ramipril 5 mg </li></ul></ul><ul><ul><li>Bp 144/82, nil else on exam </li></ul></ul><ul><ul><li>Cr 167, eGFR 36, ACR 0.7 </li></ul></ul>
    56. 56. Dave <ul><li>Old labs from previous MD show Cr 150-180 umol/L over last 3 years </li></ul><ul><li>What would you do? </li></ul>
    57. 57. Summary <ul><li>Who should be tested for CKD? </li></ul><ul><ul><li>Patients with diabetes mellitus </li></ul></ul><ul><ul><li>Patients with hypertension </li></ul></ul><ul><ul><li>Patients with heart failure </li></ul></ul><ul><ul><li>Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease </li></ul></ul><ul><ul><li>Patients with unexplained anemia </li></ul></ul><ul><ul><li>Patients with a family history of ESRD </li></ul></ul><ul><ul><li>First nations peoples </li></ul></ul>
    58. 58. Summary <ul><li>What tests should be ordered? </li></ul><ul><ul><li>eGFR to assess kidney function </li></ul></ul><ul><ul><li>random urine sample to assess for significant persistent proteinuria </li></ul></ul><ul><li>What should be done with the results? </li></ul><ul><ul><li>follow serially </li></ul></ul><ul><ul><li>assess for proteinuria </li></ul></ul><ul><ul><li>implement risk reduction strategies </li></ul></ul>Monitoring for evidence of progressive disease - declining eGFR - persistent significant proteinuria
    59. 59. Acknowledgements <ul><li>Financial support for the development and distribution of these educational materials was provided by unrestricted grants from Amgen Canada and Bristol Meyers Squibb </li></ul>
    60. 60. Quick Tips on Referral and Management of Chronic Kidney Disease <ul><li>Most patients with non-progressive CKD can be managed without referral to a nephrologist. The goals of therapy are listed below: </li></ul><ul><li>Consider reversible factors , such as medications, intercurrent illness, volume depletion, or obstruction. An abdominal ultrasound may be indicated when eGFR <60 ml/min/1.73m2. </li></ul><ul><li>Minimize further kidney injury by avoiding, if possible, nephrotoxins such as NSAID’s, aminoglycoside antibiotics, IV contrast, etc (if eGFR < 60 ml/min/1.73m2). </li></ul><ul><li>Remember to adjust dosages of renally excreted medications. </li></ul><ul><li>Implement measures to slow the rate of progression of CKD: </li></ul><ul><ul><ul><li>Target BP is < 130/80 mmHg. Most patients will need 3 or more medications. Diuretics and salt restriction are very useful, and if needed, consider furosemide BID dosing when eGFR < 30 ml/min/1.73m2 </li></ul></ul></ul><ul><ul><ul><li>Target urine protein/creatinine ratio (mg/mmol) is < 60 (< ~ 500 mg/day) or target urine albumin/creatinine ratio (mg/mmol) is < 40. ACEI and/or ARB are first line therapies in patients with albuminuria or proteinuria. </li></ul></ul></ul><ul><ul><ul><li>Control blood sugar in diabetes, target HbA1C < 7%. </li></ul></ul></ul><ul><li>Implement measures to modify CV risk factors (NB: CV risk >> ESRD risk). </li></ul><ul><ul><li>Follow the Canadian Hypertension Education Program, the Canadian Diabetes Association, and the Canadian Cardiovascular Society guidelines as per groups at highest risk for CV disease. </li></ul></ul><ul><li>Referral to a nephrologist is recommended for : </li></ul><ul><ul><li>acute kidney failure </li></ul></ul><ul><ul><li>eGFR < 30 ml/min/1.73m2. (CKD stage 4 and 5) </li></ul></ul><ul><ul><li>progressive decline of eGFR </li></ul></ul><ul><ul><li>urine protein/creatinine ratio (PCR) > 100 mg/mmol (~900 mg/24 hours) or urine albumin to creatinine ratio (ACR) > 60 mg/mmol (~500 mg/24 hr) </li></ul></ul><ul><ul><li>inability to achieve treatment targets </li></ul></ul><ul><li>NOTE: detailed CSN CKD management guidelines are under development, these quick tips should be considered as an interim approach.Insert Quick Tips sheet from the CSN CKD document </li></ul>
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