Chronic kidney disease

in primary healthcare

Kay McLaughlin RN MA(Applied) PG Cert Hlth Sc.

Pre-dialysis/Vascular Access Nurse Specialist

Renal Service

Capital & Coast District Health Board

Chronic Kidney Disease (CKD)

Case studies

CKD detection, screening &

management

New CKD resources

Case Study 1: Late : Mr L

56 year old male, acute admission September 2015

2/52 history of cough, SOB, haemoptysis, drowsiness

Type 2 Diabetes, Hypertension, Gout, CCF, AF

Lethargy, anorexia (20kg weight loss in recent months)

BP 169/98 HR 115 (AF) Afebrile

JVP 4cm+, Bilateral pitting oedema to above knees

Late : Mr L Investigations:

Sr Creatinine 1068umol/L, eGFR 4ml/min

Urea 48mmol/l

Potassium 4.6mmol/l

Calcium 2.05mmol/l

PO4 2.20mmol/l

Hb 115g/L

CXR – cardiomegaly

Renal Ultrasound – small kidneys

Late Start: Mr L Commenced haemodialysis

Struggled with accepting disease

Poor dialysis, missed treatments

Unable to work

Long term in-centre haemodialysis treatment

Poor cardiac function & mineral bone disease

Not fit for kidney transplant wait list

Survival ? 3 – 5 years*

* ANZDATA Registry 2014

Early: Ms B 43 year old female

2003 - Referred to renal service eGFR 24ml/min

Renal biopsy – Lupus nephritis

Reviewed regularly in renal outpt clinic

Working full time

Lupus & hypertension monitored & treated

October 2006 eGFR 12ml/min

Pre-dialysis education

On kidney transplant waiting list

Early: Ms B

December 2008 - eGFR 8ml/min

commenced peritoneal dialysis

Working fulltime

6 years peritoneal dialysis (APD)

2014 received a deceased donor kidney

transplant

Currently well and enjoying life

Identifying CKD Early

Prevalence of ESRD increasing in NZ at 4 - 6% pa

Doubling of dialysis numbers every 13 yrs

Once symptomatic (GFR ~ 20mL/min) then kidney failure

inevitable and complications already apparent (CVD, PTH,

anaemia)

Late referral associated with increased costs, morbidity and

reduced survival

Screening For CKD

Not thought worthwhile for total population

Should be targeted at high risk groups

Hasn’t been assessed well for cost-

effectiveness

Prevalence data not known across NZ

population

(2015) BPAC Management of CKD

Classification of Kidney Disease (National Kidney Foundation 2002)

Stage Description GFR (ml/min/1.73m2)

1 Kidney damage with normal

or increased GFR

>90ml

2 Kidney damage with mild

decrease in GFR

60 - 89

3a

3b

Moderate decrease in GFR 45 -59

30 - 44

4 Severe decrease in GFR 15 - 29

5 Kidney failure (end stage) <15

Estimated CKD in New Zealand Based on adult population 3.5 million (31/12/10)

Adapted from Chadban, 2005

Stage eGFR K/DOQI Classification Prevalence in New Zealand

1 eGFR > 90 mL/min (& proteinuria/haematuria)

31,150

2 eGFR 60 – 90 mL/min (& proteinuria/haematuria)

69,300

3 eGFR 30 -59 mL/min

377,650

4 eGFR 15 -29 mL/min

10,500

5 eGFR < 15 mL/min

3,500

Screening – High Risk Groups Annual renal function tests

Diabetes / metabolic syndrome

Cardiovascular disease

Hypertension

FHx of renal disease

>60 years if other risk factors present

Multisystem disease – SLE, vasculitis, myeloma

Maori, Pacific Island or South Asian

Managing CKD in Primary Care. National Census Statement 2015

CKD Classification & Prognosis

Adapted from KDIGO Clinical Guidelines, 2012

The ‘canary in the coal mine’

People with chronic kidney disease have:

• 10 - 20 fold greater risk of cardiac death

• Are at least 20 times more likely to die from CVD than

survive to the point of needing RRT

Noble, E. et al (2008), Nephrology Dialysis Transplantation 1-6

CKD patients who are

best managed in primary care

Stable stage 3 CKD (eGFR 30- 60ml/min)

Elderly CKD patients (>75 years)

Absent heavy proteinuria with no haematuria

Focus on BP control and CVD risk

Avoidance of nephrotoxins

BPJ: The detection and management of patients with chronic kidney disease in primary care, Issue 66, p37 – 44.

Mrs EM age 74 Decline in renal function

Known hypertension but recently well controlled

No diabetes

Rx – nifedipine, metoprolol, omeprazole, thyroxine

Recent US normal

SCr 109-134 over last 3 yrs (variable)

eGFR 46 → 34 over 3 yrs (CKD Stage 3 b)

Urinary ACR 0.7 mg/mmol (normal <3.5 mg/mmol)

Mrs EM age 74

What’s the likely diagnosis?

What is the prognosis?

How should this be treated?

Is renal review really necessary?

Mrs EM age 74 What’s the likely diagnosis?

Age and HTN related nephrosclerosis

What is the prognosis?

Likely very slow deterioration in renal function

How should this be treated?

BP control & avoidance of nephrotoxins

Is renal review really necessary?

Probably not

Management – stage 3 CKD

Blood Pressure

<130/80 mmHg

<125/75 mmHg if proteinuria (>1g)

Use ACEi / ARB first line

Likely to need multiple agents

Diet, exercise, smoking cessation

2014 Joint National Committee Guidelines (JNC 8)

Management stage 3 CKD Proteinuria:

Aim to reduce by >50%

ACEi / ARB

Lipids – CVD guidelines:

Total cholesterol target < 4.0

LDL < 2.0

HDL > 1.0

Triglycerides < 1.7

Glucose control:

Target HbA1c 50 -55 mmol/mol

New Zealand Primary Care Handbook, 2012

Medicines To Be Wary Of

NSAIDs (esp. with ACEi & diuretics) ‘Triple

Whammy’

Statins & Fibrates

Metformin *

IV contrast

* Prescriber Update 2015; 36 (4) December

Summary Identification of patients with eGFR < 60mL/min is now

common

Useful for identifying patients:

At risk of drug toxicity

At increased cardiovascular risk

At risk of progressive CKD

Proteinuria is a major prognostic marker & an important

treatment target

CKD Decision Support Module

The future of Renal Healthcare in NZ

Improve identification & management of CKD

Support & up-skill CKD management in primary

care

Improve renal specialist collaboration with primary

health

NZ Health Strategy - ‘Closer to home’

Visit the Kidney Health

New Zealand Stand

www.kidneys.co.nz