chronic kidney disease. stage 5 0.2% stage 4: 0.2% stage 3: 4.3% stage 2: 3.0% stage 1: 3.3% coresh...
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Chronic Kidney Disease
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Stage 50.2%
Stage 4: 0.2%
Stage 3: 4.3%
Stage 2: 3.0%
Stage 1: 3.3%
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J
Kidney Dis 2002;41:1-12
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CKD stage GFR (ml/min/1.73m2) Description
1 >90 Normal renal function but other evidence of organ
damage*
2 60-89 Mild reduction in renal function with other evidence of organ
damage*
3 30-59 Moderately reduced GFR
4 15-29 Severely reduced GFR
5 <15 End stage, or approaching, end stage
renal failure
* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN
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Creatinine 120
eGFR 31-40 eGFR 82-106
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Copyright ©2006 BMJ Publishing Group Ltd.
Traynor, J. et al. BMJ 2006;333:733-737
Fig 2 Commonly used formulas for estimating renal function. MDRD=modification of diet in renal disease
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Association of estimated glomerular filtration rate (GFR) with GFR measured by an isotopic reference method. Below 60 ml/min/1.73 m2 the two methods are tightly
associated, with limited scatter of the points. At higher filtration rates scatter becomes progressively worse, and in kidney donors estimated GFR underestimates renal function
compared with reference measurements. Adapted from Poggio et al.
Giles, P. D et al. BMJ 2007;334:1198-1200
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Caveats
• Only an estimate• Inaccurate at extremes of body habitus, pregnant,
amputees• Only validated in Caucasians and Afro-Caribbeans• Underestimates function in kidney donors• MDRD underestimates renal function, C-G
overestimates it• Only valid in steady state
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GFR > 60
• Estimated GFR not very accurate
• If GFR > 60, use increase in serum creatinine > 20% as indicator of renal deterioration
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Stage 50.2%
Stage 4: 0.2%
Stage 3: 4.3%
Stage 2: 3.0%
Stage 1: 3.3%
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J
Kidney Dis 2002;41:1-12
2% of NHS budget spent on RRT
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CKD stage GFR (ml/min/1.73m2) Description
1 >90 Normal renal function but other evidence of organ
damage*
2 60-89 Mild reduction in renal function with other evidence of organ
damage*
3 30-59 Moderately reduced GFR
4 15-29 Severely reduced GFR
5 <15 End stage, or approaching, end stage
renal failure
* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN
Insert p for proteinuria
3a and 3b 45-49 and 30-44
Insert p for proteinuria
3a and 3b 45-49 and 30-44
Insert p for proteinuria
3a and 3b
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NICE guidelines Sept 2008
• People who have or are at risk of developing CKD• Those who need intervention to minimise
cardiovascular risk and what that intervention should be
• Those who will develop progressive kidney disease and how they can be managed
• Those who need referral for specialist kidney care
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Offer testing for CKD
• Diabetes• HTN• CV disease: IHD, CHF, PVD, CVD• Structural disease, calculi or BPH• Multisystem eg SLE• FHx CKD 5 or hereditary kidney disease• Nephrotoxins (CNIs or ACE inhibitors)• Opportunistic detection of h’turia or p’uria
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Proteinuria
• Use albumin: creatinine ratio (ACR) (more sensitive at low levels)
• ACR in diabetes
• PCR may be used for quanitification and monitoring
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Don’t offer testing…
• On basis of – Age– Gender– Ethnicity– Obesity without metabolic syndrome, diabetes
or HTN
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Who needs a renal ultrasound?
• All people with CKD with– Progressive CKD– Haematuria– Obstructive symptoms– > 20 yrs with FHx polycystic kidneys– CKD 4-5– Prior to biopsy
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Who should be referred?
• CKD 4 and 5 (with or without diabetes)• ACR > 70 unless diabetic and already treated• ACR > 30 and haematuria• GFR declining > 5 /yr or 10 in 5 yr• Uncontrolled HTN despite 4 agents• Suspect rare or genetic cause CKD• Suspect renal artery stenosis
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Consider discussion with nephrologist by phone or letter if you feel clinic referral may
not be necessary
Single clinic visit with agreed management plan and specified criteria for re-referral may
be all that is necessary
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Identify progressive CKD
• Obtain minimum 3 GFRs over not less than 90 days
• If new finding low GFR, repeat within 2 weeks to exclude ARF
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Case history
• Mr RB, 69 years old, Type II diabetes
• “Please see this man with CKD 4…”
• PMHx:– DM, ileal conduit and pyelonephritis, dyspepsia
• DHx:– Atenolol, gliclazide, metformin, simvastatin,
lansoprazole, GTN spray
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Started lansoprazole
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Tubulo-interstitial nephritis
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Identify progressive CKD
• Obtain minimum 3 GFRs over not less than 90 days
• If new finding low GFR, repeat within 2 weeks to exclude ARF
• Define progression as GFR fall > 5 /yr or 10 in 5 yrs
• Extrapolate current rate of decline: will pt need RRT in their life time?
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Extrapolate current rate of decline: will pt need RRT in their life time?
1. Will their kidneys fail in their lifetime?
2. Will they die of something else first?
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80 yrs old
eGFR 50
No PMHx
BP 120/60
P’uria 0.3g/day
45 yrs old
eGFR 50
Type II diabetes
BP 160/90
P’uria 2.6g/day
RENAL RISK
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CKD stage 3a
Manage cardiovascular risk factors
Don’t refer
CKD stage 3p
Progressive
Do refer
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In people aged over 70 years, eGFR 45-59, if stable over time and without any other evidence of
kidney damage, unlikely to be associated with CKD related complications
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Extrapolate current rate of decline: will pt need RRT in their life time?
1. Will their kidneys fail in their lifetime?
2. Will they die of something else first?
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100 patients with eGFR < 60
(Tuesday morning in Outpatients)
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Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)
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Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD
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The majority of patients with CKD 1-3 do not progress to ESRF.
Their risk of cardiovascular death is higher than their risk of progression.
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O’Hare et al JASN 2007
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Optimise risk factors
• Cardiovascular disease
• Proteinuria
• Hypertension
• Diabetes
• Smoking
• Obesity
• Exercise tolerance
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ACE inhibitor/ ARBs
• Offer to:– Diabetes and ACR > 2.5 ± HTN/CKD– Non-diabetic with CKD and high BP and ACR
30+ mg/mmol (0.5g/24 hrs)– Non-diabetic with CKD and ACR > 70
regardless of blood pressure or risk factors– Titrate to maximum tolerated dose before add
in second agent
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What is an acceptable rise in creatinine?
Loss of nephrons
Hyperfiltration of remaining nephrons
Increased glomerular pressure
Mesangial cell and endothelial cell injury
Mesangial cell proliferation and matrix expansion
Focal sclerosis
Primary renal damage
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What is acceptable?
•25% increase eGFR
•30% increase creatinine
•K up to 6.0
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Always
•check U and Es 1-2 weeks after starting ACE inhibitor
•Recheck after dose increase
•Advise stopping ACEI with dehydrating illness
•Counsel women of child bearing age
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Blood pressure control
• Systolic < 140 (aim 120-139 mm Hg)
• Diastolic < 90 mm Hg
• If diabetes or proteinuria, aim 130/80 mm Hg
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What do we do in CKD clinic?
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Mr KH
• “Please see this well 73 year old with diabetes..”
• PMHx: DM, IHD, cerebrovascular disease, SCC • DHx: gliclazide, lansoprazole, metformin, quinine,
sildenafil, simvastatin, valsartan, clopidogrel
• BMI 33, BP 132/80• Ur 8.0, Cr 129, PCR 125 mg/l, HbA1C 8.3%
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Mr KH (cont’d)
• Address proteinuria– Maximise ACE/ RAS inhibition
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Mr KH (cont’d)
• Address proteinuria– Maximise ACE/ RAS inhibition
• Risk factor modification:– Lifestyle– Meticulous BP control– Lipid management– Glycaemic control
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Sound familiar?
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CKD 3 management in primary care
• Diabetes, ischaemic heart disease, hypertension• Risk factor management• Not much specialist renal medicine involved in
majority of CKD 3• Refer if refractory hypertension, complications of
renal failire, renal artery stenosis etc…• Identify those with progressive CKD and refer
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Stage 5
Stage 4
Stage 3
Stage 2
Stage 1
PTH increases at GFR 50-60
Ca absorption and lipoprotein activity reduced
Malnutrition, LVH, anaemia
Hypertriglyceridaemia
Hyperphosphataemia
Metabolic acidosis
Hyperkalaemia
Uraemia
The metabolic complications of CKD
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“Patients receiving comprehensive care by the renal team have shown:– slower rates of decline in renal function– greater probability of starting dialysis with
higher haemoglobin, better calcium control and permanent access
– a greater likelihood of choosing peritoneal dialysis.”
Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. for the Collaborative Study Group. Renoprotective effect of the angiotensin-receptor
antagonist irbesartan in patients with nephropathy due to type 2 diabetes N Engl J Med 2001. 345:851–860.
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Why bother?
• Manage risk factors
• Further investigations (? reversibility)
• Delay progression to ESRF
• Identify and treat complications– Bone– Anaemia– Malnutrition
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Stage 50.2%
Stage 4: 0.2%
Stage 3: 4.3%
Stage 2: 3.0%
Stage 1: 3.3%
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease in the adult US population: Third National Health and Nutrition Examination Survey. Am J
Kidney Dis 2002;41:1-12
Primary care
Secondary care
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“Since the introduction of eGFR reporting (together with a programme of education in primary care), the proportion of new dialysis patients referred late (defined as within 90 days) has fallen from 38% to 25% (p<0.01).”
BMJ 2007;334:1287 (23 June), doi:10.1136/bmj.39247.723206.3A
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Any questions?