ckd ml/lh 17.3.10. chronic kidney disease are we correctly diagnosing ckd? have we the correct...
TRANSCRIPT
CKDML/LH 17.3.10
Chronic Kidney Disease
• Are we correctly diagnosing CKD?
• Have we the correct patients on our CKD register?
• Are we managing them correctly?
Plan for today
Highlight a few issues around eGFRs
Review NICE and PACE guidance
Discuss how we diagnose and manage CKD
Identify and discuss any uncertain areas
Why introduce CKD QOF indicators?
• End stage renal failure is costly to treat, and its prevalence is increasing
• 30% of patients present late; they have worse outcomes and are more expensive to treat
• It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF
Risks of a low eGFR
Renal
• 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t)
Cardiovascular
• If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event
Possible symptoms (CKD 3 - 5)
• Tiredness
• Anorexia, nausea
• Weight loss
• Dry itchy skin
• Muscle cramps
• Ankle swelling, peri-orbital oedema
• Anaemia
NICE Sept 2008, Clinical Guideline 73
Offer CKD screening to at risk groups
• DM• Hypertensives• CVD• Multisystem diseases
e.g. SLE
• Structural renal tract disease e.g. stones, BPH
• FHx CKD 5 or hereditary kidney disease
• Long term NSAIDS
Testing eGFR
• GFR estimated from serum creatinine and age, using MDRD equation
• If abnormal, repeat the test to confirm
• Multiply eGFR result by 1.212 for African -Caribbean and African patients (Are we recording this correctly?)
eGFR and meat
• NICE specifically advises no meat for 12 hours before eGFR
• Are we doing this?
• How do we record it?
eGFRs and age
• eGFR is not validated in the >75s
(How many patients >75 have we coded with CKD 3?)
• From the age of 40 the eGFR declines by 1ml/min/yr
• NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.
Newly identified CKD
• Stage CKD on eGFR results
• Stage 1 > 90
• Stage 2 60 - 89
• Stage 3A 45 - 59
• Stage 3B 30 - 44
• Stage 4 15 - 29
• Stage 5 <15
eGFRs: ‘normal for age?’
eGFR
> 90 CKD 1
Normal renal function
60-89 CKD 2
45-59 CKD 3A
Impaired renal function
30-44 CKD 3B
15-29 CKD 4
Severely impaired
<15 CKD 5
eGFR /
Age18-29 30-39 40-49 50-59 60-69 70-79 80-89 Age
In yrs
Assess for proteinuria
• NICE advises ACR on first sample of the day (preferably)
• ACR abnormal if >30, in non diabetics• (Repeat to confirm if ACR >30 but <70)
• ACR abnormal if >2.5 in diabetic men
• ACR abnormal if >3.5 in diabetic women
Issues around proteinuria
• NICE also mentions PCRs (mg/mmol)(ACR of 30 = (approx) PCR of 50)
• But in Bradford they report PCIs (mg/mg), which correspond with 24hr urinary protein excretion
• PCR of 50 = PCI of 500 (i.e. divide by 10)
• Leeds/Bfd Biochem are considering changing to PCRs in the future, to fit with NICE
False positives
• Urinary Tract Infection
Do MSU if dipstix +ve for protein
• Menstrual contamination
• Benign orthostatic proteinuria
Assess for progressive CKD
• Check at least 3 eGFRs over at least 90 days
• Defined as a decline in eGFR of
>5 within 1 year, or >10 within 5 years
• Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction,
proteinuria and diabetes
Other baseline tests
For all• Dipstix for haematuria• CVD risk assessment • Consider DEXA scan
CKD 4 and 5• FBC and ferritin• Calcium, phosphate, PTH
Consider renal USS
• If CKD 4 or 5
• Progressive CKD
• Visible or persistent invisible haematuria
• Symptoms of urinary tract obstruction
• FHx polycystic kidney disease and >20yrs of age
Consider referral
• CKD 4 or 5 without diabetes
• ACR >70 in non diabetics
• Proteinuria (ACR>30) with haematuria
• Progressive CKD
• CKD and poorly controlled BP on 4 agents
• Suspected genetic renal disease or renal artery stenosis
Routine management
Lifestyle modification
• Smoking increases risk of progressive CKD
• Lose weight if obese
• Regular exercise
• Reduce salt if hypertensive
Routine management
Monitor eGFR
• CKD 3 6 monthly
• CKD 4 3 monthly
• CKD 5 6 weekly
Routine management
Control BP
• NICE target <140/90
• <130/80 if ACR >70
• <130/80 if diabetic
• QOF <140/85 for all
Routine management
Reduce proteinuria
• ACEIs first line
• ARBs if not tolerated
Routine management
ACEI or ARB:
• Diabetes + ACR (>2.5 men, or 3.5 women) (irrespective of hypertension or CKD stage)
• Non-Diabetic with CKD + HT + ACR >30
• Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)
Routine management
Routine anti-hypertensive treatment
• Non-diabetic + CDK + HT + ACR <30
(See NICE Hypertension guideline 34)
Routine management
CVD risk assessment • treat with a statin if CVD risk >20%
(SystmOne CVD risk calculator does NOT include adjustment for chronic renal disease, but QRISK2 does)
Immunizations• Influenza - annually• Pneumococcal - 5 yearly, due to declining
antibody levels
Routine management
Drugs• Check BNF Appendix 3: Renal Impairment
Test for anaemia• If Hb <11 first consider other causes of anaemia• Determine iron status – if serum ferritin <100
start oral iron• Consider referral for erythropoeisis stimulaing
agents (ESA’s)
Routine management
Manage bone conditions• Ca, PTH and phosphate if CKD 4 or 5• Offer biphosphonates to all “if indicated”• If indicated offer vitamin D supplements:- cholecalciferol or ergocalciferol in CKD3- alfacalcidol or calcitriol in CKD 4 and 5• If on vit D supplements they need to be
monitored
QOF indicators
• CKD1: Register of patients >18 yrs with CKD (stages 3 – 5)
• CKD2: % of pts with BP recorded in last 15 mths• CKD3: % of pts in whom last BP reading, in last
15 mths, is <140/85• CKD5: % of pts with HT + proteinuria on ACEI or
ARB (unless c/i or s/e recorded)• CKD6: % of pts with urine ACR (or PCR) test in
last 15 months
QOF indicators
• CKD points total = 38 points = £££
• CKD1 (reg) = 6 points
• CKD2 (bp) = 6 points
• CKD3 (bp controlled) = 11 points
• CKD5 (acei/arb) = 9 points
• CKD6 (acr) = 6 points