1. Chronic Kidney Disease

3. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS
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

4. CKD stage GFR (ml/min/1.73m2) Description 1 >90 2 60-89 3 30-59 4
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

6. Creatinine 120
eGFR 31-40
eGFR

7. Fig 2 Commonly used formulas for estimating renal function
Fig 2 Commonly used formulas for estimating renal function. MDRD=modification of diet in renal disease
Traynor, J. et al. BMJ 2006;333:
Copyright ©2006 BMJ Publishing Group Ltd.

8. 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:

9. 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

10. GFR > 60 Estimated GFR not very accurate
If GFR > 60, use increase in serum creatinine > 20% as indicator of renal deterioration

11. 2% of NHS budget spent on RRT
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

12. CKD stage GFR (ml/min/1.73m2) Description 1 >90 2 60-89 3 30-59 4
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
Insert p for proteinuria
Insert p for proteinuria
Insert p for proteinuria
3a and 3b
3a and 3b
3a and 3b
45-49 and 30-44
45-49 and 30-44
* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

13. 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

14. 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

15. Proteinuria
Use albumin: creatinine ratio (ACR) (more sensitive at low levels)
ACR in diabetes
PCR may be used for quanitification and monitoring

16. Don’t offer testing… On basis of Age Gender Ethnicity
Obesity without metabolic syndrome, diabetes or HTN

17. 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

18. 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

19. 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

20. 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

22. 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

23. Started lansoprazole

24. Tubulo-interstitial nephritis

25. 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?

26. Will their kidneys fail in their lifetime?
Extrapolate current rate of decline: will pt need RRT in their life time?
Will their kidneys fail in their lifetime?
Will they die of something else first?

27. 45 yrs old
eGFR 50
Type II diabetes
BP 160/90
P’uria 2.6g/day
80 yrs old
eGFR 50
No PMHx
BP 120/60
P’uria 0.3g/day
RENAL RISK

28. Manage cardiovascular risk factors
CKD stage 3p
Progressive
Do refer
CKD stage 3a
Manage cardiovascular risk factors
Don’t refer

29. 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

30. Will they die of something else first?
Extrapolate current rate of decline: will pt need RRT in their life time?
Will their kidneys fail in their lifetime?
Will they die of something else first?

31. 100 patients with eGFR < 60 (Tuesday morning in Outpatients)

32. Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

33. Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD

34. 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.

35. O’Hare et al JASN 2007

36. Optimise risk factors Cardiovascular disease Proteinuria Hypertension
Diabetes
Smoking
Obesity
Exercise tolerance

37. 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

38. What is an acceptable rise in creatinine?
Primary renal damage
Loss of nephrons
Hyperfiltration of remaining nephrons
Focal sclerosis
Hyperfiltration theory
Mesangial cell proliferation and matrix expansion
Increased glomerular pressure
Mesangial cell and endothelial cell injury

39. What is acceptable?
25% increase eGFR
30% increase creatinine
K up to 6.0

40. check U and Es 1-2 weeks after starting ACE inhibitor
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

41. Blood pressure control
Systolic < 140 (aim mm Hg)
Diastolic < 90 mm Hg
If diabetes or proteinuria, aim 130/80 mm Hg

42. What do we do in CKD clinic?

44. 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%

45. Mr KH (cont’d)
Address proteinuria
Maximise ACE/ RAS inhibition

46. Mr KH (cont’d) Risk factor modification: Address proteinuria
Maximise ACE/ RAS inhibition
Risk factor modification:
Lifestyle
Meticulous BP control
Lipid management
Glycaemic control

47. Sound familiar?

48. 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

49. The metabolic complications of CKD
Uraemia
Hypertriglyceridaemia
Hyperphosphataemia
Metabolic acidosis
Hyperkalaemia
Ca absorption and lipoprotein activity reduced
Malnutrition, LVH, anaemia
PTH increases at GFR 50-60

50. “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 :851–860.

51. Why bother? Manage risk factors
Further investigations (? reversibility)
Delay progression to ESRF
Identify and treat complications
Bone
Anaemia
Malnutrition

52. Secondary care Primary care
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

53. “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: /bmj A

54. Any questions?