2 RelevanceEnd Stage CKD places a very significant burden on patients quality of life.End Stage CKD is very expensive to manage.Deteriorating CKD is an independant risk factor for an increase in mortality from cardiovascular disease.QOF: CKD = 38 points
3 Guidelines National Service Framework 2004 -2005 NICE guidelines 2008 PACE local guidelinesQOF
4 eGFR CKD classification is based on eGFR Estimates Glomerular Filtration Rate using serum creatinine and patients Age, Sex, etcCockroft-Gault formulaMDRD formula
6 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*260-89Mild reduction in renal function with other evidence of organ damage*330-59Moderately reduced GFR415-29Severely reduced GFR5<15End stage, or approaching, end stage renal failureInsert P for proteinuria3a and 3b45-49 and 30-44* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN
8 Risks of a low eGFR Renal 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t)CardiovascularIf you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular eventeGFR is presently being used as a screening test for CKD but it has some limitations.What is not clear is whether it is the low eGFR that increases your risk, or whther it is a marker of other co-morbidities.
18 Routine management Lifestyle modification Smoking increases risk of progressive CKDLose weight if obeseRegular exerciseReduce salt if hypertensive
19 Routine management Monitor eGFR CKD 3 6 monthly CKD 4 3 monthly CKD weeklyWe have 5 patients with CKD 4 or 5 who have no hospital input and where there is no recall arrangements
20 Routine management Control BP NICE target <140/90 <130/80 if ACR >70<130/80 if diabeticQOF <140/85 for all
21 Routine management ACEI or ARB: Diabetes + ACR (>30) (irrespective of hypertension or CKD stage)Non-Diabetic with CKD + HT + ACR >30Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)
23 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)ImmunizationsInfluenza - annuallyPneumococcal - 5 yearly, due to declining antibody levels5/16 CKD 4-5 have CVD risks >30 and are not on a statin
24 Routine management Drugs Check BNF Appendix 3: Renal Impairment Test for anaemiaIf Hb <11 first consider other causes of anaemiaDetermine iron status – if serum ferritin <100 start oral iron10% of those with KD4 have anaemia and 4% of those with CKD3BRates are a lot higher in diabetics with CKD-aprox 22% will be anaemic.ESA’s tend to be initiated in hospital and then administered at the practice.
25 Consider renal USS If CKD 4 or 5 Progressive CKD Visible or persistent microhaematuriaSymptoms of urinary tract obstructionFHx polycystic kidney disease and >20yrs of age
27 Consider referral CKD 4 or 5 Proteinuria ACR >70 Proteinuria ACR>30 with haematuriaProgressive CKDCKD and poorly controlled BP on 4 agentsSuspected genetic renal disease or renal artery stenosisWe have 5 patients CKD 4/5 who have not been referred for renal opinion –may be legitimate reasons age/co morbidities etc
29 Take Home MessageCKD is an independant risk factor for cardiovascular mortality which far outweighs the risk of developing end-stage renal diseaseCKD 3 is managed in primary care with ACE-i and cardiovascular optimisation.Monitor eGFRBlood pressure control with ACECheck for proteinuria