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Canadian Society of Nephrology - Société Canadienne de Néphrologie - www.csnscn.ca Detection, monitoring and referral of chronic kidney disease Canadian.

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Presentation on theme: "Canadian Society of Nephrology - Société Canadienne de Néphrologie - www.csnscn.ca Detection, monitoring and referral of chronic kidney disease Canadian."— Presentation transcript:

1 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Detection, monitoring and referral of chronic kidney disease Canadian Society of Nephrology Implementation Committee 2007

2 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Key messages Who to test for chronic kidney disease What tests to order What to do with the results

3 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Identify patients in your practice at high risk for Chronic Kidney Disease - Patients with hypertension - Patients with diabetes mellitus - Patients with atherosclerotic coronary, cerebral or peripheral vascular disease - Patients with heart failure - Patients with unexplained anemia - Patients with a family history of end stage renal disease - First nations peoples eGFR <30 eGFR 30-60eGFR >60 Consider reversible factors: -Medication- Volume depletion -Intercurrent illness- Obstruction Repeat tests in weeks Individualized follow up and treatment CKD is diagnosed in this group only if other renal abnormalities are present (i.e. proteinuria, hematuria, anatomical) eGFR <30 eGFR Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction eGFR < 30 or progressive decline in eGFR or persistent significant proteinuria or inability to attain treatment targets Stable eGFR and no significant proteinuria

4 Canadian Society of Nephrology - Société Canadienne de Néphrologie - What is Chronic Kidney Disease The presence of Kidney Damage or an eGFR < 60 ml/min/1.73m 2 and Present for 3 months and Not treated with dialysis or transplant The diagnosis of CKD is only present in patients with eGFR 60ml/min if other abnormalities (i.e. proteinuria, hematuria, anatomical) are also present.

5 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Who should be tested for CKD? CSN endorses a case finding approach to testing for CKD, which should be focused on high-risk groups. CSN does not endorse mass population screening for CKD with either serum creatinine based tests or with urine dipstick testing.

6 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Who should be tested for CKD? Patients with diabetes mellitus Patients with hypertension Patients with heart failure Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease Patients with unexplained anemia Patients with a family history of ESRD First nations peoples

7 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Clinical case Joe is a 68 year old welder Past Medical History: appendectomy age 15, hypertension x 4 years, elevated cholesterol x 1 year, Type 2 DM x 1 year Smoker- 1 pack a day since age 21 Etoh- a case of beer on the weekend Allergy- none known Family History- father MI age 50, mother HTN age 48 Medications- hydrochlorothiazide 25 mg po od, amlodipine 5mg po od, metformin 1000 mg po bid Weight 75 kg BP 149/84 mmHg

8 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Joe should be screened for CKD because he has several risk factors. –Can you name them?

9 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Which test would you choose to assess Joes renal function? Serum creatinine 24 hour urine collection Nuclear medicine scan eGFR

10 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Joes labs Na138 mmol/L K4.5 mmol/L Cl103 mmol/L HCO3 23 mmol/L Glucose (R) 6.4 mmol/L Urea 10.1 mmol/L Creatinine 123 µmol/L CBC normal HgB A1C 5.6% Ca mmol/L PO4 = 1.10 mmol/L Albumin 38 g/L TC7.60 mmol/L TG 2.06 mmol/L LDL(C) 5.43 mmol/L HDL(C) 1.23 mmol/L

11 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Joes serum creatinine is in the normal range, doesnt that mean his kidney function is also normal?

12 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Assessing Joes renal function using eGFR 54 ml/min / 1.73m 2 (Stage 3 CKD) Clearly, Joes renal function is not normal despite a normal serum creatinine

13 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Why use eGFR? It gives the health care practitioner a different sense as to a patients level of renal function that they may not have appreciated by using simple serum creatinine measurements.

14 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Measuring renal function: whats eGFR?

15 Canadian Society of Nephrology - Société Canadienne de Néphrologie - GFR Glomerular filtration rate (GFR): is the volume of fluid filtered from the renal glomerular capillaries into the Bowmans space per unit time. Normal for a 20 year old is ~ 120ml/min

16 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Methods to assess GFR Serum urea Serum creatinine Serum cystatin C Timed urine collections –Creatinine clearance –Inulin clearance Calculated GFR calculations –based on serum creatinine –many formulas including Cockcroft Gault and MDRD Nuclear medicine methods

17 Canadian Society of Nephrology - Société Canadienne de Néphrologie - The perfect marker Endogenous Freely filtered Not secreted or reabsorbed Inexpensive to measure doesnt exist !

18 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Problems with creatinine Stevens L et al, NEJM 2006; 354:

19 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Problems with timed collections Cumbersome Prone to error No longer recommended in most situations

20 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Problems with other methods Cystatin Inulin Nuclear medicine (iothalamate, EDTA etc) Complex Time-consuming Expensive Not practical for serial monitoring

21 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Creatinine based approximations 1) Cockcroft-Gault equation CrCl (ml/min)= (140-age) x actual weight (kg) x 1.2 (if male) SCreat (µmol/L) 2) MDRD ( Modification of Diet in Renal Disease) 6 variable or abbreviated version GFR(ml/min/1.73m2)=170 (PCr) x (Age) x (0.762 if female) x (1.21 if African American) x (serum urea) x (Albumin) Weight probably not available for lab to calculate Lab has patient age and gender – can do abbreviated version

22 Canadian Society of Nephrology - Société Canadienne de Néphrologie - eGFR equation provisos eGFR calculations may be less reliable in: –individuals with near normal GFR (>60 ml/min/1.73m 2 ) –individuals with markedly abnormal body composition extreme obesity cachexia paralysis amputations Controversies exist as to the applicability of these formulae to various ethnic groups and the very elderly

23 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Estimate of Glomerular Filtration Rate (eGFR) It is not recommended that clinicians rely on serum creatinine measurements alone when assessing kidney function. CSN calls for the reporting of kidney function as an estimate of glomerular function rate (eGFR) using equations and standardized creatinine measurements If neither eGFR reporting, nor calculators are available to a physician, tables based on serum creatinine and other variables are available to provide approximations of eGFR.

24 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Developed by the BC Medical Services Commission, Guidelines and Protocols group

25 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Developed by the BC Medical Services Commission, Guidelines and Protocols group

26 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Is it just about GFR? Should also assess urine protein losses –24 hour urines are no longer recommended For same reasons as with GFR –Urine dipsticks are affected by hydration status Quantify protein excretion with random urine for: Urine albumin to creatinine ratioor Urine protein to creatinine ratio

27 Canadian Society of Nephrology - Société Canadienne de Néphrologie - What do those values mean? ACR (mg/mmol) PCR (mg/mmol) 24 hour urine >3N/A~30 mg day (albumin) <40<60~ 500 mg/day (protein) >60>100~900 mg/day (protein) Alarm values to refer Microalbuminuria (ie in diabetics)

28 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Who should be tested for CKD? Patients with diabetes mellitus Patients with hypertension Patients with heart failure Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease Patients with unexplained anemia Patients with a family history of ESRD First nations peoples

29 Canadian Society of Nephrology - Société Canadienne de Néphrologie - What tests to order? Assess kidney function with –eGFR As reported by lab As calculated using equations (and PDA!) As estimated by tables –Quantification of protein with random urine samples Urine albumin to creatinineor Urine protein to creatinine

30 Canadian Society of Nephrology - Société Canadienne de Néphrologie - What to do with the results Now that I know Joes GFR is not normal what should I do?

31 Canadian Society of Nephrology - Société Canadienne de Néphrologie - What to do with the results Is one eGFR measurement enough? Consider reversible factors Assess risk of progressive renal disease –who needs referral to Nephrology

32 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Natural history of elevated creatinine levels 1434 patients in a family medicine practice 57 patients had an elevated initial serum Cr levels (>130umol/L) and subsequent Cr levels within 4-5 years of follow-up Marcotte and Godwin, Canadian Family Physician 2006;52: ,e1-5 Initial serum Cr Latest serum creatinine (umol/L) < > >

33 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Is one eGFR measurement enough? Decisions about investigation, treatment or referral should not be made based on a single isolated test of kidney function In a primary care setting, many patients will show improvement or normalization of kidney function upon repeat testing. The diagnosis of CKD is based on serial measurements of kidney function and it is not possible to diagnose CKD on the basis of a single serum creatinine concentration transformed through equations.

34 Canadian Society of Nephrology - Société Canadienne de Néphrologie - For patients with a new finding of an eGFR between 30-60ml/min/1.73m 2 CSN recommends that clinicians determine the stability of the patients eGFR Repeat test within 2-4 weeks, and then in 3-6 months

35 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Consider reversible factors Intercurrent illness Volume depletion Medications –NSAIDs, aminoglycosides, IV contrast dye Obstruction An abdominal ultrasound may be indicated at eGFRs <60ml/min/1.73m 2

36 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Back to Joe You measure Joes eGFR in 2 weeks and then again in 3 months and it is unchanged You order an ultrasound and it is normal His urinalysis is normal

37 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Conclusions about Joe Given the stability of these we can conclude that he has stable CKD. It is important to continue to serially follow his renal function. Serial measurement is a cornerstone of chronic kidney disease management.

38 Canadian Society of Nephrology - Société Canadienne de Néphrologie - CSN recommends that most patients with non-progressive CKD can be managed by non-nephrologists without referral. The recognition that many patients with an eGFR between 30 and 60 ml/min/1.73m 2 do not have a high risk of progressive kidney disease is important.

39 Canadian Society of Nephrology - Société Canadienne de Néphrologie - CKD is common

40 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Estimated prevalence of CKD in Canadians 20 years old Stage 1 CKD > 90 ml/min 792,000 Stage 2 CKD 60 – 89 ml/min720,000 Stage 3 CKD 30 – 59ml/min1,032,000 Stage 4 CKD 15 – 29 ml/min48,000 Stage 5 CKD < 15 ml/min24,000 Stigant, C, et al. CMAJ 2003;168: Numbers are estimates based on an extrapolation of US data

41 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Other common conditions also managed by primary care physicians CVD38.7% in diabetic men 30.7 % in diabetic women Thyroid disease1/20 (Thyroid Fdn of Canada) Hypertension28% Type 2 DM8-10 % worldwide CKD is a common general health problem

42 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Estimated prevalence of CKD in Canadians 20 years old Stage 1 CKD > 90 ml/min 792,000 Stage 2 CKD 60 – 89 ml/min720,000 Stage 3 CKD 30 – 59ml/min1,032,000 Stage 4 CKD 15 – 29 ml/min48,000 Stage 5 CKD < 15 ml/min24,000 Stigant, C, et al. CMAJ 2003;168: ESRD is not common

43 Canadian Society of Nephrology - Société Canadienne de Néphrologie - If many patients with CKD do not progress to end stage renal failure why then as a primary care physician should I even be looking for them using eGFR?

44 Canadian Society of Nephrology - Société Canadienne de Néphrologie - ESRD is not the problem Patients with CKD have high rates of cardiovascular disease and many patients die before progressing to end stage renal failure thus it is important to screen for CKD.

45 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Go,A et al. NEJM 2004;351:

46 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Quick Tips on Management of CKD Implement measures to slow rate of CKD progression Treat to target BP <130/80; most will need 3 or more meds, diuretics and salt restriction are very useful Target urine ACR <40 or PCR <60. ACEI and/or ARB are first line therapies for albuminuria or proteinuria Control blood sugar in diabetes, target HbA1C <7% Implement measures to modify CV risk factors Follow guidelines as per groups at highest risk for CV disease Minimize further kidney injury If possible, avoid nephrotoxins such as NSAIDs, aminoglycosides, IV and intra-arterial contrast etc If contrast is necessary, consider prophylactic measures (if eGFR <60) Remember to adjust dosages of renally excreted medications

47 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Joe: three years later You have continued to follow his eGFR and notice that it is now 42 ml/min/1.73m 2 All clinical targets (BP, HBA1C, cholesterol) are stable No intercurrent illnesses His CKD is no longer stable Refer to Nephrology

48 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Who should be referred to a Nephrologist? Patients with acute renal failure Patients with eGFR <30ml/min/1.73m 2 Patients with progressive loss of renal function Persistent significant proteinuria (present on 2 out of 3 samples) –on dipstickor –quantified PCR >100mg/mmol or –quantified ACR >60 mg/mmol. Inability to achieve treatment targets or other difficulties in the management of the CKD patient

49 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Violet 78 year old female longstanding patient of a colleagues – followed for her hypertension and mild renal failure You are on call and see her because she is c/o nausea and lethargy Datetoday1 yr ago2 yrs ago5 yrs ago Serum Creat (µmol/l)

50 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Using an eGFR approach Datetoday1 yr ago2 yrs ago5 yrs ago Serum Cr (µmol/L) eGFR (ml/min/1.73m 2 )

51 Canadian Society of Nephrology - Société Canadienne de Néphrologie - This womans renal disease may have been underdiagnosed Using eGFR may have given a more accurate measure of her renal function Serial measurement of eGFR is a powerful tool for the clinician Nephrology referral is recommended for this patient

52 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Linda 54 yo female comes for routine annual physical –no problems identified –normal physical examination –family history of ESRD All her labs are normal – serum creatinine is 90 µmol/l Lab automatically reports an eGFR of 60 ml/min/1.73m 2 What do you do with this eGFR value? Should she be referred to a Nephrologist?

53 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Identify patients in your practice at high risk for Chronic Kidney Disease - Patients with hypertension - Patients with diabetes mellitus - Patients with atherosclerotic coronary, cerebral or peripheral vascular disease - Patients with heart failure - Patients with unexplained anemia - Patients with a family history of end stage renal disease - First nations peoples eGFR <30 eGFR 30-60eGFR >60 Consider reversible factors: -Medication- Volume depletion -Intercurrent illness- Obstruction Repeat tests in weeks Individualized follow up and treatment CKD is diagnosed in this group only if other renal abnormalities are present (i.e. proteinuria, hematuria, anatomical) eGFR <30 eGFR Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction eGFR < 30 or progressive decline in eGFR or persistent significant proteinuria or inability to attain treatment targets Stable eGFR and no significant proteinuria

54 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Linda: continued Evaluation of her urine shows no significant amount of proteinuria (ACR <40mg/mmol) and no hematuria She is followed annually Two years later –same eGFR –blood pressure is 146/94 –persistent proteinuria with ACR > 60mg/mmol Progressive CKD = referral to Nephrology

55 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Dave 81 year old man, new to your practice –ASHD, stent placed 2 years ago –PSA >100 led to biopsy and diagnosis of prostate cancer, being treated with hormone therapy alone –On atorvastatin 40 mg, aspirin 81 mg, ramipril 5 mg –Bp 144/82, nil else on exam –Cr 167, eGFR 36, ACR 0.7

56 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Dave Old labs from previous MD show Cr umol/L over last 3 years What would you do?

57 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Summary Who should be tested for CKD? –Patients with diabetes mellitus –Patients with hypertension –Patients with heart failure –Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease –Patients with unexplained anemia –Patients with a family history of ESRD –First nations peoples

58 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Summary What tests should be ordered? –eGFR to assess kidney function –random urine sample to assess for significant persistent proteinuria What should be done with the results? –follow serially –assess for proteinuria –implement risk reduction strategies Monitoring for evidence of progressive disease - declining eGFR - persistent significant proteinuria

59 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Acknowledgements Financial support for the development and distribution of these educational materials was provided by unrestricted grants from Amgen Canada and Bristol Meyers Squibb

60 Canadian Society of Nephrology - Société Canadienne de Néphrologie - Quick Tips on Referral and Management of Chronic Kidney Disease Most patients with non-progressive CKD can be managed without referral to a nephrologist. The goals of therapy are listed below: Consider reversible factors, such as medications, intercurrent illness, volume depletion, or obstruction. An abdominal ultrasound may be indicated when eGFR <60 ml/min/1.73m2. Minimize further kidney injury by avoiding, if possible, nephrotoxins such as NSAIDs, aminoglycoside antibiotics, IV contrast, etc (if eGFR < 60 ml/min/1.73m2). Remember to adjust dosages of renally excreted medications. Implement measures to slow the rate of progression of CKD: Target BP is < 130/80 mmHg. Most patients will need 3 or more medications. Diuretics and salt restriction are very useful, and if needed, consider furosemide BID dosing when eGFR < 30 ml/min/1.73m2 Target urine protein/creatinine ratio (mg/mmol) is < 60 (< ~ 500 mg/day) or target urine albumin/creatinine ratio (mg/mmol) is < 40. ACEI and/or ARB are first line therapies in patients with albuminuria or proteinuria. Control blood sugar in diabetes, target HbA1C < 7%. Implement measures to modify CV risk factors (NB: CV risk >> ESRD risk). –Follow the Canadian Hypertension Education Program, the Canadian Diabetes Association, and the Canadian Cardiovascular Society guidelines as per groups at highest risk for CV disease. Referral to a nephrologist is recommended for: –acute kidney failure –eGFR < 30 ml/min/1.73m2. (CKD stage 4 and 5) –progressive decline of eGFR –urine protein/creatinine ratio (PCR) > 100 mg/mmol (~900 mg/24 hours) or urine albumin to creatinine ratio (ACR) > 60 mg/mmol (~500 mg/24 hr) –inability to achieve treatment targets NOTE: detailed CSN CKD management guidelines are under development, these quick tips should be considered as an interim approach.Insert Quick Tips sheet from the CSN CKD document


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