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Chronic Kidney Disease. Stage 5 0.2% 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.

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Presentation on theme: "Chronic Kidney Disease. Stage 5 0.2% 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."— Presentation transcript:

1 Chronic Kidney Disease

2

3 Stage 5 0.2% 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

4 CKD stageGFR (ml/min/1.73m 2 ) Description 1>90 Normal renal function but other evidence of organ damage* Mild reduction in renal function with other evidence of organ damage* Moderately reduced GFR 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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6 Creatinine 120 eGFR 31-40eGFR

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

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 Stage 5 0.2% 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

12 CKD stageGFR (ml/min/1.73m 2 ) Description 1>90 Normal renal function but other evidence of organ damage* Mild reduction in renal function with other evidence of organ damage* Moderately reduced GFR 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 3b45-49 and Insert p for proteinuria 3a and 3b45-49 and Insert p for proteinuria 3a and 3b

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 hturia or puria

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

16 Dont 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

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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 1.Will their kidneys fail in their lifetime? 2.Will they die of something else first?

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

28 CKD stage 3a Manage cardiovascular risk factors Dont refer CKD stage 3p Progressive Do 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 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?

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 OHare 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? 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

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

40 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?

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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 (contd) Address proteinuria –Maximise ACE/ RAS inhibition

46 Mr KH (contd) 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 Stage 5 Stage 4 Stage 3 Stage 2 Stage 1 PTH increases at GFR Ca absorption and lipoprotein activity reduced Malnutrition, LVH, anaemia Hypertriglyceridaemia Hyperphosphataemia Metabolic acidosis Hyperkalaemia Uraemia The metabolic complications of CKD

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 Stage 5 0.2% 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

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?


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