Presentation on theme: "CKD ML/LH 17.3.10 What are people hoping to cover from the session today?"— Presentation transcript:
1CKD ML/LHWhat are people hoping to cover from the session today?
2Chronic Kidney Disease Are we correctly diagnosing CKD?Have we the correct patients on our CKD register?Are we managing them correctly?
3Plan for today Highlight a few issues around eGFRs Review NICE and PACE guidanceDiscuss how we diagnose and manage CKDIdentify and discuss any uncertain areasI’ve been on an update course where Lucy Jenkins offered their practice protocol -she admits to being cynical about the existence of CKD so we may want to adapt it…
4Why introduce CKD QOF indicators? End stage renal failure is costly to treat, and its prevalence is increasing30% of patients present late; they have worse outcomes and are more expensive to treatIt is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERFERF is costly in morbidity,mortality and ecconomicallyThe guidelines however are based mainly on expert opinion as little evidence is available.
5Risks 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.
8Offer CKD screening to at risk groups DMHypertensivesCVDMultisystem diseases e.g. SLEStructural renal tract disease e.g. stones, BPHFHx CKD 5 or hereditary kidney diseaseLong term NSAIDSA lot will be detected on annual review, however do we need to be more proactive in those with bph or long-term nsaids?consideration
9Testing eGFRGFR estimated from serum creatinine and age, using MDRD equationIf abnormal, repeat the test to confirmMultiply eGFR result by for African -Caribbean and African patients(Are we recording this correctly?)
10eGFR and meatNICE specifically advises no meat for 12 hours before eGFRAre we doing this?How do we record it?32 people with eGFR >60 ate meat and overnight developed CKD3! Bandolier
11eGFRs 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/yrNICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.Should we consider undiagnosing those >75 with CKD3? (66 patients potentially)Should we consider undiagnosisng those with stable eGFR’s >45, who are >70 yrs?(112 patients potentially)Would we need to still label them to ensure dose adjustments with drugs etc.
12Newly identified CKD Stage CKD on eGFR results Stage 1 > 90 Stage 3AStage 3BStageStage <15Now we have 3 readings over a 90d period showing a low egfr,we can stage them. If egfr as we do nothing with CKD2 they can be considered normalWe have 249 on the ckd register, 16 have ckd 4/5
14Assess 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 menACR abnormal if >3.5 in diabetic womenThe presence or lack of proteinuria helps indicate prognosis.
15Issues 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 excretionPCR 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
16False positives Urinary Tract Infection Do MSU if dipstix +ve for proteinMenstrual contaminationBenign orthostatic proteinuria
17Assess for progressive CKD Check at least 3 eGFRs over at least 90 daysDefined as a decline in eGFR of>5 within 1 year, or >10 within 5 yearsRisk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction,proteinuria and diabetesThis is double the rate of normal decline, however there is a lot of intrapersonal varriation-esp if you eat meat.
18Other baseline tests For all Dipstix for haematuria CVD risk assessmentConsider DEXA scanCKD 4 and 5FBC and ferritinCalcium, phosphate, PTHVisable haematuria requires urology investigations.Persistent invisible haematuria = 1+ of blood on 2 out of 3 dipstick testsConsider ruling out renal tract malignancies, then if associated with proteinuria refer for renal opinion.NICE advises offer biphosphonates to all including CKD 1-3 if indicated for prevention of osteoporosis
19Consider renal USS If CKD 4 or 5 Progressive CKD Visible or persistent invisible haematuriaSymptoms of urinary tract obstructionFHx polycystic kidney disease and >20yrs of age
20Consider referral CKD 4 or 5 without diabetes ACR >70 in non diabeticsProteinuria (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
21Routine management Lifestyle modification Smoking increases risk of progressive CKDLose weight if obeseRegular exerciseReduce salt if hypertensive
22Routine 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
23Routine management Control BP NICE target <140/90 <130/80 if ACR >70<130/80 if diabeticQOF <140/85 for all
24Routine management Reduce proteinuria ACEIs first line ARBs if not toleratedPresently 3/16 patients with CKD4or5 are on neither
25Routine 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 >30Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)
27Routine 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
28Routine 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 ironConsider referral for erythropoeisis stimulaing agents (ESA’s)10% 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.
29Routine management Manage bone conditions Ca, PTH and phosphate if CKD 4 or 5Offer biphosphonates to all “if indicated”If indicated offer vitamin D supplements:- cholecalciferol or ergocalciferol in CKD3- alfacalcidol or calcitriol in CKD 4 and 5If on vit D supplements they need to be monitored??dexa
30QOF indicatorsCKD1: Register of patients >18 yrs with CKD (stages 3 – 5)CKD2: % of pts with BP recorded in last 15 mthsCKD3: % of pts in whom last BP reading, in last 15 mths, is <140/85CKD5: % 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