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CKD ML/LH 17.3.10. Chronic Kidney Disease Are we correctly diagnosing CKD? Have we the correct patients on our CKD register? Are we managing them correctly?

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Presentation on theme: "CKD ML/LH 17.3.10. Chronic Kidney Disease Are we correctly diagnosing CKD? Have we the correct patients on our CKD register? Are we managing them correctly?"— Presentation transcript:


2 Chronic Kidney Disease Are we correctly diagnosing CKD? Have we the correct patients on our CKD register? Are we managing them correctly?

3 Plan for today Highlight a few issues around eGFRs Review NICE and PACE guidance Discuss how we diagnose and manage CKD Identify and discuss any uncertain areas

4 Why introduce CKD QOF indicators? End stage renal failure is costly to treat, and its prevalence is increasing 30% of patients present late; they have worse outcomes and are more expensive to treat It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF

5 Risks of a low eGFR Renal 1% of patients with CKD 3 will progress to ERF in their lifetime (99% wont) Cardiovascular If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event

6 Possible symptoms (CKD 3 - 5) Tiredness Anorexia, nausea Weight loss Dry itchy skin Muscle cramps Ankle swelling, peri-orbital oedema Anaemia

7 NICE Sept 2008, Clinical Guideline 73

8 Offer CKD screening to at risk groups DM Hypertensives CVD Multisystem diseases e.g. SLE Structural renal tract disease e.g. stones, BPH FHx CKD 5 or hereditary kidney disease Long term NSAIDS

9 Testing eGFR GFR estimated from serum creatinine and age, using MDRD equation If abnormal, repeat the test to confirm Multiply eGFR result by for African - Caribbean and African patients (Are we recording this correctly?)

10 eGFR and meat NICE specifically advises no meat for 12 hours before eGFR Are we doing this? How do we record it?

11 eGFRs 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/yr NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.

12 Newly identified CKD Stage CKD on eGFR results Stage 1> 90 Stage Stage 3A Stage 3B Stage Stage 5 <15

13 eGFRs: normal for age? eGFR > 90 CKD 1 Normal renal function CKD CKD 3A Impaired renal function CKD 3B CKD 4 Severely impaired <15 CKD 5 eGFR / Age Age In yrs

14 Assess 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 men ACR abnormal if >3.5 in diabetic women

15 Issues 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 excretion PCR 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

16 False positives Urinary Tract Infection Do MSU if dipstix +ve for protein Menstrual contamination Benign orthostatic proteinuria

17 Assess for progressive CKD Check at least 3 eGFRs over at least 90 days Defined as a decline in eGFR of >5 within 1 year, or >10 within 5 years Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction, proteinuria and diabetes

18 Other baseline tests For all Dipstix for haematuria CVD risk assessment Consider DEXA scan CKD 4 and 5 FBC and ferritin Calcium, phosphate, PTH

19 Consider renal USS If CKD 4 or 5 Progressive CKD Visible or persistent invisible haematuria Symptoms of urinary tract obstruction FHx polycystic kidney disease and >20yrs of age

20 Consider referral CKD 4 or 5 without diabetes ACR >70 in non diabetics Proteinuria (ACR>30) with haematuria Progressive CKD CKD and poorly controlled BP on 4 agents Suspected genetic renal disease or renal artery stenosis

21 Routine management Lifestyle modification Smoking increases risk of progressive CKD Lose weight if obese Regular exercise Reduce salt if hypertensive

22 Routine management Monitor eGFR CKD 3 6 monthly CKD 4 3 monthly CKD 5 6 weekly

23 Routine management Control BP NICE target <140/90 70 <130/80 if diabetic QOF <140/85 for all

24 Routine management Reduce proteinuria ACEIs first line ARBs if not tolerated

25 Routine 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 >30 Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)

26 Routine management Routine anti-hypertensive treatment Non-diabetic + CDK + HT + ACR <30 (See NICE Hypertension guideline 34)

27 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) Immunizations Influenza - annually Pneumococcal - 5 yearly, due to declining antibody levels

28 Routine management Drugs Check BNF Appendix 3: Renal Impairment Test for anaemia If Hb <11 first consider other causes of anaemia Determine iron status – if serum ferritin <100 start oral iron Consider referral for erythropoeisis stimulaing agents (ESAs)

29 Routine management Manage bone conditions Ca, PTH and phosphate if CKD 4 or 5 Offer biphosphonates to all if indicated If indicated offer vitamin D supplements: - cholecalciferol or ergocalciferol in CKD3 - alfacalcidol or calcitriol in CKD 4 and 5 If on vit D supplements they need to be monitored

30 QOF indicators CKD1: Register of patients >18 yrs with CKD (stages 3 – 5) CKD2: % of pts with BP recorded in last 15 mths CKD3: % of pts in whom last BP reading, in last 15 mths, is <140/85 CKD5: % 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

31 QOF indicators CKD points total = 38 points = £££ CKD1 (reg) = 6 points CKD2 (bp) = 6 points CKD3 (bp controlled) = 11 points CKD5 (acei/arb) = 9 points CKD6 (acr) = 6 points

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