Chronic kidney disease and pre-dialysis Renal Pharmacy Beginners Guide lecture 2

Objectives Provide an introduction to the management of chronic kidney disease Key aims of treatment in CKD Risk factors for CKD Frequently prescribed medication

Key aims of CKD management Identify patients early Prevent or delay the progression Prevent and manage complications Reduce risk of cardiovascular disease

Risk factors for CKD Diabetes Hypertension Acute kidney injury Cardiovascular disease Structural renal tract disease Multisystem disease known to affect kidneys including lupus https://www.nice.org.uk/guidance/cg182

Monitor those on high risk drugs Those prescribed drugs known to be nephrotoxic should have annual eGFR check. Calcineurin inhibitors Lithium Non- steroidal anti-inflammatory drugs (NSAIDs)

Prevent or delay progression Lifestyle advice Regular exercise Maintain healthy weight Stop smoking Blood pressure control Target <140/90mmHg Diabetic / proteinuria <130/80mmHg https://www.nice.org.uk/guidance/cg182/chapter/1- Recommendations Prescribe statins https://www.nice.org.uk/guidance/qs5/chapter/Quality -statement-3-Statins-for-people-with-CKD

Complications of CKD

Anaemia Consider renal anaemia when eGFR <45mL/min Exclude other possible causes of anaemia Correct iron stores Prescribe erythropoietin stimulating agents (ESA) Aim of treatment to achieve Haemoglobin of 100- 120g/L Supplied on homecare/admin on dialysis Future clinical trials oral agents HIF inhibitors https://www.nice.org.uk/guidance/ng8 https://renal.org/guidelines/

Renal bone and mineral disorders Abnormalities of calcium, phosphate, PTH and vitamin D metabolism Abnormal bone turnover Increased vascular calcification

Renal bone and mineral disorders Hyperphosphatemia Dietary advice to limit phosphate intake Phosphate binders – take with food Calcium acetate Selvelamer Lanthanum Sucroferric oxyhydroxide Aluminium hydroxide https://www.nice.org.uk/guidance/cg157/ifp/chapter/phosphate- binders-for-adults

Renal bone and mineral disorders Vitamin D supplements Alfacalcidol, calcitriol Calcium mimetics Cinacalcet, etelcalcetide Renal association guidance for targets https://www.nice.org.uk/Guidance/CG157 https://renal.org/guidelines/

Complications continues Metabolic acidosis Treat if eGFR <30mL/min and serum bicarbonate <20mmol/L Oral sodium bicarbonate May slow progression Review if renal replacement initiated

Symptom control Oedema Muscle cramps Restless legs Itching Diuretics Quinine Restless legs Clonazepam Itching Moisturising Menthol in aqueous cream Antihistamines

Summary Overview of the management of patients with chronic kidney disease Identify patients at risk of chronic kidney disease Modify risk factors for progression Overview of frequently prescribed medication

Further reading NICE guidelines Renal association guidelines www.renal.org Pharmaceutical journal /Clinical pharmacy articles International resources-KDIGO, KDOQI RPG information leaflets

Thank you