MANAGING KIDNEY DISEASE IN PRIMARY CARE

Content Recent policy changes Prevalence of CKD Screening and testing Explaining to people about CKD Proteinuria BP control CV risk assessment Referral

Policy changes National Service Framework for Renal Services 2004/2005 Introduction of eGFR 2006 Quality and Outcomes Framework (QOF) for CKD, 2006, amended 2008 and 2009 NICE guidance 2008 www.nice.org.uk/CG073

Why the changes? Serum creatinine affected by muscle mass (age/gender/weight) so: - Inaccurate for some - Insensitive - Poor marker of early renal disease Hospital labs now report eGFR alongside serum creatinine using 4 variable MDRD equation Uses creatinine, gender, age, race and multiply by 1.21 if black (African-Caribbean only)

International staging of CKD STAGE eGFR (mls/min/1.73m2) KIDNEY FUNCTION 1 >90 Normal 2 60-90 Mild reduced 3a 45-59 Mild to moderate reduced 3b 30-44 Moderate reduced 4 15-29 Severe reduced 5 <15 Kidney failure

How many people in UK have CKD (stages 3-5)? Few studies have explored prevalence NEOERICA study: CKD 8.5% (10.6% females 5.8% males) Stevens et al Kidney Int 2007; 72(1): 92-9 QI-CKD study: CKD: 6.8% (9.1% females 4.4% males) de Lusignan et al Erratum in Nephron Clin Pract 2012;120: c107 Data from GP surgeries in UK: 4.3% - But dependent on the GPs recording of names on a Register - Large variation

Overview: Management of CKD in primary care Identify those at risk by eGFR and proteinuria measurement Explain to people they have the condition and encourage self-management Control blood pressure Measure, assess and manage cardiovascular risk Medicine management

Key priority: screening and testing for CKD Estimated that only 1/3 people with CKD are actually on the CKD Register and that many are unaware that they have kidney problems CKD is defined as either “kidney damage (proteinuria, haematuria or anatomical abnormality) or GFR <60 ml/min/1.73 m2 present on at least 2 occasions for ≥90 days” “With new finding of eGFR <60, repeat within 2 weeks to exclude causes of acute deterioration” → CKD Register

Explaining to people they have CKD Key priority: Explaining to people they have CKD Words are wrong (eg ‘chronic’) Others may be better: -Kidney damage - Reduced kidney function - Part of ageing process Need for monitoring Watch out for worsening kidney damage by: - Urine test (protein) - Blood test (% kidney function)

Promoting self-management of CKD Key priority: Promoting self-management of CKD BP control: Encourage people to take their tablets as prescribed and report any side-effects. Explain that reducing raised BP is a key factor in preventing the progression of CKD BP monitoring: Advise people to monitor their own BP at home Smoking cessation Blood sugar control (if they have diabetes) Diet: To avoid processed, high-salt and high-fat foods

Promoting self-management of CKD Key priority: Promoting self-management of CKD Medicines management: - Give advice on using over-the-counter medicines (particularly anti-inflammatory drugs) - People should tell their pharmacist that they have CKD - People should be encouraged to report if using certain complementary therapies, such as Chinese herbal medicines Lifestyle modification: taking exercise and keeping to ideal weight

Key priority: Measuring proteinuria by ACR Preferably EMU or spot urine if reasonably concentrated(Not PCR or dipstick) Diabetes ACR>2.5 men = abnormal ACR>3.5 women = abnormal If abnormal send MSU to exclude infection, then repeat Prescribe ACEI or ARB if abnormal, even if normotensive Non-diabetes ACR >30 confirmed on EMU = abnormal ACR >70 referral Prescribe ACE/ARB if ACR >30 and BP above target or ACR>70 and normotensive

Key priority: BP control Diabetes or when ACR >70 Aim for systolic <130 mmHg (target range120-129 mmHg) Aim for diastolic <80 mm Hg Non-diabetes Aim for systolic <140 mmHg (target range 120-139 mmHg) Aim for diastolic <90 mmHg

Key priority: Prescription of ACE/ARB Measure serum K and eGFR: Prior to ACEi (do not start if K > 5.0 mmol/L) 1-2 weeks after institution or dose increase If K > 6.0 stop ACEi and advise on low K diet If fall in eGFR from baseline > 25% after 1-2 weeks: Consider other causes of fall in eGFR (e.g. NSAID, diuretics) Stop ACEi (or halve if lower dose tolerated) Refer to renal unit to exclude renovascular disease Inform people of possible side-effects

Assess and control cardio-vascular risk Key priority: Assess and control cardio-vascular risk Assess: QRisk/Framingham? NB: Framingham underestimates CV risk in people with CKD Proteinuria is an independent CV risk factor CONTROL Blood pressure Use statins for primary prevention of cardiovascular disease in same way as in people without CKD Offer statins for secondary prevention of CVD irrespective of lipid values Offer antiplatelet drugs to people with CKD for the secondary prevention of CVD (but the risks of bleeding may be increased with multiple antiplatelet drugs)

Referral eGFR <15 Usually immediate referral or discussion eGFR 15-29 Urgent referral or discussion; or routine referral if known to be stable eGFR 30-59 Routine referral indicated if progressive fall in GFR/rise in serum creatinine: 5ml/min/1.73m2 in one year 10ml/min/1.73m2 in 5 years Stage 4 reached (GFR <30) Refer to NICE for detailed guidance: www.nice.org.uk/CG073

Key messages Reduced kidney function can be a frequent accompaniment of ageing, which in many cases is not a cause for concern Managing CKD is part of managing CV risk Monitoring for progressive disease is very important Renal units need one year to prepare people for dialysis

Summary Ensure you have an accurate CKD Register Explain to people they have CKD and what this means Annual proteinuria screen (ACR preferable) BP control CV risk assessment and management Consider referral if appropriate

Continuing Education for CKD On-line resource for supporting GPs and practice nurses in managing CKD: www.ckdonline.org

Further Resources British Renal Society www.britishrenal.org/CKD-Forum/Educational-Resources.aspx Renal Association www.renal.org/whatwedo/InformationResources/CKDeGUIDE.aspx Blood Pressure Association www.bpassoc.org.uk National Kidney Federation www.kidney.org.uk NICE: CKD guideline www.nice.org.uk/CG073 NHS Kidney Care www.kidneycare.nhs.uk/our_work_programmes/preventing_ill_health/qof_ckd_toolkit