CKD In Primary Care Dr Mohammed Javid

Relevance End Stage CKD places a very significant burden on patients quality of life. End Stage CKD is very expensive to manage. Deteriorating CKD is an independant risk factor for an increase in mortality from cardiovascular disease. QOF: CKD = 38 points

Guidelines National Service Framework 2004 -2005 NICE guidelines 2008 PACE local guidelines QOF

eGFR CKD classification is based on eGFR Estimates Glomerular Filtration Rate using serum creatinine and patients Age, Sex, etc Cockroft-Gault formula MDRD formula

Creatinine 120 eGFR 31-40 eGFR 82-106

CKD stage GFR (ml/min/1.73m2) Description 1 >90 2 60-89 3 30-59 4 Normal renal function but other evidence of organ damage* 2 60-89 Mild reduction in renal function with other evidence of organ damage* 3 30-59 Moderately reduced GFR 4 15-29 Severely reduced GFR 5 <15 End stage, or approaching, end stage renal failure Insert P for proteinuria 3a and 3b 45-49 and 30-44 * Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

Risks of a low eGFR Renal 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t) Cardiovascular If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event eGFR 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.

100 patients with eGFR < 60

1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD

Proteinuria Indicates poorer renal prognosis Urine dipstick Protein : Creatinine ratio PCR Protein : Creatinine Index PCI Albumin : Creatinine Ratio ACR Early morning sample <5 normal, >30 significant , >70 severe Check for heamaturia

Progressive CKD Check at least 3 eGFRs over 90 days Defined as a decline in eGFR of >5 within 1 year, or >10 within 5 years

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

Routine management Monitor eGFR CKD 3 6 monthly CKD 4 3 monthly CKD 5 6 weekly We have 5 patients with CKD 4 or 5 who have no hospital input and where there is no recall arrangements

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

Routine management ACEI or ARB: Diabetes + ACR (>30) (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)

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

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 5/16 CKD 4-5 have CVD risks >30 and are not on a statin

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 10% of those with KD4 have anaemia and 4% of those with CKD3B Rates 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.

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

Consider referral CKD 4 or 5 Proteinuria ACR >70 Proteinuria ACR>30 with haematuria Progressive CKD CKD and poorly controlled BP on 4 agents Suspected genetic renal disease or renal artery stenosis We have 5 patients CKD 4/5 who have not been referred for renal opinion –may be legitimate reasons age/co morbidities etc

QOF indicators CKD points total = 38 points = £££ CKD1 (register) = 6 points CKD2 (bp checked) = 6 points CKD3 (bp controlled) = 11 points CKD5 (acei started) = 9 points CKD6 (acr checked) = 6 points

Take Home Message CKD is an independant risk factor for cardiovascular mortality which far outweighs the risk of developing end-stage renal disease CKD 3 is managed in primary care with ACE-i and cardiovascular optimisation. Monitor eGFR Blood pressure control with ACE Check for proteinuria