CKD update Dr Saqib Mahmud MRCP(UK),MRCGP

Chronic kidney disease Defined by a reduced eGFR, proteinuria, haematuria and/ or structural abnormalities persistent for more than 90 days

Introduction Prevalence – over 13% of population; rising as a consequence of DM & ObesityPrevalence – over 13% of population; rising as a consequence of DM & Obesity Primarily a marker of CV riskPrimarily a marker of CV risk Stage 3 CKD – 40 – 100% increased risk of CV eventsStage 3 CKD – 40 – 100% increased risk of CV events Minority at risk of progressive decline in renal functionMinority at risk of progressive decline in renal function

Classification Stage 1 : GFR>90 (presence of kidney damage with N or raised GFR)Stage 1 : GFR>90 (presence of kidney damage with N or raised GFR) Stage 2 : GFR 60 – 89 (presence of kidney damage with mildly reduced GFR)Stage 2 : GFR 60 – 89 (presence of kidney damage with mildly reduced GFR) Stage 3A : GFR 45 – 59Stage 3A : GFR 45 – 59 Stage 3B : GFR 30 – 44, moderately reduced GFRStage 3B : GFR 30 – 44, moderately reduced GFR Stage 4 : GFR 15 – 29, severely reduced GFRStage 4 : GFR 15 – 29, severely reduced GFR Stage 5 : GFR <15, end-stage RFStage 5 : GFR <15, end-stage RF

Basic investigations Repeat U&E, eGFR (within 3/12)Repeat U&E, eGFR (within 3/12) FBSFBS FBCFBC Dipstick urine for haematuriaDipstick urine for haematuria Urine ACR or TPCRUrine ACR or TPCR Ca, PO4Ca, PO4

Further investigations Hypercalcaemia – inv for myelomaHypercalcaemia – inv for myeloma LUTS, deteriorating renal function – renal tract USSLUTS, deteriorating renal function – renal tract USS Significant proteinuria +/- haematuria –> primary glomerular disease or vasculitis– autoimmune screen/referSignificant proteinuria +/- haematuria –> primary glomerular disease or vasculitis– autoimmune screen/refer

Management Main aims ; slow deterioration of renal function – tight control of BPMain aims ; slow deterioration of renal function – tight control of BP Reduce CV risksReduce CV risks Maintain SBP at , DBP below 80Maintain SBP at , DBP below 80 SBP below 100 – 110 may be detrimentalSBP below 100 – 110 may be detrimental ACEI / ARB confer additional benefit, slow decline of renal function & proteinuriaACEI / ARB confer additional benefit, slow decline of renal function & proteinuria

Monitoring U&E post ACEI mandatoryU&E post ACEI mandatory Stable CKD3A & B – U&Es 6/12, CKD4 -3/12Stable CKD3A & B – U&Es 6/12, CKD4 -3/12 d/c ACEI if SCr rises >30%, eGFR falls>15% baselined/c ACEI if SCr rises >30%, eGFR falls>15% baseline Thiazide diuretics lose their efficacy in Rx of HTN in CKD as GFR decline – loop diuretics Rx of choiceThiazide diuretics lose their efficacy in Rx of HTN in CKD as GFR decline – loop diuretics Rx of choice

Drug administration Certain drugs CI, require dose adjustmentCertain drugs CI, require dose adjustment d/c metformin if eGFR <30d/c metformin if eGFR <30 Insulin dose may need to be reducedInsulin dose may need to be reduced

Referral Most CKD patients managed in primary careMost CKD patients managed in primary care Consider referral; younger patients with CKD any stageConsider referral; younger patients with CKD any stage Deteriorating renal functionDeteriorating renal function Significant protienuria >1g/d or proteinuria + haematuria>1+Significant protienuria >1g/d or proteinuria + haematuria>1+ Poorly controlled HTN despite 4 drugsPoorly controlled HTN despite 4 drugs Renal anaemiaRenal anaemia