1. MANAGING KIDNEY DISEASE IN PRIMARY CARE

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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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

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

14. 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

15. 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)

16. Referral eGFR <15 Usually immediate referral or discussion
eGFR Urgent referral or discussion; or routine referral if known to be stable
eGFR 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:

17. 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

18. 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

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

20. Further Resources
British Renal Society
Renal Association
Blood Pressure Association
National Kidney Federation
NICE: CKD guideline
NHS Kidney Care