1. Section 6: Management in primary care Particular emphasis on nurse practitioner’s role

2. Effects of age on eGFR The “normal” eGFR is age-related In normal “healthy” individuals, the eGFR will fall by one percent for every year after 40 years of age An 80 year old man will have an expected eGFR of 50-60 ml/min Not all patients with reduced eGFR need active management

3. % subjects with CKD stage 3 by age and gender East Kent Data Age bands <4545-5455-6465-7475-84 >85 70 50 % 30 10 de Lusignan et al 2005

4. 0 50 100 150 2030405060 70 80 90 F EDTA “Normal” inulin GFR declines with age CKD Stage 1 CKD 2 CKD 3 CKD 4 CKD 5

5. Which individuals with abnormal eGFR should we to worry about? Those with very poor function for age Those with deteriorating function Those who may have reversible/treatable cause (unexplained proteinuria/haematuria) Those with functional consequences of CKD (anaemia, renal bone disease, persistent hyperkalaemia)

6. 2008 NICE guidance for CKD – focus on vascular risk Lifestyle modification Attention to known CV risk factors –smoking –statins for secondary prevention regardless of lipid level –Anti-platelet drugs for secondary prevention Medicines management BP targets

7. NICE 2008: recommendations for BP control in CKD No diabetes or proteinuria120-140/70-90 Diabetes or ACR>30120-130/70-80

8. NICE 2008: Diagnosis of CKD Proteinuria=ACR>30 or PCR>50 (NOT dipstick) 3 eGFR estimations <60 over a period not less than 90 days Progressive decline defined as eGFR falling by >5mls/min/year Focus on those whose observed rate of decline would necessitate RRT ‘within their lifetime’

9. NICE: 2008 Classification of CKD waking up to the impact of proteinuria Stage 1:GFR>90 + abnormal urinalysis Stage 2:GFR 60-89 + abnormal urinalysis Stage 3A:GFR 45-59 Stage 3B:GFR 30-44 Stage 4:GFR 15-29 Stage 5: GFR <15 or dialysis dependent Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)

10. QOF indicators for CKD 2009 Register of patients over 18 with CKD 3-5 6 Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months 640-90% Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less 1140-70% Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded) 440-80% Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months 640-80%

11. Monitoring of CKD Each assessment should include –Review of symptoms and fluid status –Blood pressure –Medication review (metformin, NSAIDs) –Urine ACR or PCR –Blood test for renal and bone status –FBC in advanced CKD

12. Frequency of monitoring Newly diagnosed Stable Stage 36/12annual Stage 43/126/12 Stage 53/12

13. What data is required for effective referral? Current creatinine and eGFR Previous creatinines (tracing back to last normal) Blood pressures (recent and historical) Urine dip for blood, ACR/PCR FBC, Ca, Pi Renal US only if :- stage 4 resistant HT lower tract symptoms