1. CKD ML/LH
What are people hoping to cover from the session today?

2. Chronic Kidney Disease
Are we correctly diagnosing CKD?
Have we the correct patients on our CKD register?
Are we managing them correctly?

3. Plan for today Highlight a few issues around eGFRs
Review NICE and PACE guidance
Discuss how we diagnose and manage CKD
Identify and discuss any uncertain areas
I’ve been on an update course where Lucy Jenkins offered their practice protocol -she admits to being cynical about the existence of CKD so we may want to adapt it…

4. Why introduce CKD QOF indicators?
End stage renal failure is costly to treat, and its prevalence is increasing
30% of patients present late; they have worse outcomes and are more expensive to treat
It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF
ERF is costly in morbidity,mortality and ecconomically
The guidelines however are based mainly on expert opinion as little evidence is available.

5. 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.

6. Possible symptoms (CKD 3 - 5)
Tiredness
Anorexia, nausea
Weight loss
Dry itchy skin
Muscle cramps
Ankle swelling, peri-orbital oedema
Anaemia

7. NICE Sept 2008, Clinical Guideline 73

8. Offer CKD screening to at risk groupsDM
Hypertensives
CVD
Multisystem diseases e.g. SLE
Structural renal tract disease e.g. stones, BPH
FHx CKD 5 or hereditary kidney disease
Long term NSAIDS
A lot will be detected on annual review, however do we need to be more proactive in those with bph or long-term nsaids?
consideration

9. Testing eGFR
GFR estimated from serum creatinine and age, using MDRD equation
If abnormal, repeat the test to confirm
Multiply eGFR result by for African -Caribbean and African patients
(Are we recording this correctly?)

10. eGFR and meat
NICE specifically advises no meat for 12 hours before eGFR
Are we doing this?
How do we record it?
32 people with eGFR >60 ate meat and overnight developed CKD3! Bandolier

11. eGFRs and age eGFR is not validated in the >75s
(How many patients >75 have we coded with CKD 3?)
From the age of 40 the eGFR declines by 1ml/min/yr
NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications.
Should we consider undiagnosing those >75 with CKD3? (66 patients potentially)
Should we consider undiagnosisng those with stable eGFR’s >45, who are >70 yrs?(112 patients potentially)
Would we need to still label them to ensure dose adjustments with drugs etc.

12. Newly identified CKD Stage CKD on eGFR results Stage 1 > 90
Stage 3A
Stage 3B
Stage
Stage <15
Now we have 3 readings over a 90d period showing a low egfr,we can stage them. If egfr as we do nothing with CKD2 they can be considered normal
We have 249 on the ckd register, 16 have ckd 4/5

13. eGFRs: ‘normal for age?’
> 90 CKD 1
Normal renal function
60-89 CKD 2
45-59 CKD 3A
Impaired renal function
30-44 CKD 3B
15-29 CKD 4
Severely impaired
<15
CKD 5
eGFR /
Age
18-29
30-39
40-49
50-59
60-69
70-79
80-89
In yrs

14. Assess for proteinuria
NICE advises ACR on first sample of the day (preferably)
ACR abnormal if >30, in non diabetics
(Repeat to confirm if ACR >30 but <70)
ACR abnormal if >2.5 in diabetic men
ACR abnormal if >3.5 in diabetic women
The presence or lack of proteinuria helps indicate prognosis.

15. Issues around proteinuria
NICE also mentions PCRs (mg/mmol)
(ACR of 30 = (approx) PCR of 50)
But in Bradford they report PCIs (mg/mg), which correspond with 24hr urinary protein excretion
PCR of 50 = PCI of 500 (i.e. divide by 10)
Leeds/Bfd Biochem are considering changing to PCRs in the future, to fit with NICE

16. False positives Urinary Tract Infection
Do MSU if dipstix +ve for protein
Menstrual contamination
Benign orthostatic proteinuria

17. Assess for progressive CKD
Check at least 3 eGFRs over at least 90 days
Defined as a decline in eGFR of
>5 within 1 year, or >10 within 5 years
Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction,
proteinuria and diabetes
This is double the rate of normal decline, however there is a lot of intrapersonal varriation-esp if you eat meat.

18. Other baseline tests For all Dipstix for haematuria
CVD risk assessment
Consider DEXA scan
CKD 4 and 5
FBC and ferritin
Calcium, phosphate, PTH
Visable haematuria requires urology investigations.
Persistent invisible haematuria = 1+ of blood on 2 out of 3 dipstick tests
Consider ruling out renal tract malignancies, then if associated with proteinuria refer for renal opinion.
NICE advises offer biphosphonates to all including CKD 1-3 if indicated for prevention of osteoporosis

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

20. Consider referral CKD 4 or 5 without diabetes
ACR >70 in non diabetics
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

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

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

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

24. Routine management Reduce proteinuria ACEIs first line
ARBs if not tolerated
Presently 3/16 patients with CKD4or5 are on neither

25. Routine management ACEI or ARB:
Diabetes + ACR (>2.5 men, or 3.5 women)
(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)

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

27. 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

28. 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
Consider referral for erythropoeisis stimulaing agents (ESA’s)
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.

29. Routine management Manage bone conditions
Ca, PTH and phosphate if CKD 4 or 5
Offer biphosphonates to all “if indicated”
If indicated offer vitamin D supplements:
- cholecalciferol or ergocalciferol in CKD3
- alfacalcidol or calcitriol in CKD 4 and 5
If on vit D supplements they need to be monitored
??dexa

30. QOF indicators
CKD1: Register of patients >18 yrs with CKD (stages 3 – 5)
CKD2: % of pts with BP recorded in last 15 mths
CKD3: % of pts in whom last BP reading, in last 15 mths, is <140/85
CKD5: % of pts with HT + proteinuria on ACEI or ARB (unless c/i or s/e recorded)
CKD6: % of pts with urine ACR (or PCR) test in last 15 months

31. QOF indicators CKD points total = 38 points = £££
CKD1 (reg) = 6 points
CKD2 (bp) = 6 points
CKD3 (bp controlled) = 11 points
CKD5 (acei/arb) = 9 points
CKD6 (acr) = 6 points