CKD

1
CKD

• DIAGNOSIS AND MANAGEMENT IN PRIMARY CARE
• Nitu Raje-Ghatge
• GPST3
• 10/11/09

2
Statistics

• As a health burden
• - prevalence 8.5 (CKD 3-5)
• - women 10.6, men 5.8
• - prevalence increases
• with age
• - ESRD is rare- 725/million
• population
• - 2 of NHS budget on RRT

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Statistics

• Mortality
• Drey et al
• 1076 new patients
• 4 - ESRF
• 69 died
• 46-CVD (CoD)

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30 of patients with advanced renal disease are
referred late !
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Vital role of GPs

• Common in general practice
• Asymptomatic
• Detectable by simple and easily available tests
• Robust evidence that timely intervention
• - reduces progression to ESRD
• - reduces risk of associated complications
• - reduces the risk of CVD

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BUT.. The uncertainty

• Significance of milder disease
• Age related vs pathological decline in renal
  functions

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Role of primary care

• Early identification of people who have/at risk
  of developing CKD
• Management of conditions that are risk factors
  for development of CKD
• Intervention to minimise risk of CVD
• Intervention to reduce risk of progression to
  ESRF
• Appropriate further investigation and timely
  referral to secondary care

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..Set the ball rolling

• NICE/SIGN guidelines on CKD
• Automatic reporting of eGFR when Creatinine
  requested
• Inclusion of CKD in QOF

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1) Identification of patients
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• New patient
• Symptomatic
• Asymptomatic (think laterally!)
• Under follow up for chronic illness/ nephrotoxic
  drugs

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Symptoms

• Fatigue, malaise
• GI anorexia, nausea, vomiting
• GU nocturia, polyuria
• CCF SOB, ankle swelling

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PMH/FH

• HT,DM,CVD, UTI, Connective tissue disease,
  cancer, renal disease
• Drugs
• - NSAIDS (including OTC)
• - ACEi
• - Diuretics
• - Lithium

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Social history

• Smoking, alcohol
• Support

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Red flags

• Acute renal failure
• Unwell patient with
• - 50 rise in serum creatinine
• - gt25 fall in eGFR
• - oliguria
• Newly diagnosed renal dysfunction- assume acute
• Nephrotic syndrome
• Malignant hypertension
• Hyperkalemia gt7

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Examination

• TPR/BP
• Weight, pallor, oedema
• RS
• PA- bladder, prostate, ?palpable kidneys

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Investigations

• Urine dipstick (blood, protein)
• Urine MC s (casts)
• FBC, U/E,LFT, cholesterol HDL, fasting glucose,
  calcium, phosphate, bicarbonate
• Hepatitis screen, rheumatology, HIV
• USS renal tract
• CT/MRI, Angio, renal biopsy

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Lets summarise.

• eGFR
• Haematuria
• Proteinuria

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eGFR.. P !

• MDRD equation
• - age
• - gender
• - creatinine
• - race
• Avoid eating meat for 12 hours before the test!
• Process sample within 12 hours of collection

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Important points

• eGFR not valid in
• - children (lt18 years)
• - pregnancy
• - ARF
• Correction factor for Afro-Caribbean 1.2
• Can underestimate severity of renal disease in
  malnourished, amputees
• Not validated in certain ethnic groups- Asian,
  Chinese

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Stages of CKD
CKD STAGE DESCRIPTION GFR (ml/min/1.73 m2)
1 Kidney damage with normal or increased GFR gt 90
2 Kidney damage with mild reduction in eGFR 60 89
3 Moderate reduction in eGFR a) 45 59 b) 30 44
4 Severe reduction in eGFR 15 29
5 Established kidney failure lt15 (dialysis or transplant)
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Kidney damage

• Persistent proteinuria, albuminuria, haematuria
  or known renal structural abnormality
• Add suffix P when staging CKD
• P Proteinuria
• P Prognostic significance

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Assess eGFR
gt60
lt 60
Recheck in 2/52
No acute deterioration
Acute deterioration
3 Measurements Over 90 days
Refer
Stage 4-5 CKD
Stage 3 CKD
Recheck annually
Manage in primary care
Refer
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Urine dipstick

• Blood
• Protein
• EXCLUDE MENSTRUATION AND INFECTION

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Haematuria

• Macroscopic
  Microscopic

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Macroscopic haematuria

UROLOGY Urgent 2 week referral

• RENAL
• Associated with CKD gt3
• Rapidly declining renal function
• Proteinuria
• Urological investigations normal

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Microscopic haematuria(gt 1)

• 
  
• 
  

Age gt 50
Age lt 50
Exclude renal/ bladder cancer

• Annual follow up
• Haematuria
• BP
• ACR

No
Refer/investigate
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Proteinuria

• Urine dipsticks unreliable for low levels, unless
  specific reagent strips
• Urine spot tests for
• PCR
• ACR
• Remember microalbuminuria in diabetics

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To make matters confusing..

• SIGN 2008, Renal association CKD guidelines
  recommend PCR
• NICE 2008 recommend ACR for identification BUT
  also approve PCR for quantification and
  monitoring
• Approximate conversion chart availableif
  interested!!

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Measure urine ACR
lt30 mg/mmol
30 70 mmol
gt70 mmol
Diabetic
Haematuria
Non- diabetic
lt2.5 M lt3.5 F
gt2.5 M gt3.5 F
Yes
No
Normal
Micro albuminuria
Refer
Consider ACEi/ARB
Refer
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M for..

• Management of CKD
• Monitoring

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Principles of management

Monitoring CKD
Managing risk factors
Managing CVD risk
Reducing disease progression
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Offer CKD testing

• DM
• HT
• CVD
• Structural renal tract disease
• Prostate hypertrophy
• Multisystem disease
• F/H/o CKD
• Opportunistic haematuria/proteinuria

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Lifestyle

• Smoking
• Healthy BMI
• Regular exercise
• Healthy diet ( low phosphate, potassium )
• - low salt- beware salt substitutes
• - low protein beware risk of PEM
• - alcohol consumption

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Laboratory testing
CKD STAGE TESTS FREQUENCY
1 and 2 eGFR, ACR/PCR Yearly
3 As for stage 1 and 2 Hb, K, Ca and Phosphate 6 monthly (12 monthly if stable)
4 As for stage 3 Bicarbonate and PTH 3 monthly (6 monthly if stable)
5 As for stage 4 6 weekly
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BP monitoring

• Atleast once a year
• Targets in CKD

SBP 120 139 mm Hg DBP lt90 mm Hg

• SBP 120 129 mm Hg
• DBP lt80 mm Hg
• Proteinuria
• DM with microalb

ACEi or ARB 1st line
Any
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Principles of management
Monitoring CKD
Managing associated risk factors
Managing CVD risk
Reducing disease progression
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CVD risk

• Cardiovascular prophylaxis
• Primary prevention
  Secondary prevention
• Statin (gt20)
  Statin
• SHARP study
  Aspirin
• 
  BP control

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Principles of management
Monitoring CKD
Managing associated risk factors
Managing CVD risk
Reducing disease progression
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Management of associated diseases

• ADVANCE study
• Good glycemic control in DM
• HT

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Two important aspects

• Bone protection
• Offer bisphosphonates if indicated (Stage 1-3
  CKD)
• If VIT D supplementation needed
• - Stage 1-3 Chole/ergocalciferol
• - Stage 4-5 alfacalcidol or calcitriol
• Anaemia

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Reducing disease progression- additional

• CKD 3
• Monitor Hb (CKD 3b)
• Renal tract USS if
• - lower urinary tract symptoms
• - refractory HT
• - progressive disease
• Avoid nephrotoxic drugs
• Regular review of all medications dose adjusted
  for CKD

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Reducing disease progression

• CKD 4 5
• (in conjunction with a nephrologist)
• Dietary assessment
• Hepatitis B immunisation
• Management of hyperPTH
• Management of anaemia
• Correction of acidosis
• Appropriate discussion, information and
  implementation of RRT dialysis or
  transplantation

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Referral to nephrologist
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Urgent referral (red flags)

1. ARF
2. Malignant HT
3. Hyperkalemia
4. Nephrotic syndrome

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Non urgent referral

1. High proteinuria (ACR gt 70mg/mmol)
2. Proteinuria with microscopic haematuria(ACR gt30)
3. Rapidly declining eGFR
4. Poorly controlled HT
5. Patients with /suspected with rare genetic kidney
   disease
6. Suspected RAS

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Others

• Unexplained normocytic anaemia
• Macroscopic haematuria( neg urology)
• Recurrent pulmonary edema with normal LV function
• Persistant dyselectrolytemia( Ca, PO4,K)
• Suspected systemic disease
• - SLE
• - vasculitis
• - myeloma

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In summary

• CKD is a common underdiagnosed long term
  condition
• Increased mortality from CVD
• CKD staging is by eGFR proteinuria
• Primary care management in stable CKD involves
  annual tests and reduction of CVD risk
• Patients with severe/progressive CKD/proteinuria
  should be referred to a nephrologist

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Questions..??
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Thank you for listening