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Chronic Kidney Disease

Chronic Kidney Disease. Dr Fenella Mayle Fordbridge Medical Centre 26.11.12. CKD. Chronic renal failure is the progressive loss of nephrons resulting in permanent compromise of renal function. Identification of risk groups. Testing for CKD should be undertaken in the following groups:

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Chronic Kidney Disease

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  1. Chronic Kidney Disease Dr Fenella Mayle Fordbridge Medical Centre 26.11.12

  2. CKD • Chronic renal failure is the progressive loss of nephrons resulting in permanent compromise of renal function.

  3. Identification of risk groups • Testing for CKD should be undertaken in the following groups: • Diabetes • Hypertension • Cardiovascular disease (IHD, chronic heart failure, peripheral vascular disease, cerebral vascular disease) • Structural renal tract disease, renal calculi, prostatic hypertrophy • Multisystem diseases with potential kidney involvement, eg, SLE • FHx of CKD 5 disease or hereditary kidney disease • Opportunistic detection of haematuria or proteinuria • Monitor eGFR in pt’s prescribed known nephrotoxic drugs such as lithium. • Pt’s should have annual eGFR testing if on long-term NSAIDs

  4. CKD testing • Clinicians should use urine albumin:creatinine ratio (ACR) in preference to protein:creatinine ration (PCR) in order to detect proteinuria as ACR has greater sensitivity compared to PCR for low levels of proteinuria • All patients with diabetes, and patients without diabetes with a GFR less than 60 ml/min/1.73 m^2, should have their urinary albumin/protein excretion quantified. The first abnormal result should be confirmed on an early morning sample (if not previously obtained) • Urine dipstick should be completed for assessment of renal disease, especially in those patients with risk factors such as hypertension, DM. • Proteinuria should ideally be identified using albumin:creatinine ratio (ACR). Protein should not be assessed on a standard urine dipstick reagant strip as this method is not accurate • Haematuria can be assessed on simple dipstick. Any result of 1+ or above should be considered postive. • Renal USS is not routinely required. It may be indicated in the case of • Progressive CKD • Visible or persistent haematuria • Symptoms of urinary tract obstruction • Family Hx of polycystic kidney disease in a patient over 20yrs old • CKD stage 4 or 5

  5. Interpretation of proteinuria and haematuria Non-diabetic patients • ACR <30mg/mmol = Normal • ACR 30-69 = Significant proteinuria present • ACR>70 = Heavy proteinuria present • If ACR 30-69mg/mmol, confirm with repeat test using an early morning urine sample • If ACR>70 no repeat is necessary Diabetic patients • ACR <2.5mg/mmol in men, <3.5 in women = normal • ACR >2.5 in men, >3.5 in women = microalbuminuria is present Haematuria • If present and no proteinuria, confirm on 2 out of 3 dipsticks over 4 weeks • If persistent, see further management guidelines • If present with proteinuria, patient will need specialist review

  6. Practical tip • These urinary protein figures, expressed as ACR can be difficult to put into context. They are comparable to 24-hour urinary protein excretion. • Roughly speaking • ACR of 30mg/mmol = 0.5g protein/day on a 24-hour urine • ACR of 70mg/mmol = 1g protein/day on a 24-hour urine

  7. NICE advise to take the following steps to identify progressive CKD • Obtain a minimum of three GFR estimations over a period of not less than 90 days. • Patients with a new finding of reduced eGFR (<60), repeat the eGFR within 2 weeks to exclude causes of acute deterioration of GFR - for example, acute kidney injury or initiation of ACE inhibitor/ARB therapy • define progression as a decline in eGFR of more than 5 ml/min/1.73 m^2 within 1 year, or more than 10 ml/min/1.73 m^2 within 5 years • Risk factors for progression include cardiovascular disease, proteinuria, hypertension, smoking, black or Asian ethnicity, chronic use of NSAIDs, urine outflow obstruction • focus particularly on those in whom a decline of GFR continuing at the observed rate would lead to the need for renal replacement therapy within their lifetime by extrapolating the current rate of decline

  8. Staging CKD • Stage 1: Normal GFR; GFR >90 mL/min/1.73 m2 with other evidence of chronic kidney damage • Stage 2: Mild impairment; GFR 60-89 mL/min/1.73 m2 with other evidence of chronic kidney damage • Stage 3: Moderate impairment; GFR 30-59 mL/min/1.73 m2 • Stage 3 CKD should be split into two subcategories: • GFR 45-59 ml/min/1.73 m2 (stage 3A) • GFR 30-44 ml/min/1.73 m2 (stage 3B) • Stage 4: Severe impairment: GFR 15-29 mL/min/1.73 m2 • Stage 5: Established renal failure (ERF): GFR < 15 mL/min/1.73 m2 or on dialysis (the term established renal failure is used instead of end-stage renal disease or end-stage renal failure, as this is the term used in the National Service Framework for Renal Services)

  9. CKD staging • other evidence of chronic kidney damage may be one of the following: • persistent microalbuminuria • persistent proteinuria • persistent haematuria (after exclusion of other causes, e.g. urological disease) • structural abnormalities of the kidneys demonstrated on ultrasound scanning or other radiological tests, e.g. polycystic kidney disease, reflux nephropathy • biopsy-proven chronic glomerulonephritis (most of these patients will have microalbumuria or proteinuria, and/or haematuria) • patients found to have a GFR of 60-89 mL/min/1.73 m2 without one of these markers should not be considered to have CKD and should not be subjected to further investigation unless there are additional reasons

  10. Does stage 3 CKD matter? • 5% of the adult population is estimated to have stage 3 CKD and they make up vast majority of patients on practice CKD registers. • In a typical 10,000 patient practice, every year: • 144 new pt’s with stage 3 CKD will be identified • 3 new pt’s with stage 4 will be detected • Only 1 new pt with stage 5 CKD will be detected • The BJGP review found: • The relative risk of mortality (all-cause or CVD) was higher in stage 3 compared with no CKD • The increased risk was greater in stage 3B cf to 3A • Mortality rate for stage 3B was 4.8 per 100 years compared with 1.1 for stage 3A • Over 80% of pt’s with CKD stage 3 did not show worsening of stage over 5 years • BJGP concluded that a diagnosis of stage 3 CKD does matter as it provides an opportunity to assess CVD risk and optimise care for those at highest risk.

  11. How should you manage a patient with newly identified low eGFR? • Do not view reading in isolation • Review previous results and assess rate of deterioration • Check Hx and review medications – any nephrotoxic drugs • Check BP and conduct clinical assessment – (eg, is there a palpable bladder?) • Check urine – dipstick for blood and send for ACR • Repeat eGFR within 2 weeks and rv with urine results. If all appears stable, take a third eGFR within 3 months • Stage the CKD – Read code and then investigate/refer/manage as appropriate

  12. Management of patients with chronic kidney disease (CKD) in primary care • regular measurements of kidney function using serum creatinine concentration and estimated GFR, depending on the severity of kidney impairment (annual in stage 1 and 2 and stage 3 if known to be stable, 6-monthly for newly diagnosed or progressive stage 3) • advice on smoking cessation • advice on weight loss if obese • encouragement to take regular aerobic exercise • advice to limit alcohol intake to no more than 3 units/day (men) or 2 units/day (women) • consideration of aspirin treatment for all patients with an estimated 10 year risk of cardiovascular disease of > 20%, so long as blood pressure is < 150/90 mm Hg • meticulous control of hypertension if present • lipid lowering

  13. When should patient be referred? • A patient with CKD should normally be referred to a renal specialist in the case of: • Stage 4 or 5 disease • High levels of proteinuria (ACR>70mg/mmol) • Proteinuria (ACR>30mg/mmol) and haematuria • Rapidly declining eGFR (>5ml/min/1.73m in one year, >10 in 5 years) • Poorly controlled hypertension, despite at least 4 drugs • Suspected renal artery stenosis or rare/genetic cause for CKD

  14. Hypertension in CKD • ACEi and ARbs have a renal protective effect beyond simple BP control • BP targets: usually <140/90. If DM or high levels of proteinuria (ACR>70mg/mmol), target is <130/80 • Offer ACEi first-line in : • Patients with DM and microalbuninuria (ACR>2.5 in men, >3.5 in women) • Patients with high levels of proteinuria (ACR>70) irrespective of BP control • Patients with hypertension and significant proteinuria (ACR>30)

  15. ACEi/ARBs • Use the maximum tolerated dose • Check eGFR and potassium after 1-2 weeks • If eGFR declines by less than 25% continue and monitor • If eGFR declines by more than 25% exclude acute causes and stop ACEi/ARB • If baseline potassium is >5, don’t start ACEi/ARB • If potassium increases to 6 stop ACEi/ARB • NB. If patients with ACR <30mg/mmol and no DM – treat BP as per normal hypertension guidelines

  16. Should CKD pt’s be treated with statins? • No absolute requirement for CKD pt’s to receive statins, however, as in any other pt they do form part of cardiovascular risk management. • Use of statins in primary prevention should be the same as in pt’s without CKD – offer if the CVD risk over 10 years is greater than 20%. QRISK2 risk calculator adjusts for CKD when calculating a pt’s risk score. • Statins should be used in 2y prevention irrespective of baseline lipid levels – aiming for target total chol <4 and LDL <2mmol/L

  17. Other complications: • Anaemia • If not already measured, test in CKD stage 3B, 4 and 5. Treat following NICE guidelines for anaemia • Bones • Measure PTH, calcium and phosphate only in stage 4 and 5 • Offer bisphosphonate if indicated to prevent osteoporosis in stage 1-3B. They are not recommended in stage 4 and 5.

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