Significance of Chronic Kidney Disease in 2015

Transcription

1 1 Significance f Chrnic Kidney Disease in 2015 There is still a requirement within QOF t keep a register f peple with CKD stages 3-5. The ther CKD QOF targets have been retired. This is because CKD care shuld nw be embedded within daily practice; it is nt because CKD is nw felt t be less imprtant, r verdiagnsed. A small, althugh imprtant, minrity f peple with CKD will develp mre advanced renal failure where dialysis r transplantatin may be required. Hwever, fr the verwhelming majrity, CKD is f greater significance fr ther reasns: fr safe prescribing and medicines management (including ver the cunter medicatins such as NSAIDs) as a pwerful and mdifiable risk factr fr cardivascular disease; current NICE Guidance n Lipid Mdificatin (CG181, 2014) is that: CV risk scres (eg QRISK2) are nt used in peple with CKD, and that Atrvastatin 20 mg d is ffered t all peple with CKD as a risk factr fr Acute Kidney Injury (AKI), a majr cause f avidable harm: minr impairment in egfr at any age dramatically increases the risk f AKI ACE inhibitrs, angitensin receptr blckers, and metfrmin shuld - subject t an individual risk assessment - be temprarily stpped during acute intercurrent illnesses (e.g. significant febrile illness, diarrhea and vmiting) t reduce the risk f AKI ( sick day rules ) Revised NICE Guidance n CKD was published in This guideline was develped in September 2015 and will be reviewed in September Guideline Cntents Page Title 2 Identificatin f CKD 3 Fllw-up f peple with knwn CKD 4 Selected issues in management Cardivascular risk reductin Use f ACEi and ARB Indicatins fr renal ultrasund 5 Micrscpic (nn-visible/invisible) haematuria Referral indicatins in CKD

2 Identificatin f CKD 2

3 Fllw up f peple with knwn CKD 3 All peple with CKD need lng-term mnitring f their kidney functin NICE 2015 recmmend that CKD is classified using a cmbinatin f egfr and ACR as these tw measures are independently assciated with increased risk. The frequency f mnitring f egfr (i.e. number f measures per year) is then guided by the fllwing Table (frm NICE CG182, 2014): The frequency f mnitring f ACR (r PCR) will vary accrding t individual circumstances. In many cases the ACR (PCR) will need t be measured less frequently than the egfr

4 Selected Management Issues in CKD 4 Cardivascular Risk Reductin lifestyle measures (as in the general ppulatin) bld pressure cntrl /<80 mmhg standard If diabetes r heavy prteinuria (ACR>70 mg/mml r PCR>100 mg/mml) aim / <80 mmhg lipid lwering (ffer Atrvastatin 20mg d t all peple with CKD) aspirin nly fr secndary preventin f CVD Use f ACE Inhibitrs and Angitensin Receptr Blckers Indicatins Practicalities ACR>30 mg/mml (PCR>50 mg/mml) if n diabetes if hypertensin present ACR>70 mg/mml (PCR>100 mg/mml) if n diabetes regardless f BP ACR>3 mg/mml in diabetes regardless f BP Otherwise fllw NICE standard ACD guidance D nt start if K>5 mml/l Stp if K>6 mml/l Repeat egfr and K after 1-2/52 f treatment r dse change If egfr falls by >25% stp and refer renal unit If egfr falls by <25% repeat after further 1-2/52 t ensure stable D nt use cmbinatin blckade (i.e. mre than ne f ACEi, ARB, Aliskerin) NB discuss sick day rules (see under Significance f CKD in 2015) with patient Indicatins fr Renal Ultrasund accelerated prgressin f CKD a sustained decrease in GFR f 25% r mre and a change in GFR categry within 12 mnths, r a sustained decrease in GFR f 15 ml/min/1.73 m 2 per year visible r persistent invisible haematuria symptms f urinary tract bstructin a family histry f plycystic kidney disease and are aged ver 20 years a GFR f less than 30 ml/min/1.73 m 2 (GFR categry G4 r G5) cnsidered by a nephrlgist t require a renal bipsy

5 Micrscpic (nn-visible, invisible) haematuria 5 Use reagent strips (dipsticks) nt urine micrscpy t detect nn-visible haematuria Regard 2 ut f 3 psitive (1+ r mre) dipsticks as cnfirmatin f persistent invisible haematuria (ie regard trace as negative) Persistent invisible haematuria, with r withut prteinuria, shuld prmpt investigatin fr urinary tract malignancy in apprpriate age grups (age>40, Renal Assciatin/British Assciatin f Urlgical Surgens 2008) Persistent invisible haematuria in the absence f prteinuria shuld be fllwed up annually with repeat testing fr haematuria, prteinuria r albuminuria, egfr and bld pressure as lng as the haematuria persists Referral Indicatins in CKD Frm NICE CG182: GFR <30 ml/min/1.73 m 2 (GFR categry G4 r G5), with r withut diabetes ACR 70 mg/mml r mre, unless knwn t be caused by diabetes and already apprpriately treated ACR 30 mg/mml r mre (ACR categry A3), tgether with haematuria sustained decrease in GFR f 25% r mre, and a change in GFR categry r sustained decrease in GFR f 15 ml/min/1.73 m 2 r mre within 12 mnths hypertensin that remains prly cntrlled despite the use f at least 4 antihypertensive drugs at therapeutic dses knwn r suspected rare r genetic causes f CKD suspected renal artery stensis Renal referral may als be indicated fr suspected renal anaemia, typically where Hb <11 g/l and egfr <45mL/min/1.73m 2