Structural renal tract disease, renal calculi, or benign prostatic hypertrophy.

Transcription

1 Chrnic kidney disease - nt diabetic - Management Scenari: Testing fr chrnic kidney disease Definitin Chrnic kidney disease is said t be present when there is persistent impairment f kidney functin, r evidence f kidney damage (such as prteinuria r haematuria) r structural abnrmality f the kidney. Wrsening renal impairment is assciated with a wide range f cmplicatins, such as hypertensin, anaemia, renal bne disease, malnutritin, neurpathy, and lipid abnrmalities. Peple with chrnic kidney disease are rughly twenty times mre likely t die f cardivascular disease than t prgress t end-stage renal failure. Renal functin is assessed by measuring serum creatinine and calculating estimated glmerular filtratin rate (egfr). The classificatin f chrnic kidney disease is based n egfr, the presence f prteinuria r haematuria, and whether the persn is knwn t have a structural renal abnrmality (see Classificatin f CKD). Wh shuld I test fr chrnic kidney disease? Test peple with risk factrs fr chrnic kidney disease: Diabetes (Types 1 and 2). Hypertensin. Cardivascular disease (ischaemic heart disease, chrnic heart failure, peripheral vascular disease, cerebrvascular disease). Structural renal tract disease, renal calculi, r benign prstatic hypertrphy. Multi-system diseases with ptential kidney invlvement, such as systemic lupus erythematsus. Family histry f chrnic kidney disease stage 5 r hereditary kidney disease. Thse taking nephrtxic drugs such as lithium, ciclsprin, diuretics, and lng-term nnsteridal anti-inflammatry drugs. Test peple with an incidental finding f: Prteinuria r haematuria n a urinary dipstick. A lw estimated glmerular filtratin rate. Fr example, less than 60 ml/min/1.73 m 2. D nt use besity (in the absence f diabetes r hypertensin), r age, gender, and ethnicity alne as a risk factr fr chrnic kidney disease. Hw shuld I test fr chrnic kidney disease? 1

2 Fr peple at risk f chrnic kidney disease, measure serum creatinine (t calculate estimated glmerular filtratin rate [egfr]) and urinary albumin:creatinine rati, and check urine fr haematuria by dipstick. If egfr is less than 60 ml/min/1.73 m 2, repeat within 2 weeks (unless previus values shw the egfr is stable): If the egfr remains less than 60 ml/min/1.73 m 2 with n evidence f acute deteriratin, repeat within 3 mnths t cnfirm the diagnsis f chrnic kidney disease. If the egfr is deterirating (a decrease f mre than 25% f the initial value), cnsider a diagnsis f acute kidney injury and seek specialist advice. If the urinary albumin:creatinine rati is 30 mg/mml r mre: Repeat n an early mrning urine sample (if it is 70 mg/mml r mre, there is n need t repeat the test). If dipstick test shws 1+ r mre f bld: Exclude a urinary tract infectin (UTI). Persistent haematuria is cnsidered t be present if tw ut f three dipstick tests shw 1+ r mre f bld (after exclusin f a UTI). If the egfr is 60 ml/min/1.73 m 2 r mre, the urinary albumin:creatinine rati is less than 30 mg/mml, and there is n haematuria, reassure the persn that they d nt have chrnic kidney disease. Hwever, if the persn is in a high risk grup cntinue t mnitr egfr annually. If the persn has cnfirmed chrnic kidney disease (egfr is persistently less than 60 ml/min/1.73 m 2, r there is persistent prteinuria r haematuria, r there is a structural kidney abnrmality) assess fr pssible causes, grade severity (based n classificatin system), and see Management issues. Chrnic kidney disease - nt diabetic - Management Scenari: Management f stage 1 and 2 chrnic kidney disease Definitin Chrnic kidney disease is said t be present when there is persistent impairment f kidney functin, r evidence f kidney damage (such as prteinuria r haematuria), r structural abnrmality f the kidney. Wrsening renal impairment is assciated with a wide range f cmplicatins, such as hypertensin, anaemia, renal bne disease, malnutritin, neurpathy, and lipid abnrmalities. Peple with chrnic kidney disease are rughly twenty times mre likely t die f cardivascular disease than t prgress t end-stage renal failure. 2

3 Renal functin is assessed by measuring serum creatinine and calculating estimated glmerular filtratin rate (egfr). Chrnic kidney disease stages 1 and 2 are diagnsed when the egfr is 60 ml/min/1.73 m 2 r mre and there is evidence f prteinuria r haematuria, r a structural abnrmality f the kidney (see Classificatin f CKD). Peple with chrnic kidney disease stage 1 and 2 can usually be managed in primary care. When is referral recmmended in stage 1 r 2 CKD? Refer accrding t lcal guidelines, where available. The urgency f referral shuld be based n clinical judgement. Referral t a nephrlgy specialist is usually required fr peple with: Heavy prteinuria (urinary albumin:creatinine rati 70 mg/mml r mre), unless this is knwn t be due t diabetes and already apprpriately treated. Prteinuria (urinary albumin:creatinine rati 30 mg/mml r mre) with haematuria. Uncntrlled hypertensin (despite fur antihypertensive drugs at therapeutic dses see the CKS tpic n Hypertensin - nt diabetic). A rare r genetic cause f chrnic kidney disease, r the suspicin f ne (such as plycystic kidney disease). Suspected renal artery stensis (such as refractry hypertensin, recurrent pulmnary edema with nrmal left ventricular functin, r an increase in serum creatinine f 20% r mre when started n an angitensin-cnverting enzyme inhibitr). If the persn has urinary tract bstructin (fr example the bladder is palpable), refer t a urlgist unless urgent medical interventin is needed fr prblems such as hyperkalaemia (ptassium greater than 6 mml/l) r fluid verlad. What tests shuld be mnitred in CKD stage 1 and 2 Use clinical judgement; if in dubt, seek specialist advice. The fllwing shuld be measured rutinely: Estimated glmerular filtratin rate (egfr) every 12 mnths. A test fr prteinuria every 12 mnths: If the persn is nt already knwn t have prteinuria, measure the urinary albumin:creatinine rati. 3

4 If the persn is knwn t have prteinuria, mnitring can be with urinary albumin:creatinine r prtein:creatinine ratis. If there is haematuria (with n urlgical cause), carry ut a dipstick test fr haematuria every 12 mnths r until it is n lnger persistent. Hw d I knw if the egfr has deterirated significantly? If a decline in estimated glmerular filtratin rate (egfr) is seen, repeat three times ver a perid f at least 90 days. A significant egfr decline is indicated if there is mre than a: 5 ml/min/1.73 m 2 decrease within 1 year, r 10 ml/min/1.73 m 2 decrease within 5 years. If a large decline in egfr is seen (25% r mre), repeat within 2 weeks t exclude acute kidney injury. What lifestyle advice is recmmended? Encurage peple with chrnic kidney disease t: Stp smking (if apprpriate) and drink sensible amunts f alchl (see the CKS tpics n Smking cessatin and Alchl - prblem drinking). Take regular exercise, and achieve a healthy bdy weight (see the CKS tpic n Obesity). Eat a healthy diet. Avid using ver-the-cunter nnsteridal anti-inflammatry drugs (except n medical advice). Prvide infrmatin apprpriate t the stage and cause f chrnic kidney disease. What bld pressure is recmmended? In peple with chrnic kidney disease, ideally aim fr: Systlic bld pressure less than 140 mmhg (target range mmhg). Diastlic bld pressure less than 90 mmhg. 4

5 In peple with chrnic kidney disease and a urinary albumin:creatinine rati f 70 mg/mml r mre, ideally aim fr: Systlic bld pressure less than 130 mmhg (target range mmhg). Diastlic bld pressure less than 80 mmhg. When are ACE inhibitrs r AIIRAs recmmended? Offer an angitensin-cnverting enzyme (ACE) inhibitr t peple with chrnic kidney disease if there is: Hypertensin and prteinuria with a urinary albumin:creatinine rati f 30 mg/mml r mre, r Prteinuria with a urinary albumin:creatinine rati f 70 mg/mml r mre (irrespective f bld pressure). Start with a lw dse and titrate up t the maximum tlerated therapeutic dse (within the maximum licensed dse), by dubling the dse every 1 2 weeks. After each upward titratin, mnitr the persn's renal functin, serum ptassium level, and bld pressure. If the persn cannt tlerate an ACE inhibitr (due t nn-renal adverse effects), ffer an angitensin-ii receptr antagnist (AIIRA) as an alternative (see prescribing ACE inhibitrs and AIIRAs). Fr peple with hypertensin and n prteinuria (urinary albumin:creatinine rati less than 30 mg/mml), treat in line with current guidance n hypertensin management (see the CKS tpic n Hypertensin - nt diabetic). When are statins r aspirin recmmended? Peple with chrnic kidney disease shuld be ffered antiplatelet and statin treatment as fr the rest f the ppulatin. Fr primary preventin f cardivascular disease (CVD), calculate the CVD risk based n existing risk tables (see the CKS tpic n CVD risk assessment and management). Fr secndary preventin f CVD, see the CKS tpics n Antiplatelet treatment and Lipid mdificatin - CVD preventin. Prescriptins Start angitensin-cnverting enzyme inhibitr 5

6 Age frm 18 years nwards Start enalapril: titrate frm 5mg t 10mg nce a day Enalapril 5mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start lisinpril: titrate frm 5mg t 10mg nce a day Age: frm 18 years nwards NHS cst: 1.02 Lisinpril 5mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start ramipril: initial titratin frm 2.5mg t 5mg Age: frm 18 years nwards NHS cst: 0.82 Ramipril 2.5mg capsules Take ne capsule nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw capsules nce a day. Supply 56 capsules. Start angitensin-ii receptr antagnist Age: frm 18 years nwards NHS cst: 2.30 Age frm 18 years nwards Start irbesartan: titrate frm 150mg t 300mg nce a day Irbesartan 150mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start lsartan: titrate frm 50mg t 100mg nce a day Lsartan 50mg tablets Age: frm 18 years nwards NHS cst:

7 Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Chrnic kidney disease - nt diabetic - Management Scenari: Management f stage 3 chrnic kidney disease Age: frm 18 years nwards NHS cst: Black triangle Definitin Chrnic kidney disease is said t be present when there is persistent impairment f kidney functin, r evidence f kidney damage (such as prteinuria r haematuria) r structural abnrmality f the kidney. Wrsening renal impairment is assciated with a wide range f cmplicatins, such as hypertensin, anaemia, renal bne disease, malnutritin, neurpathy, and lipid abnrmalities. Peple with chrnic kidney disease are rughly twenty times mre likely t die f cardivascular disease than t prgress t end-stage renal failure. Renal functin is assessed by measuring serum creatinine and calculating estimated glmerular filtratin rate (egfr). Chrnic kidney disease stage 3 is diagnsed when egfr is ml/min/1.73 m 2, with r withut evidence f prteinuria r haematuria r a structural abnrmality f the kidney (see Classificatin f CKD). Mst peple with chrnic kidney disease stage 3 can be managed in primary care. Treatment f cmplicatins such as anaemia and renal bne disease requires specialist input. When is referral recmmended in stage 3 CKD? Refer accrding t lcal guidelines, where available. The urgency f referral shuld be based n clinical judgement. Referral t a nephrlgy specialist is usually required fr peple with: Acute renal failure, suggested by a rapid decrease in the estimated glmerular filtratin rate (egfr) f mre than 25% f the initial value. Heavy prteinuria (urinary albumin:creatinine rati 70 mg/mml r mre), unless this is knwn t be due t diabetes and already apprpriately treated. Prteinuria (urinary albumin:creatinine rati 30 mg/mml r mre) with haematuria. 7

8 Rapidly declining egfr, defined as mre than 5 ml/min/1.73 m 2 in 1 year, r mre than 10 ml/min/1.73 m 2 within 5 years. Uncntrlled hypertensin (despite fur antihypertensive drugs at therapeutic dses see the CKS tpic n Hypertensin - nt diabetic). A rare r genetic cause f chrnic kidney disease, r the suspicin f ne (such as plycystic kidney disease). Suspected renal artery stensis (such as refractry hypertensin, recurrent pulmnary edema with nrmal left ventricular functin, r an increase in serum creatinine f 20% r mre when started n an angitensin-cnverting enzyme inhibitr). Cmplicatins f chrnic kidney disease, such as anaemia (haemglbin less than 11 g/dl) and renal bne disease (fr example abnrmal serum calcium r phsphate). If the persn has urinary tract bstructin (fr example the bladder is palpable), refer t a urlgist unless urgent medical interventin is needed fr prblems such as hyperkalaemia (ptassium greater than 6 mml/l), uraemia, acidsis, r fluid verlad. What tests shuld be mnitred in CKD stage 3 Use clinical judgement; if in dubt, seek specialist advice. In chrnic kidney disease stage 3A (estimated glmerular filtratin rate [egfr] ml/min/1.73 m 2 ): Measure egfr every 6 mnths. In chrnic kidney disease stage 3B (egfr ml/min/1.73 m 2 ): Measure egfr every 6 mnths. D a full bld cunt t exclude anaemia (haemglbin < 11 g/dl). The frequency f subsequent mnitring depends n whether there is evidence f a dwnward trend. D nt rutinely measure serum parathyrid hrmne r vitamin D unless this is clinically indicated (such as in the presence f an abnrmal calcium level). Test fr prteinuria every 12 mnths: If the persn is nt already knwn t have prteinuria, measure the urinary albumin:creatinine rati. If the persn is knwn t have prteinuria, mnitring can be with urinary albumin:creatinine r prtein:creatinine ratis. 8

9 If the persn has haematuria (with n urlgical cause), carry ut a dipstick test fr haematuria every 12 mnths r until it is n lnger persistent. Hw d I knw if the egfr has deterirated significantly? If a decline in estimated glmerular filtratin rate (egfr) is seen, repeat three times ver a perid f at least 90 days. A significant egfr decline is indicated if there is mre than a: 5 ml/min/1.73 m 2 decrease within 1 year, r 10 ml/min/1.73 m 2 decrease within 5 years. If a large decline in egfr is seen (25% r mre), repeat within 2 weeks t exclude acute kidney injury. What lifestyle advice is recmmended? Encurage peple with chrnic kidney disease t: Stp smking (if apprpriate) and drink sensible amunts f alchl (see the CKS tpics n Smking cessatin and Alchl - prblem drinking). Take regular exercise, and achieve a healthy bdy weight (see the CKS tpic n Obesity). Eat a healthy diet. Avid using ver-the-cunter nnsteridal anti-inflammatry drugs (except n medical advice). Prvide infrmatin apprpriate t the stage and cause f chrnic kidney disease. What bld pressure is recmmended? In peple with chrnic kidney disease, ideally aim fr: Systlic bld pressure less than 140 mmhg (target range mmhg). Diastlic bld pressure less than 90 mmhg. In peple with chrnic kidney disease and a urinary albumin:creatinine rati f 70 mg/mml r mre, ideally aim fr: Systlic bld pressure less than 130 mmhg (target range mmhg). 9

10 Diastlic bld pressure less than 80 mmhg. When are ACE inhibitrs r AIIRAs recmmended? Offer an angitensin-cnverting enzyme (ACE) inhibitr t peple with chrnic kidney disease if there is: Hypertensin and prteinuria with a urinary albumin:creatinine rati f 30 mg/mml r mre, r Prteinuria with a urinary albumin:creatinine rati f 70 mg/mml r mre (irrespective f bld pressure). Start with a lw dse and titrate up t the maximum tlerated therapeutic dse (within the maximum licensed dse), by dubling the dse every 1 2 weeks. After each upward titratin, mnitr the persn's renal functin, serum ptassium level, and bld pressure. If the persn cannt tlerate an ACE inhibitr (due t nn-renal adverse effects), ffer an angitensin-ii receptr antagnist (AIIRA) as an alternative (see prescribing ACE inhibitrs and AIIRAs). Fr peple with hypertensin and n prteinuria (urinary albumin:creatinine rati less than 30 mg/mml), treat in line with current guidance n hypertensin management (see the CKS tpic n Hypertensin - nt diabetic). When are statins r aspirin recmmended? Peple with chrnic kidney disease shuld be ffered antiplatelet and statin treatment as fr the rest f the ppulatin. Fr primary preventin f cardivascular disease (CVD), calculate the CVD risk based n existing risk tables (see the CKS tpic n CVD risk assessment and management). Fr secndary preventin f CVD, see the CKS tpics n Antiplatelet treatment and Lipid mdificatin - CVD preventin. Prescriptins Start angitensin-cnverting enzyme inhibitr Age frm 18 years nwards Start enalapril: titrate frm 5mg t 10mg nce a day Enalapril 5mg tablets 10

11 Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start lisinpril: titrate frm 5mg t 10mg nce a day Age: frm 18 years nwards NHS cst: 1.02 Lisinpril 5mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start ramipril: initial titratin frm 2.5mg t 5mg Age: frm 18 years nwards NHS cst: 0.82 Ramipril 2.5mg capsules Take ne capsule nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw capsules nce a day. Supply 56 capsules. Start angitensin-ii receptr antagnist Age: frm 18 years nwards NHS cst: 2.30 Age frm 18 years nwards Start irbesartan: titrate frm 150mg t 300mg nce a day Irbesartan 150mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start lsartan: titrate frm 50mg t 100mg nce a day 11 Age: frm 18 years nwards NHS cst: Lsartan 50mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Age: frm 18 years nwards

12 NHS cst: Black triangle Chrnic kidney disease - nt diabetic - Management Scenari: Management f stage 4 and 5 chrnic kidney disease Definitin Chrnic kidney disease is said t be present when there is persistent impairment f kidney functin, r evidence f kidney damage (such as prteinuria r haematuria) r structural abnrmality f the kidney. Wrsening renal impairment is assciated with a wide range f cmplicatins, such as hypertensin, anaemia, renal bne disease, malnutritin, neurpathy, and lipid abnrmalities. Peple with chrnic kidney disease are rughly twenty times mre likely t die f cardivascular disease than t prgress t end-stage renal failure. Renal functin is assessed by measuring serum creatinine and calculating estimated glmerular filtratin rate (egfr). Chrnic kidney disease stages 4 and 5 are diagnsed when egfr is ml/min/1.73 m 2 (stage 4) r less than 15 ml/min/1.73 m 2 (stage 5), with r withut evidence f prteinuria r haematuria r a structural abnrmality f the kidney (see Classificatin f CKD). Specialist referral and shared care is recmmended fr mst peple with chrnic kidney disease stages 4 and 5. Treatment f cmplicatins such as anaemia and renal bne disease require specialist input. When is referral recmmended in stage 4 r 5 CKD? Refer accrding t lcal guidelines, where available. The urgency f referral shuld be based n clinical judgement. Peple with chrnic kidney disease stage 4 r 5 shuld usually be referred t a nephrlgy specialist. Peple with urinary tract bstructin (fr example the bladder is palpable) shuld be referred t a urlgist unless urgent medical interventin is needed fr prblems such as hyperkalaemia (ptassium greater than 6 mml/l), uraemia, acidsis, r fluid verlad. What tests shuld be mnitred in CKD stage 4 and 5 Peple with chrnic kidney disease stage 4 r 5 shuld usually be under specialist care, but mnitring f bld tests may take place in primary care as part f shared care arrangements. 12

13 Measure estimated glmerular filtratin rate (egfr) every 3 mnths in stage 4 disease and every 6 weeks in stage 5 disease. Check haemglbin level, as well as serum calcium, phsphate, vitamin D, and parathyrid hrmne. Frequency f subsequent mnitring will depend n the results and clinical circumstances. Test fr prteinuria every 12 mnths: If the persn is nt already knwn t have prteinuria, measure the urinary albumin:creatinine rati. If the persn is knwn t have prteinuria, mnitring can be with urinary albumin:creatinine r prtein:creatinine ratis. If the persn has haematuria (with n urlgical cause), carry ut a dipstick test fr haematuria every 12 mnths r until it is n lnger persistent. Hw d I knw if the egfr has deterirated significantly? If a decline in estimated glmerular filtratin rate (egfr) is seen, repeat three times ver a perid f at least 90 days. A significant egfr decline is indicated if there is mre than a: 5 ml/min/1.73 m 2 decrease within 1 year, r 10 ml/min/1.73 m 2 decrease within 5 years. If a large decline in egfr is seen (25% r mre), repeat within 2 weeks t exclude acute kidney injury. What lifestyle advice is recmmended? Encurage peple with chrnic kidney disease t: Stp smking (if apprpriate) and drink sensible amunts f alchl (see the CKS tpics n Smking cessatin and Alchl - prblem drinking). Take regular exercise, and achieve a healthy bdy weight (see the CKS tpic n Obesity). Eat a healthy diet. Avid using ver-the-cunter nnsteridal anti-inflammatry drugs (except n medical advice). Prvide infrmatin apprpriate t the stage and cause f chrnic kidney disease. 13

14 What bld pressure is recmmended? In peple with chrnic kidney disease, ideally aim fr: Systlic bld pressure less than 140 mmhg (target range mmhg). Diastlic bld pressure less than 90 mmhg. In peple with chrnic kidney disease and a urinary albumin:creatinine rati f 70 mg/mml r mre, ideally aim fr: Systlic bld pressure less than 130 mmhg (target range mmhg). Diastlic bld pressure less than 80 mmhg. When are ACE inhibitrs r AIIRAs recmmended? Offer an angitensin-cnverting enzyme (ACE) inhibitr t peple with chrnic kidney disease if there is: Hypertensin and prteinuria with a urinary albumin:creatinine rati f 30 mg/mml r mre, r Prteinuria with a urinary albumin:creatinine rati f 70 mg/mml r mre (irrespective f bld pressure). Start with a lw dse and titrate up t the maximum tlerated therapeutic dse (within the maximum licensed dse), by dubling the dse every 1 2 weeks. After each upward titratin, mnitr the persn's renal functin, serum ptassium level, and bld pressure. If the persn cannt tlerate an ACE inhibitr (due t nn-renal adverse effects), ffer an angitensin-ii receptr antagnist (AIIRA) as an alternative (see prescribing ACE inhibitrs and AIIRAs). Fr peple with hypertensin and n prteinuria (urinary albumin:creatinine rati less than 30 mg/mml), treat in line with current guidance n hypertensin management (see the CKS tpic n Hypertensin - nt diabetic). When are statins r aspirin recmmended? Peple with chrnic kidney disease shuld be ffered antiplatelet and statin treatment as fr the rest f the ppulatin. Fr primary preventin f cardivascular disease (CVD), calculate the CVD risk based n existing risk tables (see the CKS tpic n CVD risk assessment and management). 14

15 Fr secndary preventin f CVD, see the CKS tpics n Antiplatelet treatment and Lipid mdificatin - CVD preventin. Prescriptins Start angitensin-cnverting enzyme inhibitr Age frm 18 years nwards Start enalapril: titrate frm 5mg t 10mg nce a day Enalapril 5mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start lisinpril: titrate frm 5mg t 10mg nce a day Age: frm 18 years nwards NHS cst: 1.02 Lisinpril 5mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Start ramipril: initial titratin frm 2.5mg t 5mg Age: frm 18 years nwards NHS cst: 0.82 Ramipril 2.5mg capsules Take ne capsule nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw capsules nce a day. Supply 56 capsules. Start angitensin-ii receptr antagnist Age: frm 18 years nwards NHS cst: 2.30 Age frm 18 years nwards Start irbesartan: titrate frm 150mg t 300mg nce a day Irbesartan 150mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. 15

16 Supply 56 tablets. Start lsartan: titrate frm 50mg t 100mg nce a day Age: frm 18 years nwards NHS cst: Lsartan 50mg tablets Take ne tablet nce a day fr 7 days (take the FIRST dse at bedtime). Then, if tlerated, take tw tablets nce a day. Supply 56 tablets. Age: frm 18 years nwards NHS cst: Black triangle 16

17 Chrnic kidney disease - nt diabetic - Management View all prescribing infrmatin Imprtant aspects f prescribing infrmatin relevant t primary healthcare are cvered in this sectin specifically fr the drugs recmmended in this CKS tpic. Fr further infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) ( r the British Natinal Frmulary (BNF) ( Angitensin-cnverting enzyme inhibitrs and angitensin II receptr antagnists Which ACE inhibitr/aiira is recmmended? CKS recmmends enalapril, lisinpril, r ramipril (ACE inhibitrs) first line. CKS recmmends irbesartan r lsartan (AIIRAs) if an ACE inhibitr is nt tlerated because f nn-renal adverse effects (fr example persistent, trublesme cugh). Basis fr recmmendatin There is n evidence t suggest that any particular angitensin-cnverting enzyme (ACE) inhibitr is mre effective than anther in the management f chrnic kidney disease [NICE, 2008]. Hwever, there is evidence frm randmized cntrlled trials t supprt the use f enalapril, lisinpril, ramipril, irbesartan, and lsartan in peple with diabetic nephrpathy. Fr supprting evidence, see the CKS tpic n Diabetes type 2. There is n evidence t suggest any advantage f an ACE inhibitr ver an angitensin-ii receptr antagnist (AIIRA); hwever, ecnmic evidence suggests increased csteffectiveness fr ACE inhibitrs cmpared with AIIRAs [NICE, 2008]. Wh shuld avid taking ACE inhibitrs r AIIRAs? Cntraindicatins t angitensin-cnverting enzyme (ACE) inhibitrs and angitensin-ii antagnists (AIIRAs) include: Histry f angiedema assciated with previus expsure t an ACE inhibitr, r hereditary r idipathic angiedema. Severe bilateral renal artery stensis (r severe unilateral renal artery stensis in peple with nly ne functining kidney). Severe hepatic impairment. Pregnancy: 17

18 ACE inhibitrs are cntraindicated during the secnd and third trimesters f pregnancy. Expsure t an ACE inhibitr during the secnd and third trimester is knwn t induce human fetal txicity (decreased renal functin, lighydramnis, delay in skull ssificatin, and nenatal txicity) [MHRA, 2007; Schaefer et al, 2007; ABPI Medicines Cmpendium, 2008; ABPI Medicines Cmpendium, 2009a; ABPI Medicines Cmpendium, 2009b; ABPI Medicines Cmpendium, 2009c]. ACE inhibitrs are nt recmmended during the first trimester f pregnancy. Evidence n the risk f teratgenicity after expsure t ACE inhibitrs during the first trimester f pregnancy is cnflicting, and an increase in the risk f cngenital malfrmatin (particularly f the cardivascular system and central nervus system) cannt be excluded [MHRA, 2007; NTIS, 2007]. Unless cntinued treatment with an ACE inhibitr is cnsidered essential, wmen wh are planning a pregnancy shuld be switched t an alternative treatment with an established safety prfile fr use in pregnancy. The balance f risks and benefits f cntinued treatment with an ACE inhibitr versus the ptential risk f cngenital anmaly shuld be discussed with the wman. When pregnancy is cnfirmed, treatment with an ACE inhibitr shuld be stpped as sn as pssible and, if apprpriate, alternative treatment shuld be started [MHRA, 2007]. Breastfeeding: ACE inhibitrs are nt recmmended fr use by wmen wh are breastfeeding [MHRA, 2009b]. During the first few weeks after delivery ACE inhibitrs can cause prfund nenatal hyptensin; preterm babies may be at particular risk [MHRA, 2009a]. In wmen wh are breastfeeding lder infants, the use f captpril, enalapril, r quinapril may be cnsidered if the use f an ACE inhibitr is necessary [MHRA, 2009a]. If used, the infant shuld be carefully fllwed up fr pssible signs f hyptensin [MHRA, 2009b]. Wh shuld start an ACE inhibitr r AIIRA under utpatient supervisin? Peple at high risk f first-dse hyptensin, hyperkalaemia, r renal failure shuld start treatment under clse supervisin (if in dubt, discuss this with a specialist). This includes peple with the fllwing features: Renal impairment, with an estimated glmerular filtratin rate (egfr) f less than 30 ml/minute/1.73 m 2. A previus decrease in egfr f mre than than 15% after taking an angitensin-cnverting enzyme (ACE) inhibitr. A strng clinical suspicin f renal artery stensis. Baseline serum ptassium f 5.0 mml/l r greater. 18

19 Hypnatraemia (sdium less than 130 mml/l). Hypvlaemia. Unstable heart failure. Receiving high-dse diuretic treatment (fr example mre than fursemide 80 mg per day) wh cannt tlerate withdrawal f this prir t starting an ACE inhibitr. Receiving high-dse vasdilatr treatment. [NICE, 2003; NICE, 2008; BNF 57, 2009] What dse f an ACE inhibitr r AIIRA shuld I prescribe and hw shuld the dse be titrated? Cnsider whether the ACE inhibitr r angitensin-ii receptr antagnist (AIIRA) shuld be started under specialist supervisin. Start with a lw dse and titrate up t the maximum tlerated therapeutic dse (within the maximum licensed dse), by dubling the dse every 1 2 weeks. After each upward titratin, mnitr the persn's renal functin, serum ptassium level, and bld pressure. D nt increase the dse further if there is wrsening renal functin r hyperkalaemia. The fllwing tables shw the recmmended dses f ACE inhibitrs and AIIRAs fr hypertensin and diabetic nephrpathy. Table 1. Recmmended dses f angitensin-cnverting enzyme (ACE) inhibitrs and angitensin-ii receptr antagnists (AIIRAs) fr hypertensin. Drug sual starting dwer starting dmaximum licensed dse (p day) CE inhibitrs nalapril 10 mg daily mg daily 0 mg sinpril 0 mg daily 5 5 mg daily 0 mg erindpril erbu mg daily mg daily mg erindpril arginmg daily 5 mg daily 0 mg amipril 25 mg daily 0 mg andlapril 5 mg daily mg IIRAs 19

20 andesartan mg daily 4 mg 2 mg besartan 50 mg daily 5 mg daily 00 mg sartan 0 mg daily 5 mg daily 00 mg alsartan 0 mg daily 0 mg daily 20 mg ata frm: BNF, Summaries f Prduct Characteristics Table 2. Recmmended dses f ACE inhibitrs and AIIRAs fr diabetic nephrpathy. Drusual starting dwer starting daximum recmmended dse (per d CE inhibitrs nalap 10 mg daily mg daily 0 mg sinp0 mg daily mg daily 0 mg amip5 mg daily 0 mg IIRAs besa50 mg daily 5 mg daily 00 mg sart0 mg daily 5 mg daily 00 mg Prducts nt specifically licensed fr the management f diabetic nephrpa ata frm: BNF, Summaries f Prduct Characteristics [NICE, 2003; NICE, 2008; BNF 57, 2009] Hw shuld I mnitr smene taking ACE inhibitrs r angitensin-ii receptr antagnists? Measure serum creatinine and electrlytes, and estimated glmerular filtratin rate (egfr): Befre starting therapy. 1 2 weeks after starting treatment. 1 2 weeks after subsequent dse increases. Once the target bld pressure has been achieved and is stable, it is usual t mnitr: Bld pressure every 3 6 mnths. 20

21 Urea and electrlytes, and egfr, every 12 mnths (unless required mre frequently because f impaired renal functin). [Jint Specialty Cmmittee n Renal Medicine f the Ryal Cllege f Physicians and Renal Assciatin, 2006; NICE, 2008; BNF 57, 2009] Hw shuld I manage abnrmal ptassium r egfr results? Sme increase in serum creatinine and ptassium is expected after starting r increasing the dse f an angitensin-cnverting enzyme (ACE) inhibitr r an angitensin-ii receptr antagnist (AIIRA). If estimated glmerular filtratin rate (egfr) decreases by 24%, r serum creatinine increases by up t 29%: D nt mdify the ACE inhibitr/aiira dse and recheck levels in a further 1 2 weeks. If egfr decreases by 25% r mre, r serum creatinine increases by 30% r mre: Investigate ther causes f deterirating renal functin, such as vlume depletin. Stp r reduce the dse f the fllwing drugs (where apprpriate) if the persn is taking them: Nephrtxic drugs (such as nnsteridal anti-inflammatry drugs). Vasdilatrs (such as calcium-channel blckers, nitrates). Ptassium supplements r ptassium-sparing diuretics. Diuretics (cnsider dse reductin if the persn is hypvlaemic). If the decrease in egfr r the increase in serum creatinine persists despite these measures: Stp the ACE inhibitr r AIIRA therapy, r Reduce the dse t a previusly tlerated lwer dse and recheck levels in 5 7 days (add an alternative antihypertensive medicatin if required). If serum ptassium is 5.0 mml/l r abve: Investigate ther causes f hyperkalaemia and treat accrdingly. Stp r reduce the dse f ptassium-sparing diuretics (amilride, triamterene, spirnlactne) r nephrtxic drugs (such as nnsteridal anti-inflammatry drugs). If serum ptassium persists between 5.0 and 5.9 mml/l despite these measures, reduce the dse f ACE inhibitrs r AIIRA t a previusly tlerated lwer dse and recheck levels in 5 7 days. 21

22 Stp ACE inhibitrs r AIIRAs if serum ptassium persists abve 6 mml/l despite these measures. Cnsider referral t a dietician: a lw-ptassium diet (up t 2 g/day), r dietary advice may help reslve hyperkalaemia. [NICE, 2008] What adverse effects f ACE inhibitrs r angitensin-ii receptr antagnists shuld I be aware f? Angitensin-cnverting enzyme (ACE) inhibitrs are generally well tlerated, but ccasinally adverse effects can ccur. Adverse effects with angitensin-ii antagnists (AIIRAs) are similar, althugh they tend t be milder. Deteriratin in renal functin Mnitr renal functin after starting an ACE inhibitr r an AIIRA, after each increase in dse, and regularly thrughut treatment. Hyperkalaemia Mnitr serum electrlytes after starting an ACE inhibitr r an AIIRA, after each increase in dse, and regularly thrughut treatment. Orthstatic hyptensin is a cmmn adverse effect f ACE inhibitrs r AIIRAs and may cause dizziness, light-headedness, and cnfusin. If hyptensin is asymptmatic, there is n need t change treatment. If hyptensin is symptmatic: If there are n signs r symptms f cngestin, cnsider reducing the dse f any cncmitant diuretic. Cnsider seeking specialist advice. Cugh ccurs in 0 15% f peple taking an ACE inhibitr, althugh it rarely necessitates stpping treatment (less than 5% f peple) [Micrmedex, 2009]. Cugh is cmmn in peple with heart failure, r it can be due t smking-related lung disease r pulmnary edema. If the cugh is trublesme (fr example it prevents the persn frm sleeping) and ther causes have been ruled ut, cnsider switching t an AIIRA. AIIRAs d nt cause cugh. [McMurray et al, 2005; Eurpean Sciety f Cardilgy, 2008] 22

23 What advice shuld I give t smene taking an ACE inhibitr r an AIIRA? Explain the imprtance f: Achieving the maximum tlerated dse f ACE inhibitr r angitensin-ii receptr antagnist. Regular mnitring f egfr and serum ptassium t achieve this safely. Advise the persn: That they may experience adverse effects, but that these rarely necessitate stpping treatment. T reprt symptms f hyptensin t their healthcare prfessinal. T avid nnsteridal anti-inflammatry drugs (these may be present in ver-the-cunter prducts) and salt substitutes that are high in ptassium. The initial dse shuld be taken late at night r at bedtime t mitigate the hyptensive effects that can ccur. If the drug is well tlerated, subsequent dses shuld be taken in the mrning. If symptms f hyptensin ccur, advise the persn t g t bed and take n further dses until they have been reviewed. [NICE, 2008] 23