CKD and risk management : NICE guideline 2008-2014 Shahed Ahmed Consultant Nephrologist shahed.ahmed@rlbuht.nhs.uk
Key points : Changing parameters of CKD and NICE guidance CKD and age related change of GFR Nice guidance on lipid management with CKD CKD Vs AKI Community AKI project
Defining CKD CKD is present when either: The MDRD-derived estimated glomerular filtration rate (egfr) is less than 60ml/min on at least two occasions over a period of no less than 90 days Or, The urine ACR is >30mg/mmol (or, PCR is > 50mg/mmol)
Classification of CKD, based on NICE 2008 Stage of CKD Estimated GFR KIDNEY FUNCTION Stage 1 Stage 2 >90ml/min with urine abnormality or abnormal renal anatomy 60-89ml/min with urine abnormality or abnormal renal anatomy Normal Mild Reduced Stage 3a 45-59ml/min Mild to moderate reduced Stage 3b 30-44ml/min Moderate reduced Stage 2 15-29ml/min Severe reduced Stage 5 <15ml/min or dialysis dependant Kidney failure
Annual CVD Mortality (%) WHY CKD is a high risk disease? CV disease mortality : General Population vs. ESRD Dialysis Patients 100 10 1 0.1 0.01 0.001 25-34 35-44 45-54 55-64 66-74 75-84 >85 Age (years) GP Male GP Female GP Black GP White Dialysis Male Dialysis Female Dialysis Black Dialysis White Foley RN, et al. Am J Kidney Dis. 1998;32:S112-S119.
Prevalence of Chronic Kidney Disease (CKD) Stages by Age Group in NHANES 1988-1994 and 1999-2004
CV events N Engl J Med. 2004 Sep 23;351(13):1296-305, Go et al, Kaiser Permanente Northern California
CKD- However, The majority of patients with CKD 1-3 do not progress to ESRF. Their risk of cardiovascular death is higher than their risk of progression.
Patients with CKD are more likely to die than go onto dialysis 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 9% 15% 25% 30% 40% Death ESRD/D Event Free No DM / CKD DM No CKD CKD No DM DM and CKD Dialysis Adapted from Collins, Adv Studies in Med, (3C) 2003, Medicare Cohort 1998-99
In CKD early identification is essential! NICE: Chronic kidney disease Early identification and management of chronic kidney disease in adults in primary and secondary care Issue date: September 2008 The Challenges: However, because of a lack of specific symptoms, CKD are often not diagnosed, or diagnosed late. 30% of people with advanced CKD disease are referred late, causing increased mortality and morbidity.
CKD How we diagnose? Serum Cr Vs GFR
egfr: Practical Implementation Issues Apply only to age > 18 (MDRD ages: 18-70) Not Validated - AKI Transplant Pregnancy Ease of use. Good fit with data at lower GFR
Estimate GFR from Serum Creatinine:, AS. Levey, et al; Ann Intern Med. 1999;130:461-470. GFR = 170 x [Pcr] -0.999 x [Age] -0.176 x [0.762 female] x [1.180 black race] x [SUN] -0.170 x [Alb] +0.318 Modified Equation 7: GFR = 186 x [Pcr] -1. 154 x [Age] -0.203 x [0.742 female] x [1.212 black race]
Age & GFR Functional changes Renal plasma flow 10%/decade Longitudinal study, mean reduction CCL 0.75ml/min/yr (92 out 0f 254 no reduction) Lindeman, R. D., Tobin, J., and Shock, N. W. (1985). Longitudinal studies on the rate of decline in renal function with age.journal of the American Geriatrics Society
NICE CKD 2008: Did we overkill CKD diagnosis? Group in NHANES 1988-1994 and 1999-2004
WHATS NEW NICE CKD 2014 The new and updated areas include: Classification of CKD and identification of people at risk of CKD complications and progression The relationship between acute kidney injury and CKD Self-management of CKD Pharmacotherapy for CKD.
Classification of chronic kidney disease Classify CKD using a combination of GFR and ACR categories and be aware that: a. Increased ACR is associated with increased risk of progression b. Decreased GFR is associated with increased risk of progression c. Increased ACR and decreased GFR in combination multiply the risk of progression.
Identification and investigation of people who have or are at risk of developing CKD Consider using egfr cystatin C to confirm the diagnosis of CKD in people with :an egfr creatinine of 45 59 ml/min/1.73 m2, sustained for at least 90 days and no proteinuria (albumin:creatinine ratio)acr less than 3mg/mmol)
CKD : aim of Rx CV risk reduction: Target BP control Rx of hyperlipidaemia Control of proteinuria Target primary disease: ex.- good control of diabetes Specific Rx for CKD
Adjusted relative risk of progression to CKD (95% CI) Blood pressure and progression of CKD 3.5 2.5 3 1860 patients with non-diabetic kidney disease Meta-analysis of 11 randomised controlled trials with or without ACEi MEDLINE Database 3.14 2 2.48 1.5 1.83 2.08 0.5 1 1.00 1.23 0 <110 110-119 120-129 130-139 140-159 160+ Systolic BP (mmhg) Jafar et al, Ann Intern Med 2003;139:244-252
Blood pressure targets NICE CKD Guidance If CKD, blood pressure target: <140 mmhg SBP (130-139) < 90 mmhg DBP (80-89) If diabetes and CKD or ACR 70 mg/mmol, blood pressure target: < 130 mmhg SBP < 80 mmhg DBP NICE Management of CKD: NICE 2008
NICE CKD 2014 Overview: management of CKD in primary care Identify those at risk by egfr and proteinuria measurement Explain to people they have the condition and encourage self-management Control blood pressure manage cardiovascular risk Medicine management
Cont.. Do not offer a combination of renin-angiotensin system antagonists to people with CKD And do not offer a renin-angiotensin system antagonist to people if pretreatment serum potassium is >5.0mmol/litre
Key priority: Promoting self-management of CKD BP control: Explain that reducing raised BP is a key factor in preventing the progression of CKD BP monitoring: Advise people to monitor their own BP at home Smoking cessation Blood sugar control (if they have diabetes) Diet: To avoid processed, high-salt and high-fat foods
Key priority: Assess & control cardio-vascular risk Statins: Use statins for primary prevention of cardiovascular disease in same way as in people without CKD Offer statins for secondary prevention of CVD irrespective of lipid values Offer antiplatelet drugs to people with CKD for the secondary prevention of CVD (but the risks of bleeding may be increased with multiple antiplatelet drugs)
NICE guideline: Lipid modification Feb 2014 prevention of CVD in primary care, use a systematic strategy to identify people aged 40-74 who are likely to be at high risk Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD (more than 10%, 10 year CVD risk on assessment) Offer statin treatment for the primary prevention of CVD with atorvastatin 20 mg. Start statin treatment in people with established CVD, type 1 diabetes or type 2 diabetes with atorvastatin 80 mg.
NICE guideline: Lipid modification Feb 2014 63. In people with stage 1 or stage 2 CKD treat as primary prevention and initiate treatment with atorvastatin 20 mg if there is no evidence of CVD and more than 10% CVD risk on assessment with QRISK2. [new 2014] 64. In people with stage 1 or stage 2 CKD and evidence of CVD, start treatment with atorvastatin 20 mg and increase dose if a greater than 40% reduction in non-hdl cholesterol is not achieved. [new 2014] 65. In people with stage 3 CKD start high-intensity statin treatment with atorvastatin 20 mg. Increase the dose if a reduction in non-hdl cholesterol of greater than 40% is not achieved. [new 2014] 66. In people with CKD stage 4 or greater start treatment with atorvastatin 20 mg and agree the use of higher doses with a renal specialist. [new 2014]
Case 32 Year old lady, generally feeling unwell. H/O- HTN, depression On Lisinopril 20 mg, Furosemide 40 mg INV- S Cr 250/ egfr 29 Urine dip NAD BP, HR, RR normal limit Rx: 1. Urgent Renal O/P ref for CKD 4 2. Stop ACEI / repeat U&E, then consider referral 3. Urgent hospital Referral for AKI
AKI : Background Up to 18% of all hospital admissions have AKI Inpatient AKI-related mortality is between 25 and 30% Between 20 and 30% of cases of AKI are preventable. Prevention could save up to 12,000 lives each year NHS costs related to AKI are between 434 and 620 million per year
Cost of AKI 23 June 2011 Health Service Journal supplement 1
e-aki alert: Early Diagnosis of AKI
e-aki alert
Patient Details: Date: New Diagnosis of AKI (Stage 1 / Stage 2/ Stage 3) (Electronic AKI alert) Baseline Cr/ date: Latest Creatinine (Cr): Urine dip test: To arrange patient review (To exclude CKD) and medication review To repeat U & E within 24-48 hours (i.e, as per AKI stages as below). AKI stage 1 AKI stage 2 AKI stage 3 -Treat underlying problems (dehydration, infection, medication review etc.) - Repeat U & Es in 24-48 hours - Hospital admission if progressive /in appropriate cases 3 -Treat underlying problems (dehydration, infection, medication review etc.) - Consider Hospital admission in appropriate cases 3 ** - Repeat U & Es in 24 hours if treated in community 5 - Treat underlying probles (dehydration, sepsis, medication review etc.) -To arrange Hospital admission in appropriate cases 3 ** - Repeat U & Es 24 hours if treated in community 5 **Discuss with AKI team / on call renal Registrar if required and appropriate
Referral Nephrology: Discuss AKI management with a nephrologist/paediatric nephrologist as soon as possible (and within 24 hours) if one of the following is present: Potential diagnosis requiring specialist treatment (for example, vasculitis or glomerulonephritis) AKI with no clear cause Inadequate treatment response Complications associated with AKI Stage 3 AKI egfr is less than < 30 ml/min/1.73 m 2 after AKI episode Patients with renal transplant and AKI CKD stage 4 or 5 Renal replacement therapy: Refer adults, children and young people immediately for RRT if any of the following are not responding to medical management: Hyperkalaemia Metabolic acidosis Symptoms or complications of uraemia such as pericarditis or encephalopathy Fluid overload +/- pulmonary oedema
Summary 1: CKD - aim of Rx First, Identify CKD CV risk reduction: Target BP control / Rx of hyperlipidaemia Control of proteinuria ACEI/ARB Target primary disease: ex.- good control of diabetes Specific Rx for CKD anaemia / bone disease CKD vs. AKI
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