Chronic Kidney Disease (CKD) and egfr: Decision and Dilemma Dr Bhavna K Pandya Consultant Nephrologist University Hospital Aintree
Topics CKD background egfr background Patient with egfr Referral Guidelines Management Guidelines Other renal related conditions
Def: CKD 1. Kidney damage for > 3 months, with or without decreased GFR, as manifest by either pathologic abnormalities; or markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests 2. GFR <60 ml/min/1.73 m2 for > 3 months, with or without kidney damage
CKD staging & Action Plan
CKD staging Published in a supplement to the American Journal of Kidney Diseases in February 2002. K/DOQI stands for Kidney Disease Outcomes Quality Initiative - a research K/DOQI involves the development of evidencebased clinical practice guidelines to improve patient outcomes.
Need for UK specific guidelines K/DOQI terminology and classification Different healthcare system Referral criteria Optimum method of management
DECLARATION As per original declaration : Our guidelines including this presentation are prepared in accordance with original K/DOQI guidelines, Renal Association and UKCKD guidelines which are dependant upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care, and should not be construed as doing so. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice.
CKD facts Prevalence exponentially with age; diabetes (Type 2 DM--25% CKD stage 3) and vascular disease Late referral; significant extra cost and poor clinical outcomes Progression of CKD Majority don t Risk of cardiovascular disease Risk of death outweighs the risk of progression
W h ich G F R value w hen s Creat = 80 µm ol/l? S Creat (? mol/l) < 65 yrs > 65 yrs Froissart, Rev Prat, 55: 2223, 2005 Measured GFR (ml/min/1.73m 2 )
Conditions in w h ich G F R should be m easured w ith an exogenous tracer Levey et al, Kidney Int, 67: 2089-2100, 2005
Burden to our region? All CKD 10% - 200,000 CKD stage 3 & > 5% - 100,000 11 Nephrologists CKD 3 & > - 9090 patients/nephrologist!! CKD 4&5 (0.4%) 727/Nephrologist
Resources No. of dialysis patients No. of CKD F.U.s Nurses-dialysing nurses, other nurses Dietician Pharmacist
Why this session? To increase awareness and understanding To exchange the views
What to do?
egfr > 60 no kidney disease Unless Proteinuria, haematuria abnormality on images Refer if: Malignant HBP Nephrotic syndrome Systemic illness e.g. vasculitis Structural abnormality on USS, e.g. Polycystic kidney disease. Or??? Management: Dipstick urine when visiting surgery next time 12 monthly review of BP, Dipstick urine and egfr Refer : if proteinuria, fall in egfr or other indications as in CKD 3
e-gfr 30 59 Stable Acutely ill Treat illness (?ARF) Repeat egfr in 1 week Refer if in s.cr>30% or in egfr>20% Previous s.creatinine NO YES
e-gfr 30 59 Stable Acutely ill Previous s.creatinine NO YES Check list: Illness-CHF, sepsis, dry, drugs, bladder symptoms, Repeat in 5 days-dipstick urine If no major change repeat in 1 month Refer : if fall in e-gfr>15% or other criteria met for CKD stage 3
e-gfr 30 59 Stable Acutely ill Previous s.creatinine NO YES in s.cr>20% Yes- Refer No- equivalent stable s.cr - CKD management programme or Refer if other criteria met according to management guidelines
e-gfr 30 59 Stable Acutely ill Previous s.creatinine Treat illness (?ARF) Repeat egfr in 1 week Refer if in s.cr>30% or in egfr>20% NO YES Check list: Illness-CHF, sepsis, dry, drugs, bladder symptoms, dipstick urine Repeat in 5 days in s.cr>20% If no major change repeat in 1 month Refer : if fall in e-gfr>15% or other criteria met for CKD stage 3 Yes- Refer No- equivalent stable s.cr - CKD management programme or Refer if other criteria met according to management guidelines
Dipstick Urine If available (&& ACR- checked twice ) If unavailable Send ACR if protein + or more Send MSSU Do not recall patient Organise dipstick test with next blood tests.*** send for ACR if protein + or more Refer: if ACR (Albumin Creatinine Ratio) > 60mg/mmol, Microscopic haematuria + proteinuria (ACR>45mg/mmol) Send MSSU
Microscopic haematuria CKD 1 and 2 Isolated microscopic haematuria -urology referral. No referral to Nephrologist-CKD management programme Refer -Associated with proteinuria (ACR>45mg/mmol on 2 occasions after excluding infection) CKD stage 3- Refer exclude urological cause in >50
Proteinuria Treat the cause if obvious e.g. Diabetes, Hypertension, ACEI and or ARB Independent and strong risk factor for progression Monitoring-ACR (Albumin Creatinine Ratio) Refer if ACR >60mg/mmol (without haematuria) or >45mg/mmol (with haematuria)
Management of CKD Stage 3 CKD management programme General Measures Weight reduction Exercise Smoking cessation (Nurse/ dietician) Influenza and Pneumococcal vaccine Drugs- HBP British Hypertensive Society guidelines, Refer if refractory high blood pressure Diabetes separate flow chart Lipids British Joint Society Guidelines Aspirin and Statins Vasculature.
Management of CKD Stage 3 CKD management programme Specific Measures Check annually ( six monthly for newly diagnosed or progressive) egfr (Refer if fall >15% or rise in s.cr >20% over 6-12 months or longer) Serum Potassium (K+) Refer if greater than 6.0 mmol Serum Calcium (Ca++) Refer if less than 2.1 mmol Serum Phosphate (Pi) Refer if greater than 1.5 mmol Haemoglobin (Hb) Refer if less than 10 gram % ( Check Haematinics including Iron levels? I V Iron. EPO funding only available for CKD stage 4 and 5.) ACR if dipstick positive as above- Refer if. USS scan of Kidneys- If deterioration of renal functions due to ACEI or ARB, Urinary tract symptoms, episodes of LVF with normal Echo Refer
CKD Stage 4 egfr 26-29 3 monthly egfr initially, if stable 6 monthly 6 monthly other parameters as in CKD 3 S. Bicarbonate refer if<22 S.PTH refer if >7.7 renal tract USS Ongoing management as in CKD stage 3 Refer if egfr Fall > 15% or Abnormal parameters or Diabetics egfr < 25 Refer all
CKD Stage 5 Refer ALL Planned management with Nephrologist Annual egfr for 1 st degree relatives of all CKD stage 5 patients (voluntary -? Insurance implications)
Anaemia Risk factor for LVH Quality of life
Anaemia egfr<60 Hb<11 Haematinics: Indices, retics; B12, Folate, Ferritin levels, Fe, TIBC, TSAT Abnormal yes Fe deficiency- yes Exclude GI bleeding Treat with iron, (?IV) No Refer for haematology work up No EPO if indicated (Management protocol) Funding? Refer-if Hb<10.0
Bone management Vitamin D deficiency Hyperparathyroidism Monitoring: CKD stage 3» Refer-s.ca++-<2.1» S.phosphate->1.5 CKD stage 4- (egfr 26-29)» s.ca++ s.phosphates.pth- refer if >7.7
Dialysis patients HBP related to fluid status and dialysis prescription requires more nephrologist s input Dipstick urine (if passes urine) if tested haematuria, proteinuria and glycosuria common. Drugs- Other co morbidities in Dialysis patients: Diabetes: Social aspect: Psychological support:
Other population group: Elderly Aging Kidney Bear in mind-no correction factor Functions deteriorate 1ml/mt/yr after the age 20-30 70 year old egfr 50!
Other population Group: Chronic Heart Failure Stage 3 Anaemia Iron EPO
Other population group: Diabetics Referral criteria same as non diabetics Except all CKD stage 4 to be referred Metformin-Not much of evidence more of experience Caution if egfr between 45 and 60 Half dose if egfr between 30 and 45 Avoid if egfr <30 EXTRA caution or STOP if dehydration NSAIDS, sepsis or other intercurrent illness
Immediate/Urgent Referrals ARF-inpatient Immediate Malignant HBP» S.Potassium>7.0 Nephrotic Syndrome ACR >300mg/mmol New advanced kidney failure egfr<15 Multisystem disease lupus, vasulitis
CKD facts Progression is associated with proteinuria and uncontrolled hypertension Optimal management of the risk factors for cardiovascular disease also reduces the risk of progression from early CKD to ERF
High risk of ESRD Proteinuria Severe hypertension Family history of ESRD Poorly controlled diabetics Glomerulonephritis
Drugs-CAUTION NSAIDs- ACEI and ARB- Metformin- Trimethoprim-caution if egfr<60 tubular effect,» s.ptassium» s. creatinine Spironolactone- caution if egfr<60» s.ptassium»arf»stop if dehydaration, NSAIDs, Severe Sepsis
egfr Review
Referral Information egfr 2 measurements if not available 2 consecutive latest s.cr and at least one egfr with dates Previous results of S.Creatinine with dates if available BP Dipstick urine with ACR results (minimum 2) Past Medical History Drug History PROFORMA
Helpline: Website: www.merseyrenalunits.nhs.uk and www.aintreerenalunit.nhs.uk Other links Contact e-mail:renal.unit@aintree.nhs.uk Courses Renal Units contacts: CKD Nurse -RLUH Consultants or SpR-Aintree
Thank You