Everything you Everything you wanted to know wanted to know

about CKDabout CKDSUE GILDERSLEVESUE GILDERSLEVE

RENAL NURSERENAL NURSE

SPECISLISTSPECISLIST

eGFR

eGFR

CKD NSFCKD NSF►Part 1 launched January 2004Part 1 launched January 2004

Dialysis and transplantationDialysis and transplantation

►Part 2 launched February 2005Part 2 launched February 2005 Chronic kidney diseaseChronic kidney disease Acute renal failureAcute renal failure End of life care End of life care

eGFRGood things about NSFGood things about NSF

Raised profile of chronic kidney diseaseRaised profile of chronic kidney disease Opportunity for education of primary care Opportunity for education of primary care

teamsteams Promotes the use of eGFRPromotes the use of eGFR Improve management particularly blood Improve management particularly blood

pressure controlpressure control Reduce morbidity and mortalityReduce morbidity and mortality Promote appropriate referralsPromote appropriate referrals

eGFR

Problems since NSFProblems since NSF Confusion re eGFR resultsConfusion re eGFR results Concern at high prevalenceConcern at high prevalence Confusion re use of ACE-I and ARBConfusion re use of ACE-I and ARB Confusion over urinary Confusion over urinary

albumincreatinine resultsalbumincreatinine results Increase in inappropriate referralsIncrease in inappropriate referrals Raised patient anxietyRaised patient anxiety

eGFR

Known CKD <1% of

population

Unrecognised CKD

10% of population

eGFR

►0.05% of UK population on dialysis or 0.05% of UK population on dialysis or with a kidney transplant with a kidney transplant (1 in 2000)(1 in 2000)

►1-2% of NHS budget1-2% of NHS budget►£25-30,000 per dialysis patient per year£25-30,000 per dialysis patient per year

Preventing 33 cases of established Preventing 33 cases of established renal failure per year saves ~£1m per renal failure per year saves ~£1m per annumannum

eGFR

Incident Counts & Adjusted Rates, Incident Counts & Adjusted Rates, By Primary DiagnosisBy Primary Diagnosis

eGFR

GMS ContractGMS Contract►ChKD 1: The practice can produce a ChKD 1: The practice can produce a

register of patients aged 18 years and over register of patients aged 18 years and over with ChKD (US NKF Stage 3-5) 6 pointswith ChKD (US NKF Stage 3-5) 6 points

►ChKD 2: The percentage of patients on the ChKD 2: The percentage of patients on the ChKD register whose notes have a record ChKD register whose notes have a record of blood pressure in the past 15 months of blood pressure in the past 15 months (40-90%) 6 points(40-90%) 6 points

eGFR

►ChKD 3: The % of patients on the ChKD ChKD 3: The % of patients on the ChKD register in whom the last blood register in whom the last blood pressure reading, measured in the pressure reading, measured in the previous 15 months is 140/85 or less previous 15 months is 140/85 or less (40-70%) 11 points(40-70%) 11 points

►ChKD4: The % of patients on the ChKD ChKD4: The % of patients on the ChKD register who are treated with an ACEi register who are treated with an ACEi or ARB (unless contra-indication or side or ARB (unless contra-indication or side effects are recorded) (40-80%) 4 pointseffects are recorded) (40-80%) 4 points

eGFR

Assessment chronic kidney Assessment chronic kidney diseasedisease

►Assessment of severity of CKD is Assessment of severity of CKD is more accurate when based on more accurate when based on eGFR rather than plasma creatinine eGFR rather than plasma creatinine (Renal NSF 2005) (Renal NSF 2005)

►eGFR takes into account creatinine, eGFR takes into account creatinine, age and sex using the MDRD age and sex using the MDRD equation(equation(MModification of odification of DDiet in iet in RRenal enal DDisease study)isease study)

eGFR

Estimating the GFR (the MDRD ‘eGFR’ equation)

• Only requires age, sex and blood creatinine level to automatically calculate eGFR

• Can be automatically generated by pathology laboratories, online or spreadsheet calculators, or by using reference tables

• Allows direct lab reporting to clinicians of estimated GFR

Estimated GFR (eGFR) =

186 x (creatinineplasma)- 1.154 x (age)- 0.203

x 0.742 if femalex 1.21 if Afro-Caribbean

eGFR

Glomerular Filtration RateGlomerular Filtration Rate►Sum of all nephron Sum of all nephron

filtration ratesfiltration rates►Best index of overall Best index of overall

functionfunction►Reduction implies a Reduction implies a

problemproblem►Translatable conceptTranslatable concept►Equates to percentage Equates to percentage

Kidney functionKidney function

eGFR

Problems with plasma creatinineProblems with plasma creatinine

Plasma creatinine determined by muscle mass as well as renal function

Normal plasma creatinine higher in:

Males vs Females

Younger vs Older

Afro-Caribbeans vs Others

eGFR

Creatinine 200umol/LCreatinine 200umol/L

eGFR 55ml/min

eGFR 5ml/min

eGFR

Influencing factors on Influencing factors on eGFReGFR

►Obesity no effect Obesity no effect ►Big muscle mass Big muscle mass creat creat eGFReGFR►Muscle wasting Muscle wasting creat creat eGFReGFR►Large meat intake Large meat intake creat creat eGFReGFR►Vegetarian Vegetarian creat creat eGFReGFR►Drugs Trimethoprin & Cimetidine Drugs Trimethoprin & Cimetidine creat creat eGFReGFR

eGFR

Chronic Kidney Disease StagesChronic Kidney Disease Stages::

Stage 1 – GFR > 90 ml/min. No kidney Stage 1 – GFR > 90 ml/min. No kidney damagedamage

Stage 2 – GFR 60 – 90 ml/min. Evidence of Stage 2 – GFR 60 – 90 ml/min. Evidence of kidney damagekidney damage

Stage 3a– GFR 45 – 60 ml/minStage 3a– GFR 45 – 60 ml/min

Stage 3b – GFR 30 - 45 ml/min Stage 3b – GFR 30 - 45 ml/min

Stage 4 – GFR 15 – 30 ml/min Stage 4 – GFR 15 – 30 ml/min

Stage 5 – Established renal failure (GFR Stage 5 – Established renal failure (GFR <15)<15)

eGFR

Stage 3 is now divided into 2 groups 3A and 3B

3A lower risk eGFR 45-59

3B higher risk eGFR 30-44

2 occasions over minimum 3 month period

eGFR

Feb 2007 Improving classification Dipstick test for proteinuria

If positive then quantify using PCR Protien Creatinine RatioThose with Proteinuria have higher risk and are classified with the addition of suffix “p” ie 2p 3Ap 4p

eGFR

MicroalbuminuriaMicroalbuminuria►Is the first marker of diabetic Is the first marker of diabetic

nephropathynephropathy►Early detection and treatment can Early detection and treatment can

delay or prevent progression to delay or prevent progression to ESRDESRD

►Valuable marker of CV risk in T2DMValuable marker of CV risk in T2DM►All patients with diabetes should be All patients with diabetes should be

screened annuallyscreened annually

eGFR

►Ratio of albumin to creatinine in Ratio of albumin to creatinine in single urine sample (Early single urine sample (Early morning) morning)

►Test only in absence of urinary Test only in absence of urinary tract infectiontract infection

►2 out of 3 +ve tests indicate need 2 out of 3 +ve tests indicate need for treatmentfor treatment

eGFR

Meaning of results

+ve > 2.5 mg/mmol in men +ve > 3.5 mg/mmol in women

eGFR

►Unable to calculate result with Unable to calculate result with urine urine microalbuminuriamicroalbuminuria <3 means <3 means negativenegative

►Unable to calculate with Unable to calculate with urine urine microalbuminuriamicroalbuminuria >100mg/l, >100mg/l, comments will be:- suggestive of comments will be:- suggestive of proteinuria. Protein level to followproteinuria. Protein level to follow

►Results can be high in people who Results can be high in people who exercise heavily, avoid testing after exercise heavily, avoid testing after heavy exercise if you suspect this may heavy exercise if you suspect this may be the casebe the case

eGFR

Microalbuminuria Then monitor yearly for regression or

progression Microalbuminuria is likely progress to

proteinuria, unless well managed Microalbuminuria is reversible Established Proteinuria is NOT

reversible If a person has proteinuria then testing

for microalbuminuria is of NO VALUE

eGFR

ProteinuriaProteinuria►24 hr protein estimations are no 24 hr protein estimations are no

longer requiredlonger required►Protein creatinine ratio can be Protein creatinine ratio can be

measured in an early morning urine measured in an early morning urine samplesample

►This x 10 gives daily protein excretionThis x 10 gives daily protein excretion►I.e. PCR = 100mg/mmol x 10 = I.e. PCR = 100mg/mmol x 10 =

1000mg= 1g1000mg= 1g

eGFR

►It is anticipated that most patients with an It is anticipated that most patients with an eGFR less than 30 ml/min will be managed eGFR less than 30 ml/min will be managed primarily by secondary care in primarily by secondary care in collaboration with primary care colleagues. collaboration with primary care colleagues. Lesser degrees of renal impairment will be Lesser degrees of renal impairment will be managed in primary care with guidance managed in primary care with guidance and protocols from secondary care. and protocols from secondary care.

Web address for eGFR calculator:Web address for eGFR calculator:

http://www.nkdep.nih.gov/professionals/gfr_calculators/mdrd_si.htm

eGFR

Why is CKD Stage 3 Why is CKD Stage 3 important:important:Stage 3A eGFR 45-59 ml/min indicates only

slight increased CV risk

Stage 3B eGFR 30-44 is associated with x5 increase in CV risk

This is very similar to patients with a previous history of myocardial infarction.

p=proteinuria further doubles current risk ie stage 3Bp

eGFR

eGFRPatients with CKD are more Patients with CKD are more

likely to die than require likely to die than require dialysisdialysis

StageStage GFR GFR (ml/min)(ml/min)

RRTRRT DeathDeath

22 60-8960-89 1.1%1.1% 19.5%19.5%

33 30-5930-59 1.3%1.3% 24.3%24.3%

44 15-2915-29 19.9%19.9% 45.7%45.7%

27,998 CKD patients followed for 5 years:

Keith DS, AIM 2004;164:659-663

eGFR

eGFR

Why is hypertension important?Why is hypertension important?►Control of HypertensionControl of Hypertension

Reduces or halts eGFR declineReduces or halts eGFR decline Control reduces risk of Control reduces risk of

cardiovascular diseasecardiovascular disease

Just as effective in the elderlyJust as effective in the elderly Most of the projected increase in Most of the projected increase in

dialysis is amongst the elderlydialysis is amongst the elderly

eGFR

Practical guidance:Practical guidance:

►Refer all patients with CKD Stage Refer all patients with CKD Stage 4 and 54 and 5

►Consider referral of Stage 3 if:Consider referral of Stage 3 if:

eGFR

Stage 3 Practical Stage 3 Practical management:management:

After excluding acute cause of After excluding acute cause of decline, refer if: decline, refer if: Younger (<55 years)Younger (<55 years) Protein 2+ or more (dipstick; Protein 2+ or more (dipstick;

PCR.100mg/mmol)PCR.100mg/mmol) GFR has fallen by more than 10 GFR has fallen by more than 10

ml/min in 1 yearml/min in 1 year Haematuria – refer urologyHaematuria – refer urology

eGFRAcute deterioration of renal Acute deterioration of renal

functionfunctionConsider possible causes for deterioration:Consider possible causes for deterioration:►Prescribed and non prescribed drugs are Prescribed and non prescribed drugs are

responsible for up to 30% of acute renal responsible for up to 30% of acute renal failurefailure

►Recent introduction of ACE/ARB allow Recent introduction of ACE/ARB allow rise of up to 30% creatinine or fall of up rise of up to 30% creatinine or fall of up to 20% eGFRto 20% eGFR

►NSAID’s or other nephrotoxic drugs NSAID’s or other nephrotoxic drugs including penicillin (gentamycin) and including penicillin (gentamycin) and chinese herbal remedies chinese herbal remedies

eGFR

►Bladder outflow obstruction (any urinary Bladder outflow obstruction (any urinary symptoms?) may need renal US symptoms?) may need renal US

►Check diuretic dose. Consider reducing or Check diuretic dose. Consider reducing or stopping diuretic if no longer needed stopping diuretic if no longer needed (check ankles, JVP, postural hypotension (check ankles, JVP, postural hypotension and any other symptoms of overload or and any other symptoms of overload or dehydration) Has diabetes been poorly dehydration) Has diabetes been poorly controlled lately?controlled lately?

►Recent angiogram? Nephrotoxic Recent angiogram? Nephrotoxic dye/contrastdye/contrast

eGFR

Stage 3 Practical Management (if not Stage 3 Practical Management (if not referred)referred) Repeat dipstick or PCR - 3A annually Repeat dipstick or PCR - 3A annually

and 3B 6monthlyand 3B 6monthly Repeat creatinine, potassium, Ca/PORepeat creatinine, potassium, Ca/PO44, ,

Hb annuallyHb annually Monitor BP annually if stable (aim Monitor BP annually if stable (aim

<130/80 or 120/70 mmHg? if <130/80 or 120/70 mmHg? if progressive proteinuria)progressive proteinuria)

Recent data suggests optimal BP is Recent data suggests optimal BP is around 132/70 as low BP can reduce around 132/70 as low BP can reduce perfusion of major organsperfusion of major organs

eGFR

VaccinationsVaccinations Smoking cessation, weight Smoking cessation, weight

reduction, low salt dietreduction, low salt diet USS renal tract only if:USS renal tract only if:

►Fall in eGFRFall in eGFR►HaematuriaHaematuria►Resistant hypertensionResistant hypertension►Bladder outflow symptomsBladder outflow symptoms

eGFR

Stage 3 and DIABETESStage 3 and DIABETES As before plusAs before plus Microalbuminuria / ACRMicroalbuminuria / ACR ACEi or ARB – ACEi or ARB – creatinine can rise up creatinine can rise up

to 30%to 30% ACEi/ARB need NOT be stopped ACEi/ARB need NOT be stopped

unless potassium rises >6.0 ( could unless potassium rises >6.0 ( could try low K+ diet before stopping) try low K+ diet before stopping)

Consider stopping potassium Consider stopping potassium sparing diuretics BEFORE sparing diuretics BEFORE introducing ACEi/ARBintroducing ACEi/ARB

eGFR

Primary prevention of Primary prevention of nephropathy in diabeticsnephropathy in diabetics

► Control BP aiming for <130/70Control BP aiming for <130/70► Improve glycaemic control aim Improve glycaemic control aim

for Hba1c 6.5-7.5% recent data for Hba1c 6.5-7.5% recent data also indicates too low can be as also indicates too low can be as bad as too highbad as too high

eGFR

Type 1 DiabetesType 1 Diabetes

►1/31/3rdrd all Type 1 DM develop all Type 1 DM develop diabetic renal diseasediabetic renal disease

►Reach stage 3 approx 10yrs after Reach stage 3 approx 10yrs after diagnosisdiagnosis

►After 20yrs they will have After 20yrs they will have progressed to overt diabetic progressed to overt diabetic nephropathynephropathy

eGFR

Type 2 DiabetesType 2 Diabetes

►Type 2 DM follow a similar Type 2 DM follow a similar pattern though are not generally pattern though are not generally diagnosed until middle agediagnosed until middle age

►Type 2 diabetics with diabetic Type 2 diabetics with diabetic nephropathy often present with nephropathy often present with microalbuminuria and microalbuminuria and hypertensionhypertension

eGFR

Diabetic NephropathyDiabetic Nephropathy►Diabetic nephropathy is Diabetic nephropathy is

progressiveprogressive►Good BP control reduces the Good BP control reduces the

decline in eGFR from 12ml/min decline in eGFR from 12ml/min per year to 5ml/min per yearper year to 5ml/min per year

►ACEi/ARB may reduce this further ACEi/ARB may reduce this further to as little as 0.3ml/min per yearto as little as 0.3ml/min per year

►Correct dyslipidaemiaCorrect dyslipidaemia

eGFR

WHY ACEi or ARB?WHY ACEi or ARB?►Management of nephropathy centres Management of nephropathy centres

on aggressive treatment of BPon aggressive treatment of BP►Inhibition of renin-angiotensin systemInhibition of renin-angiotensin system►Studies show that they reduce Studies show that they reduce

intraglomerular pressure over and intraglomerular pressure over and above their effect on systemic BPabove their effect on systemic BP

►They have been shown to reverse They have been shown to reverse microalbuminuria, reduce proteinuria microalbuminuria, reduce proteinuria and reduce the rate of decline in eGFRand reduce the rate of decline in eGFR

eGFR

DUAL BLOCKADE COMBINING DUAL BLOCKADE COMBINING ACEi AND ARBACEi AND ARB

►Can be used for further control of Can be used for further control of Hypertension if other options exhaustedHypertension if other options exhausted

►Used to reduce high levels of proteinuriaUsed to reduce high levels of proteinuria►Angiotensin II can be produced by non Angiotensin II can be produced by non

ACE pathwaysACE pathways►This has been described as the ‘ACE This has been described as the ‘ACE

escape’escape’►ARB blocks the ‘ACE escape’ ARB blocks the ‘ACE escape’

eGFR

►Cooperate study looked at dual Cooperate study looked at dual blockade in non diabetic patients, blockade in non diabetic patients, this showed a significant benefit this showed a significant benefit in dual therapyin dual therapy

►Combination may have additive Combination may have additive effects in slowing progressioneffects in slowing progression

►More study is required in DMMore study is required in DM

eGFR

Difficult to treat Difficult to treat hypertensionhypertension

►Non complianceNon compliance►White coat hypertensionWhite coat hypertension►Fluid imbalanceFluid imbalance►High salt dietHigh salt diet►Renal artery stenosisRenal artery stenosis

eGFR

Early Treatment Makes Early Treatment Makes a Differencea Difference