Section 6: Management in primary care Particular emphasis on nurse practitioner’s role

Effects of age on eGFR The “normal” eGFR is age-related In normal “healthy” individuals, the eGFR will fall by one percent for every year after 40 years of age An 80 year old man will have an expected eGFR of 50-60 ml/min Not all patients with reduced eGFR need active management

% % subjects with CKD stage 3 by age and gender East Kent Data 70 50 30 10 <45 45-54 55-64 65-74 75-84 >85 Age bands de Lusignan et al 2005

“Normal” inulin GFR declines with age EDTA F 150 CKD Stage 1 CKD 2 CKD 3 CKD 4 CKD 5 100 50 20 30 40 50 60 70 80 90

Which individuals with abnormal eGFR should we to worry about? Those with very poor function for age Those with deteriorating function Those who may have reversible/treatable cause (unexplained proteinuria/haematuria) Those with functional consequences of CKD (anaemia, renal bone disease, persistent hyperkalaemia)

2008 NICE guidance for CKD – focus on vascular risk Lifestyle modification Attention to known CV risk factors smoking statins for secondary prevention regardless of lipid level Anti-platelet drugs for secondary prevention Medicines management BP targets

NICE 2008: recommendations for BP control in CKD No diabetes or proteinuria 120-140/70-90 Diabetes or ACR>30 120-130/70-80

NICE 2008: Diagnosis of CKD Proteinuria=ACR>30 or PCR>50 (NOT dipstick) 3 eGFR estimations <60 over a period not less than 90 days Progressive decline defined as eGFR falling by >5mls/min/year Focus on those whose observed rate of decline would necessitate RRT ‘within their lifetime’

NICE: 2008 Classification of CKD waking up to the impact of proteinuria Stage 1: GFR>90 + abnormal urinalysis Stage 2: GFR 60-89 + abnormal urinalysis Stage 3A: GFR 45-59 Stage 3B: GFR 30-44 Stage 4: GFR 15-29 Stage 5: GFR <15 or dialysis dependent Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)

QOF indicators for CKD 2009 6 40-90% 11 40-70% 4 40-80% Register of patients over 18 with CKD 3-5 6 Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months 40-90% Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less 11 40-70% Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded) 4 40-80% Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months

Monitoring of CKD Each assessment should include Review of symptoms and fluid status Blood pressure Medication review (metformin, NSAIDs) Urine ACR or PCR Blood test for renal and bone status FBC in advanced CKD

Frequency of monitoring Newly diagnosed Stable Stage 3 6/12 annual Stage 4 3/12 Stage 5

What data is required for effective referral? Current creatinine and eGFR Previous creatinines (tracing back to last normal) Blood pressures (recent and historical) Urine dip for blood, ACR/PCR FBC, Ca, Pi Renal US only if :- stage 4 resistant HT lower tract symptoms