Cardiovascular Hot topics ‘CKD’ Dr Saqib Mahmud MBBS, MD, MRCP(UK), MRCPS(Glasg), MRCGP

CKD The introduction of routine reporting of The introduction of routine reporting of eGFR has led to 3 outcomes in primary care; ‘Worried patients, Increased workload ‘Worried patients, Increased workload & confused clinicians’.BMJ2006 & confused clinicians’.BMJ2006 (Referral rates remain high due to uncertainty how to manage newly diagnosed CKD cases)

Why has CKD been selected as a quality indicator?QOF Patients with CKD have very high rates of vascular disease & require aggressive management of vascular risk factors. (early CKD risk of death from CVD>ESRF)-low GFR predicts CV disease Patients with CKD have very high rates of vascular disease & require aggressive management of vascular risk factors. (early CKD risk of death from CVD>ESRF)-low GFR predicts CV disease Its incidence is rising dramatically. (doubled in last 10yrs,5% adult population) Its incidence is rising dramatically. (doubled in last 10yrs,5% adult population) S Cr does not rise until GFR has fallen by % S Cr does not rise until GFR has fallen by % Early interventions in CKD improve cardiac & renal outcomes Early interventions in CKD improve cardiac & renal outcomes

eGFR- best estimate of renal function Based on S Cr, age, sex & ethnic origin. Based on S Cr, age, sex & ethnic origin. Does not apply to children, ARF, pregnant women, oedematous & malnourished. Does not apply to children, ARF, pregnant women, oedematous & malnourished. eGFR falls after eating meat, ideally fasting sample or avoid eating cooked meat day before. eGFR falls after eating meat, ideally fasting sample or avoid eating cooked meat day before. CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFR CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFR

CKD-classification CKD stage eGFR 1 Kidney damage, normal eGFR >90 2 Kidney damage, reduced eGFR Moderate CKD Severe CKD ESRF <15 or on dialysis

Clinical Signs & Symptoms Tiredness Tiredness Anorexia, nausea, vomiting Anorexia, nausea, vomiting Generalized pruritis Generalized pruritis Nocturia, frequency, oliguria, haematuria Nocturia, frequency, oliguria, haematuria Frothy urine Frothy urine Loin pain Loin pain Pallor, peripheral & pulmonary oedema Pallor, peripheral & pulmonary oedema Pleural effusion & SOB Pleural effusion & SOB leuconychia leuconychia

QOF 2006 – CKD register CKD1- register of pts>18 with CKD3-5 CKD1- register of pts>18 with CKD3-5 CKD2-(90%) on register with record of BP in last 15/12 CKD2-(90%) on register with record of BP in last 15/12 CKD3-(70%) on register with BP<140/85 CKD3-(70%) on register with BP<140/85 CKD4-(80%) patients on ACEI/A2RB-or CI CKD4-(80%) patients on ACEI/A2RB-or CI Worth 27pts=£3,364/- Worth 27pts=£3,364/-

Conditions with risk of developing CKD Hypertension Hypertension Diabetes Diabetes Heart failure Heart failure Vascular disease Vascular disease Urinary outflow obstruction Urinary outflow obstruction Multi-system diseases eg;RA, SLE, vasculitis Multi-system diseases eg;RA, SLE, vasculitis APKD or reflux nephropathy APKD or reflux nephropathy Long term Drugs- lithium, cyclosporin,NSAIDs,mesalazine Long term Drugs- lithium, cyclosporin,NSAIDs,mesalazine

Monitoring renal function Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, microalbuminuria, haematuria without urological cause or known polycystic kidney disease or GN. (Annual U & Es) Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, microalbuminuria, haematuria without urological cause or known polycystic kidney disease or GN. (Annual U & Es) Stage 3  6/12 Stage 3  6/12 Stages 4 & 5  3/12 Stages 4 & 5  3/12

Urine tests Dipstick urinalysis for protein, Dipstick urinalysis for protein, If +ve  msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45) If +ve  msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45) In diabetics, dipstick negative  ACR for microalbuminuria (+>2.5mg/mmol- males,>3.5 in women) In diabetics, dipstick negative  ACR for microalbuminuria (+>2.5mg/mmol- males,>3.5 in women)

Management – is easy ‘CKD rarely means dialysis’ ‘CKD rarely means dialysis’ Monitor renal function closely- assess rate of change Monitor renal function closely- assess rate of change Tight BP control with preferential use of ACEI or A2RB Tight BP control with preferential use of ACEI or A2RB Pay close attention to CV risk Pay close attention to CV risk

New patient with eGFR<60 Review previous results ?rate of deterioration Review previous results ?rate of deterioration Review medication ?nephrotoxicity Review medication ?nephrotoxicity Check BP, urine, full clinical assessment eg ?palpable bladder Check BP, urine, full clinical assessment eg ?palpable bladder Repeat U&E within 5/7 (?rapid progression) Repeat U&E within 5/7 (?rapid progression) Referral criteria- renal function stable  monitor Referral criteria- renal function stable  monitor Stage 4(if stable, monitor) & 5 should be referred Stage 4(if stable, monitor) & 5 should be referred Stage 3 if deteriorating function Stage 3 if deteriorating function

Long term management to delay progression and reduce CV events Life style advise  smoking cessation, wt reduction, exercise, low protein diet Life style advise  smoking cessation, wt reduction, exercise, low protein diet Aspirins & statins if CVD risk 15-20% Aspirins & statins if CVD risk 15-20% (evidence is that all CKD patients are high risk) (evidence is that all CKD patients are high risk) Strict BP control-QOF2 target <140/85, but renal guidelines best practice target is 130/80 - UK CKD&JBS2 guidelines. Strict BP control-QOF2 target <140/85, but renal guidelines best practice target is 130/80 - UK CKD&JBS2 guidelines. Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBs Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBs Aspirin->BP BP<150/90, target TC<4,LDL<2

Additional management-CKD3 Renal USS if LUTS, refractory HTN, unexpected fall in GFR Immunise-influenza, pneumococcus, Hep B in CKD4&5 If HB<11-exclude other causes, refer for ESA, iv Fe

Renal osteodystrophy Renal failure  failure of Vit D hydroxylation  secondary hyperparathyroidism Renal failure  failure of Vit D hydroxylation  secondary hyperparathyroidism  increased # risk due to faulty bone remodelling & lowered BMD.  increased # risk due to faulty bone remodelling & lowered BMD. Check PTH levels, if low check 25-hydroxy Vit D levels Check PTH levels, if low check 25-hydroxy Vit D levels Rx- ergo or colecalciferol with calcium/bisphosphonates Rx- ergo or colecalciferol with calcium/bisphosphonates

Bone disease in CKD Recent Irish study found 76% of osteoporosis cases in CKD patients Recent Irish study found 76% of osteoporosis cases in CKD patients Patients with CKD 4&5 had significantly lower BMD at hip & spine + high bone turnover Patients with CKD 4&5 had significantly lower BMD at hip & spine + high bone turnover 2 fold increased risk of vertebral fractures 2 fold increased risk of vertebral fractures Statins - known to have beneficial effect in prevention of osteoporosis as well as decreased incidence of sepsis in CKD! Statins - known to have beneficial effect in prevention of osteoporosis as well as decreased incidence of sepsis in CKD!

ACEI / A2RB- Rx or the cause ACEI/A2RBs improve outcomes but in some patients can be nephrotoxic ACEI/A2RBs improve outcomes but in some patients can be nephrotoxic A slight reduction in GFR ( 30% A slight reduction in GFR ( 30% Heart failure-rise in CR upto 50% baseline or 200umol/l is acceptable-(NICE) Heart failure-rise in CR upto 50% baseline or 200umol/l is acceptable-(NICE)

Renal artery stenosis GFR- difference b/w flow of blood into glomeruli via afferent arteriole & flow out via efferent arteriole GFR- difference b/w flow of blood into glomeruli via afferent arteriole & flow out via efferent arteriole This is not dependent on AT II normally but kidneys can increase GFR by local production of AT II which vasoconstricts efferent arteriole This is not dependent on AT II normally but kidneys can increase GFR by local production of AT II which vasoconstricts efferent arteriole In -GFR is dependent on AT II mediated efferent arteriole vasoconstriction In RAS-GFR is dependent on AT II mediated efferent arteriole vasoconstriction

Renin- Angiotensin system

RAS-cont RAS is likely if rise in S Cr in absence of significant drop in BP RAS is likely if rise in S Cr in absence of significant drop in BP ‘Flash pulmonary oedema’-bilateral RAS predisposes to episodic catastrophic pulmonary oedema-often misdiagnosed as LVF until ACEI Rx causes rapid rise in S Cr ‘Flash pulmonary oedema’-bilateral RAS predisposes to episodic catastrophic pulmonary oedema-often misdiagnosed as LVF until ACEI Rx causes rapid rise in S Cr Renal function usually reverts to baseline on stopping ACEI Renal function usually reverts to baseline on stopping ACEI Small kidneys in Renal USS-strong indicator Small kidneys in Renal USS-strong indicator

RAS-cont

Rx in RAS Ca channel blockers (dihydropyridines)- Rx of choice in RAS Ca channel blockers (dihydropyridines)- Rx of choice in RAS Also indicated when ACE Is are not tolerated Also indicated when ACE Is are not tolerated Targeting BP lowering aggressive is more important than choice of Rx- ALHAT study Targeting BP lowering aggressive is more important than choice of Rx- ALHAT study

Prescribing in CKD Avoid NSAIDs, codeine Avoid NSAIDs, codeine Withold ACEIs in hypovolaemic states-gastroenteritis etc Withold ACEIs in hypovolaemic states-gastroenteritis etc Antibiotics, digoxin, metformin etc – Antibiotics, digoxin, metformin etc – ‘use with caution’ ‘use with caution’ (reduce dose or frequency) (reduce dose or frequency)

What about elderly patients with low eGFR- how should we manage them? The guideline makes no age distinctions The guideline makes no age distinctions BMJ2006;it is ageist not to Rx CKD just because someone is elderly. BMJ2006;it is ageist not to Rx CKD just because someone is elderly. BJGP editorial Dec2006;elderly with CKD still benefit from CV risk factor intervention and strict BP control in elderly slows rate of renal decline BJGP editorial Dec2006;elderly with CKD still benefit from CV risk factor intervention and strict BP control in elderly slows rate of renal decline Use clinical judgement & patient circumstances Use clinical judgement & patient circumstances

Key points….. CKD patients have high risks of CV events & so CVD prevention should be fundamental to the management of CKD CKD patients have high risks of CV events & so CVD prevention should be fundamental to the management of CKD Risk of ESRF is very low (ckd3-1.1%:24.3% CV death-5yr) Risk of ESRF is very low (ckd3-1.1%:24.3% CV death-5yr) Best practice target BP is 130/80 with preferential use of ACEI / A2RB Best practice target BP is 130/80 with preferential use of ACEI / A2RB Consider aspirin and statins Consider aspirin and statins Life style advise & low protein diet Life style advise & low protein diet Consider Bisphosphonates & Ca for CKD assoc bone disease Consider Bisphosphonates & Ca for CKD assoc bone disease ACEIs not necessary for all CKD pts ACEIs not necessary for all CKD pts

Thank you- questions ??? ‘The enemy of good ‘The enemy of good is better’