The management of renal problems in primary care Hugh Gallagher Consultant Nephrologist St Helier Hospital

The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

Nephrology workload “High” maintenance –Dialysis (HD/PD) –Predialysis –Acute renal failure –Acute transplantation –“Special”, eg vasculitis “Low” maintenance –CKD –Long term transplant follow up –Hypertension –Others

“Local health organisations can work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of glomerular filtration rate (eGFR), calculated and reported automatically by all clinical biochemistry laboratories.” Renal NSF Part 2, Dept of Health, 2004

MDRD formula –Age –Sex –Creatinine –Ethnicity (black vs. non-black) Cockcroft-Gault formula –Age –Sex –Creatinine –Weight

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M70150

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M M60170

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M M

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M M F60170

AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M M F

K-DOQI Classification of CKD StageGFR (ml/min) Description 1> 90 1 Kidney damage with normal or  GFR Kidney damage with mild  GFR Moderate  GFR Severe  GFR 5< 15Kidney failure Chronic kidney disease is defined as either kidney damage or GFR 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

K-DOQI Classification of CKD StageGFR (ml/min) DescriptionPrevalence (%) 1> 90 1 Kidney damage with normal or  GFR Kidney damage with mild  GFR Moderate  GFR Severe  GFR 0.2 5< 15Kidney failure0.2 Chronic kidney disease is defined as either kidney damage or GFR 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

Prevalence of Unreferred CKD in East Kent East Kent population 601,000 Small ethnic population Study period Oct Sept 2002 Using opportunistic serum creatinine –Monthly screening of Chemical Pathology Database –Review after two months

Males serum creatinine  180  mol/L Females serum creatinine  135  mol/l Approximate to GFR < 30-40ml/min/1.73m 2 CKD definition

Prevalence 5554pmp Median Age 82 (18-103) Median GFR 28.0 ( ) 41.8% Male 17.8% diabetes CRF Population CRF Population Calculated GFR (mls/min) Number of cases Prevalence 0.55% Median Age 82 (18-103) Median GFR 28.0 ( ) 41.8% Male 17.8% diabetes CKD population

Unreferred CRF population Unreferred CRF population Median Age 83 (18-103) Median GFR 28.5 ( ) 39.2% Male 17.7% Diabetes Calculated GFR (mls/min) Number of patients Prevalence 0.47% Median Age 83 (18-103) Median GFR 28.5 ( ) 39.2% Male 17.7% Diabetes Unreferred population

< ( ) 23.4 ( ) eGFR (ml/min/1.73m) < Women (%) < (18-103)70 (18-91)Age (yrs) Prevalence (pmp) PUnreferredKnown John et al AJKD 2004;43: DOD/ Comparison of known and unreferred populations

In real money... GP practice 10,000 patients –Stage 3 CKD: 500 patients –Stage 4 CKD: 20 patients –Stage 5 CKD: 20 patients –Unreferred stage 4 and 5: 28 patients Renal unit, serving 1.8 million population –Unreferred stage 4 and stage 5: 5,100 patients

The introduction of eGFR will facilitate early recognition of CKD It will also result in increased awareness of advanced CKD previously not recognised as such A “coping” strategy needs to be developed before eGFR reporting is introduced

The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

Causes of CKD in the elderly

Functional consequences of CKD Hypertension Anaemia Disorders of Ca/Pi/PTH metabolism –renal osteodystrophy –vascular calcification

Snapshot of a CKD population in primary care GFR estimated on patients from 12 practices in Surrey, Kent and Greater Manchester 19% of sample (5% population) stage 3-5 CKD mean age 74 years (control 57 years) 75% stage 3-5 (22% control) co-existing circulatory disease 25% stage 3-5 (men) prostatic disease 15% stage 3-5 anaemic by WHO (4% requiring treatment by European Best Practice guidelines) 3% recorded as having a renal disease

Comorbidities in CKD

The “epidemic” of CKD What is a typical CKD patient? A role for increased primary care involvement? How can we achieve this?

Most CKD patients are stable

Cardiovascular diseases in CKD Damage to the heart (Uraemic cardiomyopathy ) Damage to the arteries (Uraemic arteriopathy)

Uraemic Cardiomyopathy Thickening of the wall Dilation of the heart Myocardial scarring Calcification Conduction defects

Uraemic Arteriopathy Thickening of the wall Atherosclerosis Stiffening of the artery Calcification

Adapted from Levey AS et al. Am J Kidney Dis 1998; 32: Cardiovascular Mortality Rates are Higher among Dialysis Patients General population: male General population: female Dialysis: male Dialysis: female

Go, A. S. et al. N Engl J Med 2004;351: Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization among 1,120,295 Ambulatory Adults, According to the Estimated GFR

Most renal patients die of CV causes well before they reach ESRD Their management is therefore that of their CV risk

Risk factors CVS DISEASE –Hypertension –Dyslipidaemia –Smoking –Obesity –Lack of exercise PROGRESSION –Hypertension –Dyslipidaemia –Smoking –Obesity –Lack of exercise

Patient choice…..

“No added value” consultations “The BP today was too high at 160/90. I have not made any changes today but suggest you repeat it in 2 weeks….” Where are blood tests performed?

Protocol-based nurse-led clinics IT support GMS contract

The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

Principles Collaborative approach between primary and secondary care Concise practice guidelines for referral and management Role for practice and community-based specialist nurses Support from nephrologists for all stages Dedicated nephrology care for predialysis and deteriorating

Dangers Late referral Missing ARF Undertreatment of renal anaemia and abnormalities of bone biochemistry Issues around clinical responsibility Workload

Short-term goals Education Pilot and issue guidelines for –management of newly discovered abnormal eGFR in primary care –management of CKD (including indications for referral) in primary care Implement eGFR reporting by St Helier laboratories Link the management of CKD to that of CV risk

Longer-term goals Specialist nurse-led community based renal clinics Protocol-based approach for management of renal anaemia and bone disease in the community Renegotiation of GMS contract Commissioning arrangements

The nephrologist’s view

The GP’s view