CKD ML/LH 17.3.10 What are people hoping to cover from the session today?

Chronic Kidney Disease Are we correctly diagnosing CKD? Have we the correct patients on our CKD register? Are we managing them correctly?

Plan for today Highlight a few issues around eGFRs Review NICE and PACE guidance Discuss how we diagnose and manage CKD Identify and discuss any uncertain areas I’ve been on an update course where Lucy Jenkins offered their practice protocol -she admits to being cynical about the existence of CKD so we may want to adapt it…

Why introduce CKD QOF indicators? End stage renal failure is costly to treat, and its prevalence is increasing 30% of patients present late; they have worse outcomes and are more expensive to treat It is hoped that managing CVD risk factors aggressively will slow or reduce the progression to ERF ERF is costly in morbidity,mortality and ecconomically The guidelines however are based mainly on expert opinion as little evidence is available.

Risks of a low eGFR Renal 1% of patients with CKD 3 will progress to ERF in their lifetime (99% won’t) Cardiovascular If you have an eGFR <60 you are at higher risk of all cause mortality and any cardiovascular event eGFR is presently being used as a screening test for CKD but it has some limitations. What is not clear is whether it is the low eGFR that increases your risk, or whther it is a marker of other co-morbidities.

Possible symptoms (CKD 3 - 5) Tiredness Anorexia, nausea Weight loss Dry itchy skin Muscle cramps Ankle swelling, peri-orbital oedema Anaemia

NICE Sept 2008, Clinical Guideline 73

Offer CKD screening to at risk groups DM Hypertensives CVD Multisystem diseases e.g. SLE Structural renal tract disease e.g. stones, BPH FHx CKD 5 or hereditary kidney disease Long term NSAIDS A lot will be detected on annual review, however do we need to be more proactive in those with bph or long-term nsaids? consideration

Testing eGFR GFR estimated from serum creatinine and age, using MDRD equation If abnormal, repeat the test to confirm Multiply eGFR result by 1.212 for African -Caribbean and African patients (Are we recording this correctly?)

eGFR and meat NICE specifically advises no meat for 12 hours before eGFR Are we doing this? How do we record it? 32 people with eGFR >60 ate meat and overnight developed CKD3! Bandolier

eGFRs and age eGFR is not validated in the >75s (How many patients >75 have we coded with CKD 3?) From the age of 40 the eGFR declines by 1ml/min/yr NICE says that in those >70 yrs with a stable eGFR >45, there is v little risk of developing CKD related complications. Should we consider undiagnosing those >75 with CKD3? (66 patients potentially) Should we consider undiagnosisng those with stable eGFR’s >45, who are >70 yrs?(112 patients potentially) Would we need to still label them to ensure dose adjustments with drugs etc.

Newly identified CKD Stage CKD on eGFR results Stage 1 > 90 Stage 3A 45 - 59 Stage 3B 30 - 44 Stage 4 15 - 29 Stage 5 <15 Now we have 3 readings over a 90d period showing a low egfr,we can stage them. If egfr 60-90 as we do nothing with CKD2 they can be considered normal We have 249 on the ckd register, 16 have ckd 4/5

eGFRs: ‘normal for age?’ > 90 CKD 1 Normal renal function 60-89 CKD 2 45-59 CKD 3A Impaired renal function 30-44 CKD 3B 15-29 CKD 4 Severely impaired <15 CKD 5 eGFR / Age 18-29 30-39 40-49 50-59 60-69 70-79 80-89 In yrs

Assess for proteinuria NICE advises ACR on first sample of the day (preferably) ACR abnormal if >30, in non diabetics (Repeat to confirm if ACR >30 but <70) ACR abnormal if >2.5 in diabetic men ACR abnormal if >3.5 in diabetic women The presence or lack of proteinuria helps indicate prognosis.

Issues around proteinuria NICE also mentions PCRs (mg/mmol) (ACR of 30 = (approx) PCR of 50) But in Bradford they report PCIs (mg/mg), which correspond with 24hr urinary protein excretion PCR of 50 = PCI of 500 (i.e. divide by 10) Leeds/Bfd Biochem are considering changing to PCRs in the future, to fit with NICE

False positives Urinary Tract Infection Do MSU if dipstix +ve for protein Menstrual contamination Benign orthostatic proteinuria

Assess for progressive CKD Check at least 3 eGFRs over at least 90 days Defined as a decline in eGFR of >5 within 1 year, or >10 within 5 years Risk factors include NSAIDS, smoking, hypertension, urinary outflow obstruction, proteinuria and diabetes This is double the rate of normal decline, however there is a lot of intrapersonal varriation-esp if you eat meat.

Other baseline tests For all Dipstix for haematuria CVD risk assessment Consider DEXA scan CKD 4 and 5 FBC and ferritin Calcium, phosphate, PTH Visable haematuria requires urology investigations. Persistent invisible haematuria = 1+ of blood on 2 out of 3 dipstick tests Consider ruling out renal tract malignancies, then if associated with proteinuria refer for renal opinion. NICE advises offer biphosphonates to all including CKD 1-3 if indicated for prevention of osteoporosis

Consider renal USS If CKD 4 or 5 Progressive CKD Visible or persistent invisible haematuria Symptoms of urinary tract obstruction FHx polycystic kidney disease and >20yrs of age

Consider referral CKD 4 or 5 without diabetes ACR >70 in non diabetics Proteinuria (ACR>30) with haematuria Progressive CKD CKD and poorly controlled BP on 4 agents Suspected genetic renal disease or renal artery stenosis We have 5 patients CKD 4/5 who have not been referred for renal opinion –may be legitimate reasons age/co morbidities etc

Routine management Lifestyle modification Smoking increases risk of progressive CKD Lose weight if obese Regular exercise Reduce salt if hypertensive

Routine management Monitor eGFR CKD 3 6 monthly CKD 4 3 monthly CKD 5 6 weekly We have 5 patients with CKD 4 or 5 who have no hospital input and where there is no recall arrangements

Routine management Control BP NICE target <140/90 <130/80 if ACR >70 <130/80 if diabetic QOF <140/85 for all

Routine management Reduce proteinuria ACEIs first line ARBs if not tolerated Presently 3/16 patients with CKD4or5 are on neither

Routine management ACEI or ARB: Diabetes + ACR (>2.5 men, or 3.5 women) (irrespective of hypertension or CKD stage) Non-Diabetic with CKD + HT + ACR >30 Non-Diabetic with CKD + ACR >70 (irrespective of presence of HT or CVD)

Routine management Routine anti-hypertensive treatment Non-diabetic + CDK + HT + ACR <30 (See NICE Hypertension guideline 34)

Routine management CVD risk assessment treat with a statin if CVD risk >20% (SystmOne CVD risk calculator does NOT include adjustment for chronic renal disease, but QRISK2 does) Immunizations Influenza - annually Pneumococcal - 5 yearly, due to declining antibody levels 5/16 CKD 4-5 have CVD risks >30 and are not on a statin

Routine management Drugs Check BNF Appendix 3: Renal Impairment Test for anaemia If Hb <11 first consider other causes of anaemia Determine iron status – if serum ferritin <100 start oral iron Consider referral for erythropoeisis stimulaing agents (ESA’s) 10% of those with KD4 have anaemia and 4% of those with CKD3B Rates are a lot higher in diabetics with CKD-aprox 22% will be anaemic. ESA’s tend to be initiated in hospital and then administered at the practice.

Routine management Manage bone conditions Ca, PTH and phosphate if CKD 4 or 5 Offer biphosphonates to all “if indicated” If indicated offer vitamin D supplements: - cholecalciferol or ergocalciferol in CKD3 - alfacalcidol or calcitriol in CKD 4 and 5 If on vit D supplements they need to be monitored ??dexa

QOF indicators CKD1: Register of patients >18 yrs with CKD (stages 3 – 5) CKD2: % of pts with BP recorded in last 15 mths CKD3: % of pts in whom last BP reading, in last 15 mths, is <140/85 CKD5: % of pts with HT + proteinuria on ACEI or ARB (unless c/i or s/e recorded) CKD6: % of pts with urine ACR (or PCR) test in last 15 months

QOF indicators CKD points total = 38 points = £££ CKD1 (reg) = 6 points CKD2 (bp) = 6 points CKD3 (bp controlled) = 11 points CKD5 (acei/arb) = 9 points CKD6 (acr) = 6 points