Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC MANAGING KIDNEY DISEASE IN PRIMARY CARE Slide Set 1 (rev Sept2014)

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Content Recent policy changes Prevalence of CKD Screening and testing Explaining to people about CKD Proteinuria BP control CV risk assessment Referral

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) National Service Framework for Renal Services 2004/2005 Introduction of eGFR 2006 Quality and Outcomes Framework (QOF) for CKD Latest version 2014/15 NICE guidance Updated Policy changes

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Serum creatinine affected by muscle mass (age/gender/weight) so: - Inaccurate for some - Insensitive - Poor marker of early renal disease Hospital labs now report eGFR alongside serum creatinine From 2014: Labs to use CKD-EPI equation to estimate GFRcreatinine Why the changes?

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Few studies have explored prevalence NEOERICA study: CKD 8.5% (10.6% females 5.8% males) Stevens et al Kidney Int 2007; 72(1): 92-9 QI-CKD study: CKD: 6.8% (9.1% females 4.4% males) de Lusignan et al Erratum in Nephron Clin Pract 2012;120: c107 Data from GP surgeries in UK: 4.3% - But dependent on the GPs recording of names on a Register - Large variation How many people in UK have CKD (stages 3-5)?

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Classification of CKD ( rev 2014 ) CKD is classified according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR), using 'G' to denote the GFR category and 'A' for the ACR category (A1–A3) For example: A person with an eGFR of 25 ml/min/1.73 m 2 and an ACR of 15 mg/mmol has CKD G4A2. A person with an eGFR of 50 ml/min/1.73 m 2 and an ACR of 35 mg/mmol has CKD G3aA3. An eGFR of less than 15 ml/min/1.73 m 2 (GFR category G5) is referred to as kidney failure.

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Identify those at risk by eGFR and proteinuria measurement Explain to people they have the condition and encourage self-management Control blood pressure Assess and manage cardiovascular risk Medicine management Overview: Management of CKD in primary care

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Estimated that only 1/3 people with CKD are actually on the CKD Register and that many are unaware that they have kidney problems CKD is defined as either “kidney damage (proteinuria ie ACR>3mg/mmol, haematuria or anatomical abnormality) or GFR <60 ml/min/1.73 m 2 present on at least 2 occasions for ≥90 days ” NB: Consider use of eGFRcystatin C once more widely available “With new finding of eGFR <60, repeat within 2 weeks to exclude causes of acute deterioration” → CKD Register Key priority: screening and testing for CKD

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Investigations for CKD ( rev 2014 ) Use the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation to estimate GFRcreatinine (NB remember correction factor for people of African-Caribbean or African family origin (multiply eGFR by 1.159)

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Investigations for CKD ( rev 2014 ) Consider using eGFRcystatinC at initial diagnosis to confirm or rule out CKD in people with: – an eGFRcreatinine of 45–59 ml/min/1.73 m 2, sustained for at least 90 days and – no proteinuria (albumin:creatinine ratio [ACR] less than 3 mg/mmol) or other marker of kidney disease

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Investigations for CKD ( rev 2014 ) Do not diagnose CKD in people with: – an eGFRcreatinine of 45–59 ml/min/1.73 m 2 and – an eGFRcystatinC of more than 60 ml/min/1.73 m 2 and – no other marker of kidney disease

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Words are wrong (eg ‘chronic’) Others may be better: - Kidney damage - Reduced kidney function - Part of ageing process Need for monitoring Watch out for worsening kidney damage by: - Urine test (protein) - Blood test (% kidney function) Key priority: Explaining to people they have CKD

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) BP control: Encourage people to take their tablets as prescribed and report any side-effects. Explain that reducing raised BP is a key factor in preventing the progression of CKD BP monitoring: Advise people to monitor their own BP at home Smoking cessation Blood sugar control (if they have diabetes) Diet: To avoid processed, high-salt, high-fat foods and low protein diets Key priority: Promoting self-management of CKD

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Medicines management: - Give advice on using over-the-counter medicines (particularly anti-inflammatory drugs) - People should tell their pharmacist that they have CKD - People should be encouraged to report if using certain complementary therapies, such as Chinese herbal medicines Lifestyle modification: taking exercise and keeping to ideal weight Key priority: Promoting self-management of CKD

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) To detect and identify proteinuria, use urine ACR in preference to protein:creatinine ratio (PCR) For the initial detection of proteinuria, if the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. Regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria Key priority: Measuring proteinuria by ACR

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Diabetes or when ACR >70 Aim for systolic <130 mmHg (target range mmHg) Aim for diastolic <80 mm Hg Non-diabetes Aim for systolic <140 mmHg (target range mmHg) Aim for diastolic <90 mmHg Key priority: BP control

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Prescription of ACEi/ARB (1) Offer a low-cost renin–angiotensin system antagonist to people with CKD and: – Diabetes and an ACR of >3 mg/mmol (ACR category A2 or A3) – Non-diabetes: hypertension and ACR > 30 mg/mmol (ACR category A3) – an ACR of >70 mg/mmol (irrespective of hypertension or cardiovascular disease) Do not offer a combination of renin–angiotensin system antagonists to people with CKD. Follow the treatment recommendations in Hypertension (NICE clinical guideline 127) for people with CKD, hypertension and an ACR <30 mg/mmol (ACR categories A1 and A2), if they do not have diabetes.

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Measure serum K and eGFR: – Prior to ACEi (do not start if K > 5.0 mmol/L) – 1-2 weeks after institution or dose increase If K > 6.0 stop ACEi and advise on low K diet If fall in eGFR from baseline > 25% after 1-2 weeks: – Consider other causes of fall in eGFR (e.g. NSAID, diuretics) – Stop ACEi (or halve if lower dose tolerated) – Refer to renal unit to exclude renovascular disease – Inform people of possible side-effects Prescription of ACEi/ARB (2)

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Key priority: Control cardiovascular risk Reduced eGFR and proteinuria are both powerful independent cardiovascular risk factors CONTROL Blood pressure Offer Atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD (ref NICE CG181) Offer antiplatelet drugs to people with CKD for the secondary prevention of cardiovascular disease, but be aware of the increased risk of bleeding

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Use the Table to guide the frequency of eGFR monitoring (number of times/year by GFRcreatinine and ACR category) with the person with, or at risk of, CKD Monitoring

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Referral ( rev 2014 ) GFR <30 ml/min/1.73 m 2 (GFR category G4 or G5), with or without diabetes ACR >70 mg/mmol unless known to be caused by diabetes and already appropriately treated ACR >30 mg/mmol (ACR category A3), together with haematuria Sustained decrease in GFR of 25% or more, and a change in GFR category or sustained decrease in GFR of 15 ml/min/1.73 m 2 or more within 12 months Hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses (see also Hypertension NICE clinical guideline 127) Known or suspected rare or genetic causes of CKD Suspected renal artery stenosis.

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Reduced kidney function can be a frequent accompaniment of ageing, which in many cases is not a cause for concern Managing CKD is part of managing CV risk Monitoring for progressive disease is very important Renal units need one year to prepare people for dialysis Key messages

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Summary Ensure you have an accurate CKD Register Explain to people they have CKD and what this means Annual proteinuria screen (ACR preferable) BP control CV risk management Consider referral if appropriate

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Continuing Education for CKD On-line resource for supporting GPs and practice nurses in managing CKD:

Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No Registered Charity No Registered Scottish Charity No. SC Slide Set 1 (rev Sept2014) Further Resources British Renal Society Renal Association Blood Pressure Association National Kidney Federation NICE: CKD guidelines (2014)