1. CKD Update Naveed Ghaffar CKD Lead NMCCG

2. Outline Introduction- CCG Work Physiology: The Kidney in health CKD : The kidney in disease NICE Update: July NMCCG CKD Algorithm AKI NCEPOD Medicines- Nikki lawton

3. Introduction- CCG Work May this year Secondary Care referrals Met with Renal Physicians CKD Workshop CKD Triager AQUA

4. Physiology- The Kidney in health Retroperitoneal Vertebral Column T12- L3 Innervation T10-12, L1 Functional Unit- Nephron Glomerulus- Filter

5. Physiology- The Kidney in health 2

6. Physiology- The Kidney in health 3

7. Physiology- The Kidney in health 4

8. Physiology- The Kidney in health 5

9. Physiology- The Kidney in health 6 Excretory: >Excretion of waste products, drugs Regulatory: > Control of fluid volume and composition Endocrine: > Production of EPO, Renin, PGs, endothelins Metabolic: > Metabolism of VitD, small molecular proteins

10. CKD: The Kidney in disease 1 ‘Abnormalities of kidney function or structure present for more than 3 months, with implications for health” This includes all people with markers of kidney damage and those with a GFR of less than 60 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage) (NICE)

11. CKD: The Kidney in disease 2 Frequently unrecognized Co-exists with other diseases Risk increases with age Increased risk of adverse outcomes Usually asymptomatic- but detectable Often diagnosed late Prevention, Prevention, Prevention!

12. CKD: The Kidney in disease 3: Presentation

13. CKD: The Kidney in disease 4: Causes Vascular disease: HTN Urinary tract obstruction: Calculi, Prostate Congential and Inherited disease Glomerular disease: DM Tubulointerstitial disease

14. CKD: The Kidney in disease 5: Investigations GFR, ACR Urinalysis Microscopy Urea, Creatinine, FBC Immunology USS, CT Biopsy

15. CKD: The Kidney in disease 5: Complications Anaemia Bone disease Cardiovascular disease Skin Gastrointestinal system Metabolic abnormalities Muscle, Nerves

16. CKD: The Kidney in disease 6: Management Blood pressure control Risk factors Monitor for progression AKI PREVENTION IS THE KEY

17. NICE Update Classification Identification and Investigation Definition of progression Relationship between AKI and CKD Self management Pharmacotherapy- Nikki

18. CLASSIFICATION ACR Categories(mg/mmol) A1 30 G1 >90 1 G2 60-89 1 G3a 45-59112 G3b 30-44 2 G4 15-29223 G5 4 >4 CLASSIFICATION AND FREQUENCY OF MONITORING OF GFR/YR ACR Categories(mg/mmol) A1 30 G1 >90 1 G2 60-89 1 G3a 45-59112 G3b 30-44 2 G4 15-29223 G5 4 >4 CLASSIFICATION AND FREQUENCY OF MONITORING OF GFR/YR

19. Identification and Investigation Cystatin C ACR 3-70mmol/l: confirm on EMS DO NOT use reagent strips to confirm Haematuria 1+ or more DO NOT use microscopy to confirm

20. NMCCG CKD Algorithm

21. Progression CVD, Proteinurea, AKI, HTN, DM, Smoking, African, Afro-Caribean or Asian family origin, Chronic use of NSAIDS, Untreated Urinary tract outflow obstruction Monitor people for development or progression of CKD for at least 2-3 yrs after AKI Advise people who have had an AKI that they are at increased risk of CKD developing or progressing

22. AKI ADMISSIONS NORTH PRACTICES YEARADMISSIONSCOST 09-1079361,960 10-11113390, 824 11-12111332,067 12-13144434, 360 13-14171520,307

23. NCEPOD: AKI National deaths 564 deaths between Jan 1 st 2007-March 31 st 2007 “Systematic failings in management” “Very basics of medical care were omitted” “Failure of clinicians to recognise and manage” “Global failure of the sick patient”

24. Conclusion CKD and AKI Important Prevention is they key Manage risk factors Don’t ignore dropping GFRs Watch out for AKI Proactive approach