1. Section 6: Management in primary care
Particular emphasis on nurse practitioner’s role

2. Effects of age on eGFR The “normal” eGFR is age-related
In normal “healthy” individuals, the eGFR will fall by one percent for every year after 40 years of age
An 80 year old man will have an expected eGFR of ml/min
Not all patients with reduced eGFR need active management

3. % % subjects with CKD stage 3 by age and gender East Kent Data 70 5030 10
<45
45-54
55-64
65-74
75-84
>85
Age bands
de Lusignan et al 2005

4. “Normal” inulin GFR declines with age
EDTA F
150
CKD
Stage 1
CKD 2
CKD 3
CKD 4
CKD 5
100 50 20 30 40 50 60 70 80 90

5. Which individuals with abnormal eGFR should we to worry about?
Those with very poor function for age
Those with deteriorating function
Those who may have reversible/treatable cause (unexplained proteinuria/haematuria)
Those with functional consequences of CKD (anaemia, renal bone disease, persistent hyperkalaemia)

6. 2008 NICE guidance for CKD – focus on vascular risk
Lifestyle modification
Attention to known CV risk factors
smoking
statins for secondary prevention regardless of lipid level
Anti-platelet drugs for secondary prevention
Medicines management
BP targets

7. NICE 2008: recommendations for BP control in CKD
No diabetes or proteinuria
/70-90
Diabetes or ACR>30
/70-80

8. NICE 2008: Diagnosis of CKD
Proteinuria=ACR>30 or PCR>50 (NOT dipstick)
3 eGFR estimations <60 over a period not less than 90 days
Progressive decline defined as eGFR falling by >5mls/min/year
Focus on those whose observed rate of decline would necessitate RRT ‘within their lifetime’

9. NICE: 2008 Classification of CKD waking up to the impact of proteinuria
Stage 1: GFR>90 + abnormal urinalysis
Stage 2: GFR abnormal urinalysis
Stage 3A: GFR 45-59
Stage 3B: GFR 30-44
Stage 4: GFR 15-29
Stage 5: GFR <15 or dialysis dependent
Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)

10. QOF indicators for CKD 2009 6 40-90% 11 40-70% 4 40-80%
Register of patients over 18 with CKD 3-5 6
Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months
40-90%
Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less 11
40-70%
Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded) 4
40-80%
Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months

11. Monitoring of CKD Each assessment should include
Review of symptoms and fluid status
Blood pressure
Medication review (metformin, NSAIDs)
Urine ACR or PCR
Blood test for renal and bone status
FBC in advanced CKD

12. Frequency of monitoring
Newly diagnosed
Stable
Stage 3
6/12
annual
Stage 4
3/12
Stage 5

13. What data is required for effective referral?
Current creatinine and eGFR
Previous creatinines (tracing back to last normal)
Blood pressures (recent and historical)
Urine dip for blood, ACR/PCR
FBC, Ca, Pi
Renal US only if :-
stage 4
resistant HT
lower tract symptoms