1. CKD In Primary Care
Dr Mohammed Javid

2. Relevance
End Stage CKD places a very significant burden on patients quality of life.
End Stage CKD is very expensive to manage.
Deteriorating CKD is an independant risk factor for an increase in mortality from cardiovascular disease.
QOF: CKD = 38 points

3. Guidelines National Service Framework 2004 -2005 NICE guidelines 2008
PACE local guidelines
QOF

4. eGFR CKD classification is based on eGFR
Estimates Glomerular Filtration Rate using serum creatinine and patients Age, Sex, etc
Cockroft-Gault formula
MDRD formula

5. Creatinine 120
eGFR 31-40
eGFR

6. CKD stage GFR (ml/min/1.73m2) Description 1 >90 2 60-89 3 30-59 4
Normal renal function but other evidence of organ damage* 2
60-89
Mild reduction in renal function with other evidence of organ damage* 3
30-59
Moderately reduced GFR 4
15-29
Severely reduced GFR 5
<15
End stage, or approaching, end stage renal failure
Insert P for proteinuria
3a and 3b
45-49 and 30-44
* Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

8. 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.

9. 100 patients with eGFR < 60

10. 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

11. 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD

12. Proteinuria Indicates poorer renal prognosis Urine dipstick
Protein : Creatinine ratio PCR
Protein : Creatinine Index PCI
Albumin : Creatinine Ratio ACR
Early morning sample
<5 normal, >30 significant , >70 severe
Check for heamaturia

13. Progressive CKD Check at least 3 eGFRs over 90 days
Defined as a decline in eGFR of
>5 within 1 year, or >10 within 5 years

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

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

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

21. Routine management ACEI or ARB: Diabetes + ACR (>30)
(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)

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

23. 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

24. 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
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.

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

27. Consider referral CKD 4 or 5 Proteinuria ACR >70
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

28. QOF indicators CKD points total = 38 points = £££
CKD1 (register) = 6 points
CKD2 (bp checked) = 6 points
CKD3 (bp controlled) = 11 points
CKD5 (acei started) = 9 points
CKD6 (acr checked) = 6 points

29. Take Home Message
CKD is an independant risk factor for cardiovascular mortality which far outweighs the risk of developing end-stage renal disease
CKD 3 is managed in primary care with ACE-i and cardiovascular optimisation.
Monitor eGFR
Blood pressure control with ACE
Check for proteinuria