1. Cardiovascular Hot topics Dr Saqib Mahmud, MRCP(UK)

2. CKD The introduction of routine reporting of The introduction of routine reporting of eGFR has led to 3 outcomes in primary care; ‘Worried patients, Increased workload ‘Worried patients, Increased workload & confused clinicians’.BMJ2006 & confused clinicians’.BMJ2006

3. Why has CKD been selected as a quality indicator?QOF2 2006 Patients with CKD have very high rates of vascular disease & require aggressive management of vascular risk factors. (early CKD risk of death from CVD>ESRF)-low GFR predicts CV disease Patients with CKD have very high rates of vascular disease & require aggressive management of vascular risk factors. (early CKD risk of death from CVD>ESRF)-low GFR predicts CV disease Its incidence is rising dramatically. (doubled in last 10yrs,5% adult population) Its incidence is rising dramatically. (doubled in last 10yrs,5% adult population) S Cr does not rise until GFR has fallen by 50- 70% S Cr does not rise until GFR has fallen by 50- 70% Early interventions in CKD improve cardiac & renal outcomes Early interventions in CKD improve cardiac & renal outcomes

4. eGFR- best estimate of renal function Based on S Cr, age, sex & ethnic origin. Based on S Cr, age, sex & ethnic origin. Does not apply to children, ARF, pregnant women, oedematous & malnourished. Does not apply to children, ARF, pregnant women, oedematous & malnourished. eGFR falls after eating meat, ideally fasting sample or avoid eating cooked meat day before. eGFR falls after eating meat, ideally fasting sample or avoid eating cooked meat day before. CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFR CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFR

5. CKD-classification CKD stage eGFR 1 Kidney damage, normal eGFR >90 2 Kidney damage, reduced eGFR 60-89 3 Moderate CKD 30-59 4 Severe CKD 15-29 5ESRF <15 or on dialysis

6. QOF 2006 – CKD register CKD1- register of pts>18 with CKD3-5 CKD1- register of pts>18 with CKD3-5 CKD2-(90%) on register with record of BP in last 15/12 CKD2-(90%) on register with record of BP in last 15/12 CKD3-(70%) on register with BP<140/85 CKD3-(70%) on register with BP<140/85 CKD4-(80%) patients on ACEI/A2RB-or CI CKD4-(80%) patients on ACEI/A2RB-or CI Worth 27pts=£3,364/- Worth 27pts=£3,364/-

7. Conditions with risk of developing CKD Hypertension Hypertension Diabetes Diabetes Heart failure Heart failure Vascular disease Vascular disease Urinary outflow obstruction Urinary outflow obstruction Multi-system diseases eg;RA, SLE, vasculitis Multi-system diseases eg;RA, SLE, vasculitis APKD or reflux nephropathy APKD or reflux nephropathy

8. Monitoring renal function Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, microalbuminuria, haematuria without urological cause or known polycystic kidney disease or GN. (Annual U & Es) Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, microalbuminuria, haematuria without urological cause or known polycystic kidney disease or GN. (Annual U & Es) Stage 3  6/12 Stage 3  6/12 Stages 4 & 5  3/12 Stages 4 & 5  3/12

9. Urine tests Dipstick urinalysis for protein, Dipstick urinalysis for protein, If +ve  msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45) If +ve  msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45) In diabetics, dipstick negative  ACR for microalbuminuria (+>2.5mg/mmol- males,>3.5 in women) In diabetics, dipstick negative  ACR for microalbuminuria (+>2.5mg/mmol- males,>3.5 in women)

10. Management – is easy ‘CKD rarely means dialysis’ ‘CKD rarely means dialysis’ Monitor renal function closely- assess rate of change Monitor renal function closely- assess rate of change Tight BP control with preferential use of ACEI or A2RB Tight BP control with preferential use of ACEI or A2RB Pay close attention to CV risk Pay close attention to CV risk

11. New patient with eGFR<60 Review previous results ?rate of deterioration Review previous results ?rate of deterioration Review medication ?nephrotoxicity Review medication ?nephrotoxicity Check BP, urine, full clinical assessment eg ?palpable bladder Check BP, urine, full clinical assessment eg ?palpable bladder Repeat U&E within 5/7 (?rapid progression) Repeat U&E within 5/7 (?rapid progression) Referral criteria- renal function stable  monitor Referral criteria- renal function stable  monitor Stage 4(if stable, monitor) & 5 should be referred Stage 4(if stable, monitor) & 5 should be referred Stage 3 if deteriorating function Stage 3 if deteriorating function

12. Long term management to delay progression and reduce CV events Life style advise  smoking cessation, wt reduction, exercise, low protein diet Life style advise  smoking cessation, wt reduction, exercise, low protein diet Aspirins & statins if CVD risk >20% Aspirins & statins if CVD risk >20% (evidence is that all CKD patients are high risk) (evidence is that all CKD patients are high risk) Strict BP control-QOF2 target <140/85, but renal guidelines best practice target is 130/80 Strict BP control-QOF2 target <140/85, but renal guidelines best practice target is 130/80 Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBs Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBs

13. Additional management-CKD3 Renal USS if LUTS, refractory HTN, unexpected fall in GFR Immunise-influenza, pneumococcus, Hep B in CKD4&5 If HB<11-exclude other causes, refer for ESA, iv Fe

14. Renal osteodystrophy Renal failure  failure of Vit D hydroxylation  secondary hyperparathyroidism Renal failure  failure of Vit D hydroxylation  secondary hyperparathyroidism  increased # risk due to faulty bone remodelling & lowered BMD.  increased # risk due to faulty bone remodelling & lowered BMD. Check PTH levels, if low check 25-hydroxy Vit D levels Check PTH levels, if low check 25-hydroxy Vit D levels Rx- ergo or cole-calciferol with calcium Rx- ergo or cole-calciferol with calcium

15. ACEI / A2RB- Rx or the cause ACEI/A2RBs improve outcomes but in some patients can be nephrotoxic ACEI/A2RBs improve outcomes but in some patients can be nephrotoxic A slight reduction in GFR ( 30% A slight reduction in GFR ( 30%

16. Prescribing in CKD Avoid NSAIDs, codeine Avoid NSAIDs, codeine Antibiotics, digoxin, metformin etc – Antibiotics, digoxin, metformin etc – ‘use with caution’ ‘use with caution’ (reduce dose or frequency) (reduce dose or frequency)

17. What about elderly patients with low eGFR- how should we manage them? The guideline makes no age distinctions The guideline makes no age distinctions BMJ2006;it is ageist not to Rx CKD just because someone is elderly. BMJ2006;it is ageist not to Rx CKD just because someone is elderly. BJGP editorial Dec2006;elderly with CKD still benefit from CV risk factor intervention and strict BP control in elderly slows rate of renal decline BJGP editorial Dec2006;elderly with CKD still benefit from CV risk factor intervention and strict BP control in elderly slows rate of renal decline Use clinical judgement & patient circumstances Use clinical judgement & patient circumstances

18. Take - aways….. CKD patients have high risks of CV events and require aggressive management of vascular risk factors CKD patients have high risks of CV events and require aggressive management of vascular risk factors Risk of ESRF is very low Risk of ESRF is very low Best practice target BP is 130/80 with preferential use of ACEI / A2RB Best practice target BP is 130/80 with preferential use of ACEI / A2RB Consider aspirin and statins Consider aspirin and statins

19. Thank you ‘The enemy of good ‘The enemy of good is better’