1. CKD: the primary/secondary care interface Daniel Ford Consultant Renal Physician UHCW

2. Overview Background History, classification and controversies! Complications CVD, CKD progression, other complications CKD Management Management of CKD: role of primary and secondary care Referral guidelines Who to screen and when to refer Discussion

3. Overview Background –History of CKD –Classification –Model of CKD

4. History of CKD Chronic renal failure/impairment NKF/KDOQI CKD guidelines –Terminology –Definition/classification –MDRD eGFR –Association of level of kidney function with complications –Risk factors for progression [AJKD Suppl. Feb 2002]

5. CKD Classification www.NICE.org.uk/guidance/CG73

6. Model of CKD Levey AS, et al. KI 2007; 72(3): 247-259

8. Overview Background Complications of CKD –Cardiovascular disease –Hypertension –Anaemia –Bone-mineral metabolism –Poor nutritional and functional status –Progression of CKD

9. Complications of CKD

10. Hypertension –80% HD patients, 50% PD patients –CKD progression associated with HTN –HTN associated with level of eGFR Buckalew VM, et al. AJKD 1996; 28: 811-821

11. Complications of CKD Anaemia NHANES III

12. Complications of CKD Cardiovascular disease Go et al. NEJM 2004; 351:1296-1305

13. Overview Background Complications of CKD Management of CKD –Diagnosis –Managing complications –Progression of CKD –Pre-ERF planning –Primary vs. secondary care management

14. Diagnosis CKD classification does not mandate a diagnosis Generic management of CKD Disease-specific management

15. Diagnosis of patients starting RRT during 2011 DiagnosisPercentage of patients Diabetes24.8 Glomerulonephritis13.3 Pyelonephritis7.1 Hypertension7.0 Polycystic kidney disease7.2 Renal vascular disease6.9 Other16.3 Uncertain17.3 UKRR 15 th Annual Report

16. CKD Progression What is significant progression? What risk factors are associated with progression? Why is progressive CKD important?

17. CKD Progression What is significant progression? –Most patients with CKD will not progress to ERF How many patients in the UK have CKD? How many start RRT each year?

18. CKD Progression What is significant progression? –Most patients with CKD will not progress to ERF How many patients in the UK have CKD? –4.94 million (8% of 61.8M) How many start RRT each year? –6,730 –i.e. 0.13% of CKD patients per year Stevens et al. KI 2007;72:92-99 ONS 2009 estimates UKRR 13 th Annual Report (2009 data)

19. CKD Progression What is significant progression?

20. CKD Progression What is significant progression? –eGFR decline >5ml/min/1.73m²/year –Or >10ml/min/1.73m² in 5 years

21. CKD Progression What is significant progression? –eGFR decline >5ml/min/1.73m²/year –Or >10ml/min/1.73m² in 5 years What risk factors are associated with progression?

22. Hypertension Diabetes mellitus Albuminuria Cardiovascular disease Smoking Ethnicity NSAIDS

23. CKD Progression What is significant progression? What risk factors are associated with progression? Why is progressive CKD important?

24. Overview Background Complications of CKD Management of CKD –Diagnosis –Managing complications –Progression of CKD –Pre-ERF planning –Primary vs. secondary care management

25. (Dialysis) planning Consequences of late presentation Rate of late presentation

26. Consequences of late presentation Higher mortality, morbidity, hospital stay, cost Due to poorer clinical state at presentation, lack of vascular access No possibility of pre-emptive transplantation Winkelmayer WC. J Am Soc Nephrol 2003; 14: 486-492.

27. Rate of late presentation 250 patients starting RRT 96/250 (38%) referred within < 4 months 43/96 (43%) of late referred patients were avoidable –Known raised serum creatinine –Risk factors for progressive renal disease, e.g. diabetic nephropathy –Late referral as likely from hospital as from GP Roderick P. Q J Med 2002; 95: 363-370

28. UKRR 13 th Annual Report

29. Planning All children, young people and adults approaching established renal failure are to receive timely preparation for renal replacement therapy so the complications and progression of their disease are minimised, and their choice of clinically appropriate treatment options is maximised People with established renal failure receive timely evaluation of their progress, information about the choices available to them, and for those near the end of life a jointly agreed palliative care plan, built around their individual needs and preferences Renal NSF part 1. www.dh.gov.uk Renal NSF part 2. www.dh.gov.uk

30. Planning Dialysis Haemodialysis (hospital, satellite, home) Peritoneal dialysis (CAPD, APD) Transplantation Deceased-donor transplant Living-donor transplant (including pre-emptive) Other options (e.g. kidney-pancreas, paired-exchange, desensitisation) Conservative care

31. Overview Background Complications of CKD Management of CKD –Diagnosis –Managing complications –Progression of CKD –Pre-ERF planning –Primary vs. secondary care management

32. CKD Management Identification (Renal) diagnosis Progression –eGFR monitoring –BP control –ACE/ARB if appropriate CVD risk management BP control Anaemia management Bone mineral metabolism Nutrition RRT planning/education

33. CKD Management in primary care Identification (Renal) diagnosis Progression –eGFR monitoring –BP control –ACE/ARB if appropriate CVD risk management BP control Anaemia management Bone mineral metabolism Nutrition RRT planning/education

34. CKD Management in primary care 8% of UK population has CKD 3-5 Stevens et al. KI 2007; 72: 92-99 Primary careRenal care CKD 384.6%1.5% CKD 462.7%25.1% CKD 530.0%61.1% Richards et al. NDT 2008; 23: 556-561

35. QoF CKD 1: The practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD). CKD 2: The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. CKD 3: The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less CKD 5: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded). CKD 6: The percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months

36. Overview Background Complications of CKD Management of CKD Referral guidelines –Who should be tested? –Frequency of testing –Who should be referred? –What information is required?

37. Who should be offered testing for CKD? Diabetes (type 1 and 2) Hypertension Cardiovascular disease Receiving nephrotoxic drugs (NSAIDS, lithium) Structural renal disease (stones, prostatic hypertrophy) Relevant multisystem diseases (e.g. SLE) Family history of CKD5 or hereditary disease

38. Who should be offered testing for CKD? Diabetes (type 1 and 2) Hypertension Cardiovascular disease Receiving nephrotoxic drugs (NSAIDS, lithium) Structural renal disease (stones, prostatic hypertrophy) Relevant multisystem diseases (e.g. SLE) Family history of CKD5 or hereditary disease If neither diabetes nor hypertension is present, do not use obesity as a risk marker If none of the above is present, do not use age, gender or ethnicity as risk markers

39. Overview Background Complications of CKD Management of CKD Referral guidelines –Who should be tested? –Frequency of testing –Who should be referred? –What information is required?

40. How often to test for progression?

41. Overview Background Complications of CKD Management of CKD Referral guidelines –Who should be tested? –Frequency of testing –Who should be referred? –What information is required?

42. NICE CKD Guidelines Sep 2008 Referral algorithm, p 19-21 www.NICE.org.uk/guidance/CG73

44. People with CKD in the following groups should usually be referred for specialist assessment: Stage 4 & 5 CKD (with/without DM) Heavy proteinuria (ACR>70mg/mmol) Proteinuria (ACR>30) and haematuria Rapidly declining eGFR –5ml/min in 1 year –10ml/min in 5 years Poorly controlled hypertension (4 agents) Rare or genetic causes of CKD Suspected renal artery stenosis

45. Considerations Consider discussing management issues with a specialist by letter, e- mail or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist. Once referral has been made and a plan jointly agreed, it may be possible for routine follow-up to take place at the patient’s GP surgery rather than in a specialist clinic. If this is the case, criteria for future referral or re-referral should be specified. Take into account the individual’s wishes and comorbidities when considering referral. People with CKD and renal outflow obstruction should be referred to urological services, unless urgent medical intervention is required, e.g. for treatment of hyperkalaemia, severe uraemia, acidosis or fluid overload.

46. Overview Background Complications of CKD Management of CKD Referral guidelines –Who should be tested? –Frequency of testing –Who should be referred? –What information is required?

47. What information is required? Reason for referral Latest blood results Rate of progression –Serial creatinine results Risk of progression –uACR/PCR Likely diagnosis/need for tissue diagnosis Other co-morbidities/ complications Drug history (OTC meds & relevant changes)

48. Summary Why these guidelines were introduced How to manage patients with CKD Who, when & how to refer Where to find further information on CKD www.renal.org/CKDguide/ckd.html www.nice.org.uk/guidance/CG73