1. AKI and CKD: Top ten facts for primary care physicians
Richard Smith

2. KIDNEYS

3. CKD: Does it really matter?
Richard Smith
Consultant Nephrologist

6. The talk in one slide: Risk management
Significant biochemical changes have no ‘immediate’ clinical correlate
CKD(3) and AKI are associated with significant risk
Recognise the patient at risk and manage this
CKD(3):
Confers significant cardiovascular risk and risk of AKI
Progression to RRT is rare (1.3%)
Progression to worse CKD (and therefore worse
cardiovascular and AKI risk) is common

7. CKD: Does it really matter?60 50 40 30 20 10
eGFR
CKD3
CKD3 X
CKD4
CKD4
RRT

8. CKD3: Does it really matter?60 50 40 30 20 10
eGFR
CKD3 X
CKD4
RRT

9. Risks associated with CKD
Cardiovascular Risk

10. Reduced kidney function is associated with a higher risk of CV events
1.0
1.4
2.0
2.8
3.4
Hazard ratio for CV event 1 2 3 4
≥60
45-59
30-44
15-29
<15
eGFR (mL/min/1.73m2)
Go 2004: pg 1301a
CKD3
Go 2004: pg 1300a pg 1301b
Go 2004: pg 1297a
Go et al. N Engl J Med : 1296– Tonelli et al. J Am Soc Nephrol : 2034–2047
Eeg-Olofsson et al. J Internal Medicine : 471–482 Khaw Nature Reviews Endocrinology :
Go 2004: pg 1301a
Go 2004: pg 1301a
1. Go AS et al. N Engl J Med. 2004;351:

11. Age-related glomerulosclerosis is amplified by systemic atherosclerosis
Kasiske BL. Kidney Int 1987; 31:

12. Risk factors for cardiovascular disease
Risk factors for chronic kidney disease
Hypertension
Smoking
Obesity
Diabetes
Dyslipidaemia
Reduced GFR
Proteinuria
Hypertension
Smoking
Obesity
Diabetes
Dyslipidaemia
Atherosclerosis
Heart failure

13. SHARP: Major Atherosclerotic Events 5-year benefit per 1000 patients

14. Risk of decline of GFR in elderly people
10,184 community-dwelling subjects aged 66 or over
Decline in eGFR greatest in diabetic patients (2.1 and 2.7 ml/min/1.73m2/year in F and M respectively)
Decline in eGFR in non-diabetic patients: 0.8 and 1.4 ml/min/1.73m2/year in F and M respectively
Decline more likely if baseline eGFR <30
Hemmelgarn BR. Kidney International 2006: 29: 2155

15. CKD progression Steps to identify progressive CKD
Obtain a minimum of three eGFR over not less than 90 days
In new cases of reduced eGFR repeat within 2 weeks to exclude acute deterioration
Slow progression by treating BP
In CKD >140/90 mmHg
In CKD and diabetes or ACR  70mg/mmol > 130/80 mmHg
NOTES FOR PRESENTERS:
Key points to raise:
Acute deterioration of GFR may include acute kidney injury or initiation of angiotensin-converting enzyme inhibitor (ACE inhibitor)/angiotensin-II receptor blocker (ARB) therapy.
An eGFR result less than 60 ml/min/1.73 m2 in a person not previously tested should be confirmed by repeating the test within 2 weeks.
Focus on those where decline of GFR at observed rate would lead to renal replacement therapy within their lifetime by extrapolating the current rate of decline.
Work with people who have the following risk factors for progression of CKD to optimise their health: cardiovascular disease; proteinuria; hypertension; diabetes; smoking; black or Asian ethnicity; chronic use of NSAIDS; urinary outflow tract obstruction.
Additional information:
People with CKD should be offered education and information tailored to the stage and cause of CKD, the associated complications and the risk of progression.
The chronic use of NSAIDs may be associated with progression of CKD and acute use is associated with a reversible fall in GFR.
Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression.
For patients with access to the internet, the Renal Patient View system may provide a convenient means of accessing the results of their blood tests and information about their diagnosis and treatment.
Recommendation in full:
Take the following steps to identify progressive CKD:
Obtain a minimum of three GFR estimations over a period of not less than 90 days; in people with a new finding of
reduced eGFR, repeat the eGFR within 2 weeks to exclude causes of acute deterioration of GFR – for example, acute
kidney injury or initiation of ACE inhibitor/ARB therapy; define progression as a decline in eGFR of more than 5
ml/min/1.73 m2 within 1 year, or more than 10 ml/min/1.73 m2 within 5 years; focus particularly on those in whom a decline
in GFR continuing at the observed rate would lead to the need for renal replacement therapy within their lifetime by
extrapolating the current rate of decline.

16. Risks associated with CKD
Acute Kidney Injury

17. 17

18. NICE Guidance 28th August 2013
The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care
Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year
Inadequate assessment of risk factors in 24% of patients admitted with AKI
Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia

19. CKD3: Is it really CKD? 60 50 40 30 20 10
eGFR
CKD3 X
CKD4
RRT

20. Do not ignore eGFR 30-59ml/min until know direction of travel and significant causes ruled out

21. Diagnostic Criteria for Primary Care
A rise in serum creatinine of ≥26.5 μmol/L in 48 hours
A rise in serum creatinine of ≥50% in 7 days
AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or × baseline
AKI stage 2: a rise in creatinine of × baseline
AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L

22. Kidney medicine in primary care: BaNES
776 AKI spells over 12 months
No differences between practices
19% of patients die in hospital
24% have diabetes
20% have diabetes and are >65 yrs old
Case note review:
Presentation usually with ‘other’ diagnosis
Also
500 new referrals at Ipswich Hospital

23. Case 1 48 yr old man. Routine health check.
Found to have eGFR of 35ml/min
Referred for investigation of his “CKD 3”
No previous eGFR
Protein No haematuria
BP 122/74
Renal biopsy demonstrated FSGS

24. Case 2 Mrs MA 74 year old eGFR 46ml/min/1.73m2
Dipstick of urine revealed + protein
USS demonstrated ‘normal’ size kidneys
Serum electrophoresis revealed a paraprotein with urinary BJP

25. Fact 1: Haematuria and proteinuria are
flags for further investigation
Fact 2: Combined renal length <20cm
makes CKD likely
Still need to exclude A/CKD

26. Case 3 Mr PS 80 year old ‘Stable’ IHD Not diabetic No ACEI
Acutely SOB with possible rigor
Few crackles L base
Clarithromycin prescribed

27. 24 hours later confused and hypotensive
Emergency admission
Treated as CAP according to hospital
protocol
Rx Vancomycin 1g x 2
Gentamicin 160mg x 2

28. 48 hours later AKI diagnosed
Baseline eGFR 42ml/min/1.73m2
Admission eGFR 22ml/min/1.73m2
‘48h’ eGFR 12ml/min/1.73m2
4 week hospital admission
Probably avoidable with recognition that patient likely to have CKD and risk conferred by this CKD

29. Case 4
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Most recent HbA1c 7.4%
First thoughts?
Rx Ramipril 5mg daily and Metformin 500mg bd

30. Case 5
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Rx Ramipril 5mg daily and Metformin 500mg bd
Pyrexial. BP 130/74. Euvolaemic
WCC 10.6x109/l CRP 48ng/ml
eGFR 42ml/min with a potassium of 4.2mmol/l

31. Case 6
92 year old is seen in clinic having been found by GP to have ‘CKD4’
She is well with an eGFR of 26ml/min
Rest of biochemistry is safe, urine reveals neither blood nor protein
What do I do?
USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction
eGFR was 28ml/min in 2008

32. Fact 1: Haematuria and proteinuria are flags for further investigation
Fact 2: Direction of travel is everything!
Fact 3: Risk factors for AKI include age >65, diabetes, CVD and ACEI/ ARB
Fact 4: Infection is a trigger for AKI in at risk patients even if not involving
urinary tract

33. Case 7
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do?

34. Case 7
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do
Dipstick of urine revealed blood ++ and protein ++

35. Fact 1: Dipstick of urine is your get. out of jail free card
Fact 1: Dipstick of urine is your get out of jail free card Particularly if hypertension.

36. Case 8 78 year old with stable CKD3. Rx Ramipril 5mg daily
eGFR June ml/min April ml/min
Cares for terminally ill husband therefore deferred R hip
replacement
What pain killers would you recommend?
Pharmacist recommended Ibuprofen 400mg daily
4th July ml/min
Stopped Brufen
14th July ml/min

37. X Fact 5: NSAID/COX inhibitors/COX-2 inhibitors
Fact 6: Consider stopping ACEI/ARB
Even in patient with stable kidney function if ‘at risk’
Fact 7: Restart ACEI/ARB when acute event resolved
Patients who need ACEI/ARB should not be deprived of them because of undue concerns about AKI

38. Fact 8: Stop metformin if risk of AKI
Fact 9: Metformin can be used in CKD3
Avoid in CKD3b if significant risk of AKI

39. Kidney medicine in primary care: 7 minutes
Recognition and Prevention of AKI
Is this an at risk patient?
Age >65 years
Vascular disease DM
ACEI/ARB
CKD
Is glomerular perfusion threatened ?
Hypotension or sepsis
NSAID/COXi/COX-2i

40. Fact 10: Slides and more info available at
Wales Deanery CPD for GPs
Clinical
Acute Kidney Injury
Quiz: