1. The management of renal problems in primary care Hugh Gallagher Consultant Nephrologist St Helier Hospital

2. The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

3. The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

4. Nephrology workload “High” maintenance –Dialysis (HD/PD) –Predialysis –Acute renal failure –Acute transplantation –“Special”, eg vasculitis “Low” maintenance –CKD –Long term transplant follow up –Hypertension –Others

6. “Local health organisations can work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of glomerular filtration rate (eGFR), calculated and reported automatically by all clinical biochemistry laboratories.” Renal NSF Part 2, Dept of Health, 2004

7. MDRD formula –Age –Sex –Creatinine –Ethnicity (black vs. non-black) Cockcroft-Gault formula –Age –Sex –Creatinine –Weight

8. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M70150

9. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M7015046

10. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M7015046 80M60170

11. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M7015046 80M6017026

12. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M7015046 80M6017026 80F60170

13. AgeSexWeight (kg) Serum creatinine ( μ mol/L) Estimated GFR (ml/min) 60M7015046 80M6017026 80F6017022

14. K-DOQI Classification of CKD StageGFR (ml/min) Description 1> 90 1 Kidney damage with normal or  GFR 260-89 1 Kidney damage with mild  GFR 330-59 Moderate  GFR 415-29 Severe  GFR 5< 15Kidney failure Chronic kidney disease is defined as either kidney damage or GFR 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

15. K-DOQI Classification of CKD StageGFR (ml/min) DescriptionPrevalence (%) 1> 90 1 Kidney damage with normal or  GFR 3.3 260-89 1 Kidney damage with mild  GFR 3.0 330-59 Moderate  GFR 4.3 415-29 Severe  GFR 0.2 5< 15Kidney failure0.2 Chronic kidney disease is defined as either kidney damage or GFR 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging

16. Prevalence of Unreferred CKD in East Kent East Kent population 601,000 Small ethnic population Study period Oct 2000 - Sept 2002 Using opportunistic serum creatinine –Monthly screening of Chemical Pathology Database –Review after two months

17. Males serum creatinine  180  mol/L Females serum creatinine  135  mol/l Approximate to GFR < 30-40ml/min/1.73m 2 CKD definition

18. Prevalence 5554pmp Median Age 82 (18-103) Median GFR 28.0 (3.6-42.8) 41.8% Male 17.8% diabetes CRF Population CRF Population Calculated GFR (mls/min) 40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5 Number of cases 1600 1400 1200 1000 800 600 400 200 0 Prevalence 0.55% Median Age 82 (18-103) Median GFR 28.0 (3.6-42.8) 41.8% Male 17.8% diabetes CKD population

19. Unreferred CRF population Unreferred CRF population Median Age 83 (18-103) Median GFR 28.5 (4.1-42.8) 39.2% Male 17.7% Diabetes Calculated GFR (mls/min) 40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5 Number of patients 1400 1200 1000 800 600 400 200 0 Prevalence 0.47% Median Age 83 (18-103) Median GFR 28.5 (4.1-42.8) 39.2% Male 17.7% Diabetes Unreferred population

20. <0.01 28.5 (4.1-42.8) 23.4 (4.8-39.8) eGFR (ml/min/1.73m) <0.0160.843.8Women (%) <0.0183 (18-103)70 (18-91)Age (yrs) 4708846 Prevalence (pmp) PUnreferredKnown John et al AJKD 2004;43:825-835 DOD/0604-04 Comparison of known and unreferred populations

21. In real money... GP practice 10,000 patients –Stage 3 CKD: 500 patients –Stage 4 CKD: 20 patients –Stage 5 CKD: 20 patients –Unreferred stage 4 and 5: 28 patients Renal unit, serving 1.8 million population –Unreferred stage 4 and stage 5: 5,100 patients

22. The introduction of eGFR will facilitate early recognition of CKD It will also result in increased awareness of advanced CKD previously not recognised as such A “coping” strategy needs to be developed before eGFR reporting is introduced

23. The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

25. Causes of CKD in the elderly

26. Functional consequences of CKD Hypertension Anaemia Disorders of Ca/Pi/PTH metabolism –renal osteodystrophy –vascular calcification

27. Snapshot of a CKD population in primary care GFR estimated on patients from 12 practices in Surrey, Kent and Greater Manchester 19% of sample (5% population) stage 3-5 CKD mean age 74 years (control 57 years) 75% stage 3-5 (22% control) co-existing circulatory disease 25% stage 3-5 (men) prostatic disease 15% stage 3-5 anaemic by WHO (4% requiring treatment by European Best Practice guidelines) 3% recorded as having a renal disease

28. Comorbidities in CKD

29. The “epidemic” of CKD What is a typical CKD patient? A role for increased primary care involvement? How can we achieve this?

30. Most CKD patients are stable

31. Cardiovascular diseases in CKD Damage to the heart (Uraemic cardiomyopathy ) Damage to the arteries (Uraemic arteriopathy)

32. Uraemic Cardiomyopathy Thickening of the wall Dilation of the heart Myocardial scarring Calcification Conduction defects

33. Uraemic Arteriopathy Thickening of the wall Atherosclerosis Stiffening of the artery Calcification

34. Adapted from Levey AS et al. Am J Kidney Dis 1998; 32: 853-906. Cardiovascular Mortality Rates are Higher among Dialysis Patients General population: male General population: female Dialysis: male Dialysis: female 10 100 1 0.01 0.1 0.001

35. Go, A. S. et al. N Engl J Med 2004;351:1296-1305 Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization among 1,120,295 Ambulatory Adults, According to the Estimated GFR

36. Most renal patients die of CV causes well before they reach ESRD Their management is therefore that of their CV risk

37. Risk factors CVS DISEASE –Hypertension –Dyslipidaemia –Smoking –Obesity –Lack of exercise PROGRESSION –Hypertension –Dyslipidaemia –Smoking –Obesity –Lack of exercise

38. Patient choice…..

39. “No added value” consultations “The BP today was too high at 160/90. I have not made any changes today but suggest you repeat it in 2 weeks….” Where are blood tests performed?

40. Protocol-based nurse-led clinics IT support GMS contract

41. The “epidemic” of CKD What is a typical CKD patient? A role for increasing primary care involvement? How can we achieve this?

42. Principles Collaborative approach between primary and secondary care Concise practice guidelines for referral and management Role for practice and community-based specialist nurses Support from nephrologists for all stages Dedicated nephrology care for predialysis and deteriorating

43. Dangers Late referral Missing ARF Undertreatment of renal anaemia and abnormalities of bone biochemistry Issues around clinical responsibility Workload

44. Short-term goals Education Pilot and issue guidelines for –management of newly discovered abnormal eGFR in primary care –management of CKD (including indications for referral) in primary care Implement eGFR reporting by St Helier laboratories Link the management of CKD to that of CV risk

45. Longer-term goals Specialist nurse-led community based renal clinics Protocol-based approach for management of renal anaemia and bone disease in the community Renegotiation of GMS contract Commissioning arrangements

46. The nephrologist’s view

47. The GP’s view