CKD-Chronic Kidney Disease

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Becky Allcock

What is CKD?
New term for chronic renal failure Classified into 5 stages according to eGFR
Stage Stage Stage Stage Stage 12345eGFR >90 eGFR 60-89 eGFR 30-59 eGFR 15-29 eGFR <15

Diagnosis requires abnormalities to be present

for at least 3 months. Its common- 5% have stage 3-5

Where did all this come from?

Guidelines published by committee on renal
disease, RCP, Renal association and RCGP
Chronic Kidney disease in adults:UK guidelines for identification, management and referral March 2006

SIGN 97-Feb 2007 NICE guideline in progress-Due Sept 2008 QOF points-CKD is one of the new clinical
domains

What is eGFR?
Estimated glomerular filtration rate More sensitive marker of CHRONIC renal
impairment than creatinine. Similar to creatinine clearance

How do we calculate it?

Thankfully its done for us in Tayside MDRD formula 86 x (Creat / 88.4)- x (Age)- x (0.742 if
1.154 0.203

female) x (1.210 if black).

On-line calculator www.renal.org Lab result is better measure than

calculation

Whats normal?
Trend over time is useful >90ml/min/1.73m is normal 60-90 does not itself indicate CKD unless
evidence of kidney damage Tayside gives numerical value up to 60 eGFR <60 represents CKD eGFR decreases with age from 40 by a loss of 1ml/min/year

What do we need to do about a low eGFR?

If unexpected look at historic creatinine
-if big change or no historic records repeat in 1 week if well -if unwell consider acute renal injury rpt test and discuss with specialist

Check patients blood pressure

-target BP is 130/85, if there is proteinuria a lower target is recommended 120/75 -QOF target is 140/85 -Treat with ACEI OR ARB (angiotensin II receptor blockers) -Check potassium before and after two weeks and after dose change -If someone is well controlled on other agents and no proteinuria do not change jut because CKD3 -If BP >150/90 and on three antihypertensives should be referred to appropriate specialist

What do we need to do about a low eGFR?

Test for proteinuria
dip-stick annually, change in BP, oedema or systemic disease is an indication for dip-stick testing -consider infection -if positive dip stick send white topped plain bottle to lab for total protein:creatinine ratio (TPCR) -Normal TPCR is <15mg/mmol ->45mg/mmol is considered proteinuria
-urine

-Check

for anaemia Hb <11g/dl

What do we need to do about a low eGFR?

Manage other cardiovascular risk Improve control of heart failure and diabetes Medication review of drugs which impair renal

function In men consider prostatic disease causing outflow obstruction Asses stability of disease (by monitoring creatinine every 6-12 months) Identify those that need referral to nephrology

Who requires referral to nephrology?

A Summary-further guidance www.renal.org
-Those with acute renal failure -Those with significant proteinuria (>1g/day) equivalent to protien:creatinine ratio of 100mg/mmol -Microscopic haematuria (may need urology referral first) -All stage 5 (stage 4 should be discussed) -Those with functional consequence of CKD eganaemia, bone disease, refractory hypertension

What info is required for referral?

Dates and results of previous serum creatinine Serum potassium Haemoglobin Past medical history and full drug history Blood pressure Dipstick result and total protein:creatinine ratio if more than trace of protein present ?Renal u/s-local policy If diabetic HbA1c Details of prostate disease Some may not be appropriate for referral

How often to measure eGFR

Annually in at risk groups Stage: 1 and 2 (only diagnosed if renal

impairment)-annually Stage 3: 6/12 on diagnosis, annually when stable Stage 4: 3/12 on diagnosis, six monthly when stable Stage 5: Three monthly

What QOF points are available?

Practice needs to produce a register of patients

over 18 years of age with CKD 3-5. (6 points) Percentage of those on the register who have a recorded BP in last 15 months (6 points) Percentage of patients on the register in whom last BP reading in last 15 months is <140/85 (11 points) Percentage of patients on CKD register who are treated with an ACEI or ARB unless contraindicated or side effects recorded. (4 points)

References
CKD Frequently asked questions. April
2007 www.renal.org Chronic Kidney disease in adults:UK guidelines for identification, management and referral March 2006 www.bma.org.uk/ap.nsf/content/gof06 www.opsi.gov.uk