Embed Size (px)
Citation preview
CKD:CKD:the primary/secondary care the primary/secondary care interfaceinterface
Daniel Ford
Consultant Renal Physician
UHCW
Overview
BackgroundHistory, classification and controversies!
ComplicationsCVD, CKD progression, other complications
CKD ManagementManagement of CKD: role of primary and secondary care
Referral guidelinesWho to screen and when to refer
Discussion
Overview
Background– History of CKD– Classification– Model of CKD
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]
Model of CKD
Levey AS, et al. KI 2007; 72(3): 247-259
Overview
Background
Complications of CKD– Cardiovascular disease– Hypertension– Anaemia– Bone-mineral metabolism– Poor nutritional and functional status– Progression of CKD
Complications of CKD
Complications of CKD
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
Complications of CKD
Anaemia
NHANES III
Complications of CKD
Cardiovascular disease
Go et al. NEJM 2004; 351:1296-1305
Overview
Background
Complications of CKD
Management of CKD– Diagnosis– Managing complications– Progression of CKD– Pre-ERF planning– Primary vs. secondary care management
Diagnosis
CKD classification does not mandate a diagnosis
•Generic management of CKD
•Disease-specific management
Diagnosis of patients starting RRT during 2011
Diagnosis Percentage of patients
Diabetes 24.8
Glomerulonephritis 13.3
Pyelonephritis 7.1
Hypertension 7.0
Polycystic kidney disease 7.2
Renal vascular disease 6.9
Other 16.3
Uncertain 17.3
UKRR 15th Annual Report
CKD Progression
What is significant progression?
What risk factors are associated with progression?
Why is progressive CKD important?
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?
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;72:92-99ONS 2009 estimatesUKRR 13th Annual Report (2009 data)
CKD Progression
What is significant progression?
CKD Progression
What is significant progression?– eGFR decline >5ml/min/1.73m²/year– Or >10ml/min/1.73m² in 5 years
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?
What risk factors are associated with progression?
• Hypertension• Diabetes mellitus• Albuminuria
• Cardiovascular disease
• Smoking• Ethnicity• NSAIDS
CKD Progression
What is significant progression?
What risk factors are associated with progression?
Why is progressive CKD important?
Overview
Background
Complications of CKD
Management of CKD– Diagnosis– Managing complications– Progression of CKD– Pre-ERF planning– Primary vs. secondary care management
(Dialysis) planning
Consequences of late presentation
Rate of late presentation
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.
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
UKRR 13th Annual Report
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
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
Overview
Background
Complications of CKD
Management of CKD– Diagnosis– Managing complications– Progression of CKD– Pre-ERF planning– Primary vs. secondary care management
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
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
CKD Management in primary care
8% of UK population has CKD 3-5
Stevens et al. KI 2007; 72: 92-99
Primary care Renal care
CKD 3 84.6% 1.5%
CKD 4 62.7% 25.1%
CKD 5 30.0% 61.1%
Richards et al. NDT 2008; 23: 556-561
QoFCKD 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
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?
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
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
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?
How often to test for progression?
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?
NICE CKD Guidelines Sep 2008Referral algorithm, p 19-21www.NICE.org.uk/guidance/CG73
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
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.
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?
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)
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
