Dr Michael Gordon
GP
Gleadless Medical
Centre
Sheffield michael.gordon@sheffield.ac.uk

Dr Michael Gordon
Primary Care Lead
Yorkshire & The Humber Renal Network

Dr Michael Gordon
(emisWeb expert…not)

ACR measurement fiddly but important
• Measure albumin:creatinine ratio on a spot urine sample (preferably early morning)
• If the initial ACR is >30 and <70 mg/mmol, confirm by a subsequent early morning sample. If the initial
ACR is >70mg/mmol a repeat sample need not be tested
• In people without diabetes, clinically significant proteinuria is present when ACR >30mg/mmol.
• In people with diabetes microalbuminuria (ACR
>2.5mg/ mmol in men and ACR >3.5mg/mmol in women) is clinically significant

• NICE output
• QOF requirements
• Remembering everything v knowing where to look
• Getting excited about niche areas – e.g. CKD
• Thinking hard when tired – Lab results.

Proteinuria predicts progression of CKD
RR of progression
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
<0.5
0.5-
0.9
1.0-
1.4
1.5-
1.9
2.0-
2.9
3.0-
3.9
Urine protein excretion (g/day)
4.0-
4.9
5.0-
5.9
6.0+
Ann Intern Med 2003;139:244-252

CV Deaths/100 patient-years
20
15
10
5
0
40
35
30
25 albuminuria<30mg/dl albuminuria<300mg/dl
Muntner P et al JASN 2002;13:745 albuminuria>300mg/dl

CVD the big killer

For
 Brighten the room
 Info at fingertips
 Promotes humility
Against
 Clutter
 Get lost
 Undermine aura of omniscience
 Gathering data to check

Packages of care for patients with Chronic Kidney Disease
CKD
ACR< 30 (microalbuminuria)
Stage eGFR BP target
ACE/ARB use U&E
Other
Tests to consider Refer
ACR 30-69 (proteinuria)
Read ACE/ARB
Code BP target use U&E
Other
Tests to consider Refer
ACR > 70 (proteinuria)
Read ACE/ARB
Code BP target use U&E
Other
Tests to consider Refer
Read
Code
1
> 90
& renal damage < 140/90
Not
Indicated 12m 1Z18 < 130/80
Preferred
First
Line 12m 1Z17 < 130/80
Preferred
First
Line 12m 1Z17
2
3a
3b
4
5
60-89
& renal damage < 140/90
45-59
30-44
15-29
<15
< 140/90
< 140/90
< 140/90
< 140/90
Not
Indicated 12m
Not
Indicated 6m
Not
Indicated 6m Hb
Hb
Ca/PO4
Not
Indicated 3m
PTH
US
Not
Indicated 6w
Hb
Ca/PO4
PTH
US
1Z1A < 130/80
1Z1E < 130/80
1Z1G < 130/80
Usual 1Z1J < 130/80
Usual 1z1L < 130/80
Preferred
First
Line
Preferred
First
Line
Preferred
First
Line
12m
6m
Preferred
First
Line
Preferred
First
Line
6m Hb
Hb
Ca/PO4
3m
PTH
US
6w
Hb
Ca/PO4
PTH
US
1Z19 < 130/80
1Z1D < 130/80
1Z1F < 130/80
Usual 1Z1H < 130/80
Usual 1Z1K < 130/80
Preferred
First
Line
Preferred
First
Line
Preferred
First
Line
12m
6m
Preferred
First
Line
Preferred
First
Line
6m Hb
Hb
Ca/PO4
3m
PTH
US
6w
Hb
Ca/PO4
PTH
US
1Z19
Usual !Z1D
Usual 1Z1F
Usual 1Z1H
Usual 1Z1K
The Basic Package for all stages of CKD

CVD risk assessment

Nephrotoxic drug avoidance

Co-morbidities e.g. Heart Failure and prostatic obstruction – optimize treatment.

Dietary & lifestyle advice. Low fat, sodium and potassium.
Stop smoking.
Progression of CKD
 eGFR decline of > 5ml in 1 year (based on 3 readings over 90 days) or
10ml in 5 years – Seek advice from secondary care.
Anaemia

Hb < 11g may be considered as renal anaemia when other causes have been excluded.
African/Carribean patients
 eGRF correction factor x 1.21 should be applied.
Diabetes & CKD

BP target <130/80 applies to all with microalbuminuria i.e.
Male > 2.5mg/mmol, Female > 3.5g/mmol. (2 or more measurements)

ACE/ARB use is indicated as first line treatment at all CKD stages .
Haematuria – see http://www.baus.org.uk/Resources/BAUS/Documents/PDF%20Documents/BA
US%20in%20general/haematuria_consensus_guidelines_July_2008.pdf
This table is based on NICE CKD 2008 guidelines. © Michael Gordon 2011

• What do you need to know about the patient to make sense of the result?
• What else do you need to know to care for the patient optimally?

• Gender
• Diabetic?
• CKD already?
• Latest and previous eGFR
• Coded for microalbuminuria already
• Previous ACR readings
• BP – latest
• BP – appropriate target
• ACE/ARB use
• ACE/ARB allergy

• Check the facts (concepts)
• Follow user defined flowchart
• End in user specified output
• Applicable in a wide range of clinical situations

emis Web protocols – building blocks
1. Concepts
– Something asked of the recorded data
– e.g. gender, Lastest BP < 140/90, coding present
2. Questions
– Posed to the operator
– e.g. has the patient got specific symptoms
3. Outputs
– Guidance for the operator
– e.g. a text box saying repeat in 1 year

emisWeb protocols – construction process
• Pencil, paper rubber
• Build in emisWeb
• Whiteboard, post-it notes, peer scrutiny
• Attach to f12 key to run
• Engage colleagues to test

• Type 2 Diabetes
• Latest BP 140/82
• Not coded for microalbuminuria/proteinuria
• No recent consultation with UTI symptoms
• 2 previous ACRs > 3.5
• Allergic to ace/arb
• Latest ACR - 3.6

• Type 2 Diabetes
• Latest eGFR 65
• Latest BP 129/79
• No recent symptoms of UTI
• On Ramipril
• Previous ACRs two > 2.5
• No microalbuminuria coded
• Latest ACR - 25

• Not diabetic
• Last eGFR 45
• CKD stage 3 coded
• Latest BP 120/78
• On Losartan
• No UTI symptoms
• Latest ACR - 35

• Not diabetic
• CKD stage 3 coded
• Last eGFR 50
• Latest BP 130/80
• No UTI symptoms
• Latest ACR - 50

• NHS Kidney Care – How to Guides
– Hosting videos and protocol to download
• Partners at Gleadless Medical