CKD presentation
2.12.10
CKD definition
“Irreversible impairment of kidney function”
How do you accurately assess renal
function?
Serum creatinine
eGFR(more accurate than Cr)
Complex meaurements
Background
• 1 in 10 people in the UK have chronic kidney disease
(CKD)
•
Treatment can prevent or delay the progression of CKD
and reduce the risk of cardiovascular disease.
• CKD is frequently unrecognised, often existing with other
conditions such as cardiovascular disease or diabetes.
• 30% of patients with advanced CKD are referred late to
nephrology services from primary and secondary care.
CKD stages
Stage Description
GFR
QOF
1
Normal kidney function but urine findings,
structural abnormalities or genetic trait point to
kidney disease
>90
No
2
Mildly reduced kidney function, with other
findings point to kidney disease
60-89
No
3
Moderately reduced kidney function
45-59 (3a) Yes
30-44 (3b)
4
Severely reduced kidney function
16-29
Yes
5
Very severe, or established kidney failure
<15
Yes
Prevalence
UK study (Drey et al, AJKD 2003) - 5554 per million population have CKD
stages 3-4
US study (NHANES; AJKD 2003) - 4.5% of adult population have CKD stages
3-4
2/3 > 70 years old
1/4 diabetic
3/4 hypertensive
Prevalence
31.2
% of population
35
30
25
20
15
10
5
0
4.3
0.2
0.2
CKD5, GFR<15 CKD4, GFR 15- CKD3, GFR 30- CKD2, GFR 6089, mild
59, moderate
29, severe
or dialysis
CKD stage
Growing problem in UK
USRDS, 2000
Causes of Severe(4-5) CKD
•
•
•
•
40%
20%
20%
10%
Diabetes (mostly type 2)
Reno-vascular disease
Hypertension
Urological problems (inc.
congenital abnormalities of
urinary tract)
• Glomerulo-nephritis & vasculitis
• Congenital kidney disease
Early identification
– Offer testing for CKD where the following
risk factors are present:
• diabetes
• hypertension
• cardiovascular disease
• structural renal tract disease
• renal calculi
• prostatic hypertrophy
• multisystem diseases with potential kidney involvement
• opportunistic detection of haematuria or proteinuria
• family history of stage 5 CKD or hereditary kidney disease
Who should be tested for CKD?
At risk individuals
• Diabetes
• HTN
• Cardiovascular (IHD, PVD, CVD, CCF)
• Structural renal tract disease, calculi or
prostatic hypertrophy
• Multisystem disease with renal impairment
• FHx of CKD5 or hereditary kidney disease
• Opportunistic detection of haematuria or
proteinuria
Management of CKD 3-5 patients
• Slow progression
Hypertension
Proteinuria
• Manage cardiovascular risk
Statins, DM control, Smoking
• Manage renal-specific complications/risks
Anaemia
Bone disease
• Prepare for renal replacement therapy
CKD 3 management in primary
care
• DM, IHD, Htn
• Risk factor management
• Not much specialist renal medicine involved in
majority of CKD 3
• Refer if refractory hypertension, complications of
renal failire, renal artery stenosis etc…
• Identify those with progressive CKD and refer
Identify progressive CKD
• Obtain minimum 3 GFRs over not less
than 90 days
• If new finding low GFR, repeat within 2
weeks to exclude ARF
• Define progression as GFR fall > 5 /yr or
10 in 5 yrs
ACE inhibitor/ ARBs
• Offer to:
– Diabetes and ACR > 2.5 ± HTN/CKD
– Non-diabetic with CKD and high BP and ACR
30+ mg/mmol (0.5g/24 hrs)
– Non-diabetic with CKD and ACR > 70
regardless of blood pressure or risk factors
– Titrate to maximum tolerated dose before add
in second agent
The metabolic complications of CKD
Uraemia
Stage 5
Hypertriglyceridaemia
Hyperphosphataemia
Stage 4
Ca absorption and
lipoprotein activity
reduced
Metabolic acidosis
Hyperkalaemia
Stage 3
Malnutrition, LVH, anaemia
PTH increases at
GFR 50-60
Stage 2
Stage 1
When to refer
• Diagnostic uncertainty
• Rapidly deteriorating renal function. >5% GFR
per year or >10% over 5 years
• Haematoproteinuria (without biopsy diagnosis)
• Poorly controlled BP or proteinuria despite
angiotensin blockade
• Developing hyperparathyoidism, anaemia or
difficult to manage CKD complications
• To prepare for dialysis (Stage 4/5 CKD)
If EGFR <60
• look at previous results (rate of change)
• review medication
• assess clinically
– urinary symptoms, bladder, BP, heart
• dipstick urine
– blood and protein – refer
– protein only – greater than ++ – refer
• repeat serum creatinine within 5 days if new
finding
• either enter into a chronic disease management
program or refer
EFGR <30
• refer to nephrology if
– diagnostic uncertainty
– candidate for RRT
– metabolic complications that would respond to
treatment even if not for RRT
• anaemia
• hypocalcaemia, vitamin D deficient, hyperparathyroidism
• hyperkalaemia
– symptom control as part of conservative care program
Blood pressure control
– In people with CKD aim for:
systolic blood pressure below 140 mmHg
(target range 120–139 mmHg)
diastolic blood pressure below 90 mmHg
– In people with CKD and diabetes
- or when ACR  70mg/mmol, aim for:
systolic blood pressure below 130 mmHg
(target range 120–129 mmHg)
diastolic blood pressure below 80 mmHg
CVD and CKD
• Risk of CVD is doubled in Stage 3 CKD
• Risk of CVD is doubled with microalbuminuria
• Annual mortality from CVD is increased 10 – 100
times with kidney failure (Stage 5 CKD)
• First year CVD mortality x5 greater with Stage 5
CKD + DM (17%) than Stage 5 CKD alone
(3.5%)
Late referral
• Late referral associated with
– increased age
– more frequent co-morbidity
• diabetes
• renovascular disease
• cardiac failure
Late referral
• Consequences
– no vascular access
– prolonged hospitalization (40 vs 15 days/year)
– increased mortality
Proteinuria
• Use albumin: creatinine ratio (ACR) (more
sensitive at low levels)
• ACR in diabetes
• PCR may be used for quanitification and
monitoring