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THE CHALLANGES OF MANAGING TRADITIONAL CARDIOVASCULAR RISK
FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE III AND IV ACROSS
THE NORTH WEST– A RE-AUDIT 2013
Dr C Goldsmith, Consultant Nephrologist, Aintree Hospital, Liverpool.
Dr G Gulcicek, Foundation Year 2 Trainee, Mrs T Powell, Regional Renal Audit Coordinator,
Manchester Royal Infirmary, Department of Renal Medicine.
INTRODUCTION: Chronic Kidney Disease (CKD) is increasingly recognised as a public health problem in the UK. People diagnosed with CKD are at high risk of future cardiovascular disease irrespective of the presence of traditional risk factors such as diabetes, hypertension and smoking. The recognition of the importance of non-traditional risk factors such as uraemia, bone mineral disorder, anaemia, salt and fluid overload is becoming better understood. Nevertheless modification of traditional risk factors remains the cornerstone of patient management and this re-audit was performed to assess adherence to Renal Association standards in hospitals across North West England.
METHODOLOGY: Patient data was gathered prospectively from renal clinics from
Manchester Royal Infirmary, Aintree Hospital, Arrowe Park Hospital and Royal Salford
Hospital between November 2012 to April 2013. Inclusion criteria were adults aged 18 and over with an estimated GFR of <59 mls/min/1.73m². There were a total of 157 patients whose data was obtained from computer systems and clinic records. The data was collated and analysed centrally by the regional audit coordinator. A data collection form was used that included patient demographics, drugs, co-morbidities and recent laboratory data.
RESULTS: 41% risk of cardiovascular disease for patients in CKD stage IV, (27.1% in 2011) and 49% risk in Stage IIIb (42.7% in 2011). The risk is increased with decreasing eGFR with
70% cardiovascular risk in CKD Stage IV (50.7% in 2011). Hypertension (HTN) attributed the most with 91% followed by Diabetes Mellitus (DM) and anaemia (HB<11)
Table 1. Cardiovascular Risk Factors for CKD patients Stage III and IV in North West Region
<30 30-44 45-59
2011
50.7
2013
70
2011
42.7
2013
49
2011
27.1
2013
41
23
87.8
10
32
91
32
16.1
86.6
4.1
56
95
14
12
71.4
2.9
52
85
12
BP was poor with <30% of diabetic and <40% of non diabetic patients have a spot clinic BP less than <130/80 or <140/90 respectively. BMI was calculated in 81 patients (51%) of which only 12 patients had a BMI within the healthy range. 75 patients (47%) of the group had diabetes and in those patients the recorded Hbalc 27% were below (27%) or above (46%) recommended target Hba1c of 6.5-7.5. A total of 35 of 87 patients with a recorded cholesterol achieved a total cholesterol of <4mmol/l. Statin were used in 70% with a recorded intolerance of 6% although the use of ezetimibe was low <10%. Smoking status was well recorded compared to 2011 audit with a prevalent current smoking rate of 7.6%. There were high rates of cardiovascular, cerebrovascular and PVD of up 20% or greater amongst the group.
However the use of ACE or ARBs showed wide variability of 33 and 81% between centres.
Beta blocker use was high (>70%) across the region. Between 15-20% of patients were prescribed iron, erythrocyte stimulating agents and vitamin D respectively. However, binder usage was low at <5% across the population studied.
CONCLUSION: The audit concluded that overall the risk of cardiovascular disease rose dramatically with worsening CKD and that cardiovascular risk factors are poorly addressed in the tested sample of 157 patients with CKD Stage III and IV. Similar to 2011, incomplete documentation of history and risk factors for cardiovascular disease remain unfulfilled across the North West. Traditional risk factors such as HTN, cholesterol and diabetic control compared to renal association standards was poor. Formatted letters that highlight the relevant traditional and non-traditional risk factors for CKD progression for Nephrologists and
General Practioners may help address this. Patient education is recommended to include lifestyle and dietary modification.