A48(Th)
PROGRESSION OF CKD – AN ASSESSMENT OF NSF/NICE RECOMMONDATIONS
Huang, Q1, Xie, C1, Yarwood-Smith, H2, Shiva Kumar, K3
1
University of Birmingham, 2Dudley Primary Care Trust, 3Dudley Group of Hospitals
Trust, West Midlands
INTRODUCTION: Chronic kidney disease (CKD) is associated with increased morbidity and
mortality and is a significant burden on the National Health Service. Progression to end-stage
renal failure is challenging to control and slow down. To aid the prevention and management of
complications of CKD, the National Service Framework (NSF) and National Institute for Health
and Clinical Excellence (NICE) have set out guidelines. Renin-angiotensin antagonists (RAA)
including angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers
(ARB) play a key role in slowing down decline in renal function. The aim of this study was to
investigate the effectiveness of measures taken since the NSF recommendations.
METHOD: This study was carried out at a large primary care practice and the referral hospital
in Dudley, West Midland during 2010. Patient records on the primary care CKD register were
reviewed for control of blood pressure (BP), proteinuria/ microalbuminuria, and estimated
glomerular filtration rate (eGFR) over a five-year period. In addition, patients’ co-morbidities
and treatment with ACEI, ARB and direct renin inhibitor (DRI) were recorded. Effective BP
management was defined as <140/90 mmHg for non-diabetics, and <130/80 mmHg for
diabetics. Progression of CKD was defined as eGFR decline >10ml/min/1.73m2 in 5 years, or
>2 ml/min/1.73m2 per year. Furthermore, the new patient take on rate at the referral hospital for
the past 5 years was also collected.
RESULTS: A total of 1323 CKD patients (Stage 3A to 5), including 295 diabetic patients, were
included (833 female, 490 male; median age of 77yrs). In terms of BP management, 32% (94)
diabetics and 70% (720) non-diabetics reached their recommended targets. 25% (73) of diabetic
patients had microalbuminuria, 86% (63) of these patients were treated with RAA and 38% (28)
were on the maximum licensed dose. 48% (142) diabetics and 32% (330) non-diabetics showed
progression of CKD. Among the progressive group, 73% (346) of the patients were treated with
ACEI/ARB, 25% (117) of these patients were on the maximum licenced dose, and 1% (4) were
on both agents. In addition, patients with progression demonstrated more vascular comorbidities
than the non-progressive group. Interestingly, eGFR was static or improved in 42% (427) of
non-diabetics and 33% (98) of diabetics.
DISCUSSION: BP was poorly controlled, particularly in the diabetic CKD. The diabetic group
not surprisingly showed more severe renal deterioration compared to the non-diabetic group
despite a greater number receiving RAA. For patients who were treated with RAA, only a small
proportion was on the maximal licensed dose and a minority was managed with dual blockade.
There was no significant difference in drug management between the progressive and the nonprogressive CKD patients.
CONCLUSION: CKD management in primary care has improved significantly. The NSF
recommendations have started to reduce the new patient take on rate for dialysis in the Dudley
area. However there is further scope to optimise the treatment especially in the progressive
group. We propose an aggressive approach for CKD patients with diabetes and vascular
complications to optimise treatment of microalbuminuria/ proteinuria and hypertension.
Possible strategies are the use of supra-physiological dosage of ACEI/ARB/DRI or meticulous
dual renin-angiotensin system blockade, especially in younger patients. Further study is
currently being undertaken and preliminary observations in forty patients over a mean period of
20 months has shown an improvement in urinary albumin creatinine ratio with no deterioration
in eGFR.