Transcript Document

CKD:
the primary/secondary care
interface
Daniel Ford
Consultant Renal Physician
UHCW
Overview
Background
History, classification and controversies!
Complications
CVD, CKD progression, other complications
CKD Management
Management of CKD: role of primary and secondary
care
Referral guidelines
Who 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]
CKD Classification
www.NICE.org.uk/guidance/CG73
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;72:92-99
ONS 2009 estimates
UKRR 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
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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
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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
QoF
CKD 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?
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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?
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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 2008
Referral algorithm, p 19-21
www.NICE.org.uk/guidance/CG73
People with CKD in the following groups should usually be
referred for specialist assessment:
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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, email 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
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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