Transcript Renal Blood Tests

RENAL BLOOD TESTS
WHAT DO THEY MEAN, WHERE TO GO FOR WHAT TO DO
WHAT WE WILL COVER
• WHO TO SCREEN
• WHAT DO THE RESULTS MEAN
• HOW TO CATEGORISE / CLASSIFY
• MANAGEMENT
• MONITORING
CHRONIC KIDNEY DISEASE (CKD)
• SCREENING FOR CKD – RISK FACTORS
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AGE <60 YEARS
DIABETES, CARDIOVASCULAR DISEASE, UROLOGICAL DISEASE
FAMILY HISTORY OF KIDNEY DISEASE
HYPERTENSION
SMOKING
OBESITY
ETHNICITY – MAORI, PACIFIC, INDO ASIAN (SAME AS CVRA COHORT)
NEPHROTOXIC DRUGS
• ALBUMIN CREATININE RATIO (ACR), ESTIMATED GLOMERULAR FILTRATION RATE (e-GFR) AND MSU
PROTIENURIA
FACTORS AFFECTING URINARY PROTEIN EXCRETION
• INCREASES PROTEIN EXCRETION
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STRENUOUS EXERCISE
POORLY CONTROLLED DM
HEART FAILURE
UTI
ACUTE FEBRILE ILLNESS
UNCONTROLLED HYPERTENSION
HAEMATURIA
MENSTRUATION
PREGNANCY
• DECREASES PROTEIN EXCRETION:
• ACEI/ARB
• NSAIDS
MANAGEMENT OF MICROALBUMINURIA
Men = ACR >2.5mg/mmol AND <25mg/mmol*
Women = ACR >3.5mg/mmol AND <35mg/mmol*
• LOW SALT DIET
• SMOKING CESSATION
• TARGET BP < 130/80 mmhg
• USE ACEI/ARB
• HBA1C < 55 mmol/mol
• STATIN
• ASPIRIN
* Clinical Pathways can differ from Primary Care Handbook
GOALS OF MANAGEMENT OF CKD
MEN = URINE ACR > 25 mg/mmol OR eGFR < 45 ml/min/1.73m2
WOMEN = > 35 mg/mmol OR eGFR < 45 ml/min/1.73m2
• INVESTIGATIONS TO EXCLUDE TREATABLE DISEASE
• REDUCE PROGRESSION OF KIDNEY DISEASE
• REDUCE CVD RISK
• EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS
• AVOIDANCE OF NEPHROTOXIC MEDICATIONS OR VOLUME DEPLETION
• ADJUSTMENT OF MEDICATION DOSES TO LEVELS APPROPRIATE FOR KIDNEY FUNCTION
• APPROPRIATE REFERRAL TO A NEPHROLOGIST WHEN INDICATED
* Clinical Pathways can differ from Primary Care Handbook
MONITORING OF CKD
• CLINICAL ASSESSMENT:
• BLOOD PRESSURE
• WEIGHT
• LABORATORY ASSESSMENT:
• URINE ACR
• BIOCHEMICAL PROFILE INCLUDING UREA, CREATININE AND ELECTROLYTES
• EGFR
• HBA1C (FOR PEOPLE WITH DIABETES)
• FASTING LIPIDS
• FULL BLOOD COUNT
• CALCIUM AND PHOSPHATE
• PARATHYROID HORMONE (6-12 MONTHLY IF EGFR < 45 ML/MIN/1.73M2)
BLOOD PRESSURE REDUCTION
• CKD CAN CAUSE AND AGGRAVATE HYPERTENSION WHICH CAN CONTRIBUTE TO THE PROGRESSION OF CKD
• REDUCING BLOOD PRESSURE TO BELOW THRESHOLD LEVELS IS ONE OF THE MOST IMPORTANT GOALS IN THE
MANAGEMENT OF CKD
• TARGET BP < 140/90 MMHG IF NO PROTEINURIA PRESENT AND LESS AGGRESSIVE TARGET IN ELDERLY
• ACE INHIBITOR OR ARB IS RECOMMENDED AS FIRST LINE THERAPY
• MONITORING OF CREATININE AND POTASSIUM 5-10 DAYS AFTER STARTING AN ACE INHIBITOR OR ARB AND AFTER EACH
DOSE INCREMENT
• COMBINED THERAPY OF ACE INHIBITOR AND ARB IS NOT RECOMMENDED
• MAXIMUM TOLERATED DOSES OF ACE INHIBITOR OR ARB ARE RECOMMENDED
• HYPERTENSION MAY BE DIFFICULT TO CONTROL AND MULTIPLE (3-4) MEDICATIONS ARE FREQUENTLY REQUIRED
NOTE: ACE INHIBITORS AND ARBS CAN CAUSE A REVERSIBLE REDUCTION IN GFR WHEN TREATMENT IS INITIATED. IF THE REDUCTION IS LESS THAN 25% AND STABILISES WITHIN TWO
MONTHS OF STARTING THERAPY, THE ACE INHIBITOR OR ARB SHOULD BE CONTINUED. IF THE REDUCTION IN GFR EXCEEDS 25% BELOW THE BASELINE VALUE, THE MEDICATION
SHOULD BE CEASED AND CONSIDERATION SHOULD BE GIVEN TO REFERRAL TO A NEPHROLOGIST FOR BILATERAL RENAL ARTERY STENOSIS
GLYCAEMIC CONTROL
• TARGET HBA1C < 55 mmol/mol
• FOR PEOPLE WITH DIABETES, BLOOD GLUCOSE CONTROL SIGNIFICANTLY REDUCES THE RISK
OF DEVELOPING CKD, AND IN THOSE WITH CKD REDUCES THE RATE OF PROGRESSION
• METFORMIN - MAX DOSE 2 G/DAY WHEN eGFR < 45 AND STOP WHEN eGFR < 30
PLEASE NOTE THE INCREASING RISK OF HYPOGLYCAEMIC EVENTS IN STAGE 4/5 CKD. THERE IS
POTENTIAL INCREASED EFFECT OF MEDICINES AS RENAL FUNCTION DETERIORATES SO
CONSIDERATION AND CAUTION IS REQUIRED
LIPID LOWERING TREATMENTS
• TC:HDL RATIO < 4
• LIPID-LOWERING TREATMENT SHOULD BE CONSIDERED WHERE APPROPRIATE FOR CVD RISK
REDUCTION
• CARE OF INCREASING RISK OF SIDE-EFFECTS, ESPECIALLY RHABDOMYOLYSIS
LIFESTYLE MODIFICATION
• CESSATION OF SMOKING
• WEIGHT REDUCTION
• LOW-SALT DIET
• PHYSICAL ACTIVITY
• MODERATE ALCOHOL CONSUMPTION
ARE SUCCESSFUL IN REDUCING OVERALL CVD RISK
ABSOLUTE CARDIOVASCULAR RISK ASSESSMENT
• PATIENTS WITH MODERATE OR SEVERE CKD (URINE ACR > 25 mg/mmol IN MALES OR > 35 mg/mmol
IN FEMALES OR eGFR < 45 mL/min/1.73m2) ARE THE HIGHEST RISK OF A CARDIOVASCULAR EVENT.
THEY DO NOT NEED TO BE ASSESSED BY THE CARDIOVASCULAR RISK TOOL
• FOR THESE GROUPS, IDENTIFYING ALL CARDIOVASCULAR RISK FACTORS PRESENT WILL ENABLE
INTENSIVE MANAGEMENT BY LIFESTYLE INTERVENTIONS (FOR ALL PATIENTS) AND
PHARMACOLOGICAL INTERVENTIONS (WHERE INDICATED)
• CONSIDER COMMENCING ASPIRIN FOR THOSE AT HIGH CVD RISK (ORANGE/RED RISK), THOSE
WITH CKD 3B (eGFR < 45) AND/OR PROTEINURIA WITH A PCR > 50 (ACR > 30)
AND/OR/ESPECIALLY THOSE WHO HAVE HAD A MYOCARDIAL EVENT. SEE CKD MANAGEMENT IN
GENERAL PRACTICE BY KIDNEY HEALTH AUSTRALIA/ANZSN/RACGP
COMMONLY PRESCRIBED DRUGS THAT MAY NEED
TO BE REDUCED IN DOSE OR CEASED IN CKD
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ANTIVIRALS
BENZODIAZEPINES
COLCHICINE
DABIGATRAN
DIGOXIN
EXENATIDE
FENOFIBRATE
GABAPENTIN
INSULIN
LITHIUM
• METFORMIN (MAX DOSE 2 G/DAY EGFR 30-45
ML/MIN/1.73 M2 AND STOP IF EGFR < 30
ML/MIN/1.73 M2)
• OPIOID ANALGESICS
• SAXAGLIPTIN
• SITAGLIPTIN
• SOTALOL
• SPIRONOLACTONE
• SULPHONYLUREAS (ALL)
• VILDAGLIPTIN
COMMONLY PRESCRIBED DRUGS THAT CAN
ADVERSELY AFFECT KIDNEY FUNCTION IN CKD:
• NSAIDS AND COX-2 INHIBITORS
• BEWARE THE 'TRIPLE WHAMMY' OF NSAID/COX-2 INHIBITOR, ACE INHIBITOR AND DIURETIC (LOW DOSE
ASPIRIN IS OKAY) WHICH CAN RESULT IN A POTENTIALLY SERIOUS INTERACTION, ESPECIALLY IF VOLUMEDEPLETED OR CKD IS PRESENT. ENSURE INDIVIDUALS ON BLOOD PRESSURE MEDICATION ARE AWARE OF
THE NEED TO DISCUSS APPROPRIATE PAIN RELIEF MEDICATION WITH A GENERAL PRACTITIONER OR
PHARMACIST.
• RADIOGRAPHIC CONTRAST AGENTS
• AMINOGLYCOSIDES
• LITHIUM
• CALCINEURIN INHIBITORS
WHAT DO YOU KNOW?
• WHO TO SCREEN
• WHAT DO THE RESULTS MEAN
• HOW TO CATEGORISE / CLASSIFY
• MANAGEMENT
• MONITORING
INDICATIONS FOR REFERRAL TO A NEPHROLOGIST
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REFERRAL TO A SPECIALIST RENAL SERVICE OR NEPHROLOGIST IS RECOMMENDED:
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IF EGFR < 30 ML/MIN/1.73M2
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PERSISTENT SIGNIFICANT ALBUMINURIA (URINE ACR > 70 MG/MMOL)
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A CONSISTENT DECLINE IN EGFR FROM A BASELINE OF < 60 ML/MIN/1.73M2 (A DECLINE > 5 ML/MIN/1.73M2 OVER A SIX MONTH PERIOD WHICH IS CONFIRMED ON
AT LEAST THREE SEPARATE READINGS)
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GLOMERULAR HAEMATURIA WITH MACROALBUMINURIA
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CKD AND HYPERTENSION THAT IS DIFFICULT TO GET TO TARGET DESPITE AT LEAST THREE ANTI-HYPERTENSIVE AGENTS.
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ANYONE WITH AN ACUTE PRESENTATION AND SIGNS OF ACUTE NEPHRITIS (OLIGURIA, HAEMATURIA, ACUTE HYPERTENSION AND OEDEMA)
SHOULD BE REGARDED AS A MEDICAL EMERGENCY AND SHOULD BE REFERRED WITHOUT DELAY.
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ALSO TAKE INTO ACCOUNT THE INDIVIDUAL'S WISHES AND COMORBIDITIES WHEN CONSIDERING REFERRAL.
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REFERRAL IS NOT NECESSARY IF:
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STABLE EGFR ≥ 30 ML/MIN/1.73M2
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URINE ACR < 30 MG/MMOL (WITH NO HAEMATURIA)
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CONTROLLED BLOOD PRESSURE.
THE DECISION TO REFER OR NOT MUST ALWAYS BE INDIVIDUALISED. PARTICULARLY IN YOUNGER INDIVIDUALS THE INDICATIONS FOR REFERRAL MAY
BE LESS STRINGENT.