Transcript Cardiovascular Hot topics

Cardiovascular Hot topics
Dr Saqib Mahmud, MRCP(UK)
CKD
• The introduction of routine reporting of
eGFR has led to 3 outcomes in primary care;
• ‘Worried patients, Increased workload
& confused clinicians’.BMJ2006
Why has CKD been selected as a quality
indicator?QOF2 2006
• Patients with CKD have very high rates of
vascular disease & require aggressive
management of vascular risk factors. (early CKD risk
of death from CVD>ESRF)-low GFR predicts CV disease
• Its incidence is rising dramatically. (doubled in last
10yrs,5% adult population)
• S Cr does not rise until GFR has fallen by 50-
•
70%
Early interventions in CKD improve cardiac &
renal outcomes
eGFR-best
estimate of renal function
• Based on S Cr, age, sex & ethnic origin.
• Does not apply to children, ARF, pregnant
women, oedematous & malnourished.
• eGFR falls after eating meat, ideally
fasting sample or avoid eating cooked
meat day before.
• CKD-diagnosed 2 eGFRs 3/12 apart, not
on the basis of single eGFR
CKD-classification
CKD stage
1
2
eGFR
Kidney damage,
>90
normal eGFR
Kidney damage, reduced 60-89
eGFR
3
Moderate CKD
30-59
4
Severe CKD
15-29
5
ESRF
<15 or
on dialysis
QOF 2006 – CKD register
• CKD1- register of pts>18 with CKD3-5
• CKD2-(90%) on register with record of BP
in last 15/12
• CKD3-(70%) on register with BP<140/85
• CKD4-(80%) patients on ACEI/A2RB-or CI
• Worth 27pts=£3,364/-
Conditions with risk of developing CKD
• Hypertension
• Diabetes
• Heart failure
• Vascular disease
• Urinary outflow obstruction
• Multi-system diseases eg;RA, SLE, vasculitis
• APKD or reflux nephropathy
Monitoring renal function
• Stage 1 & 2 requires evidence of renal
damage eg; Proteinuria, microalbuminuria,
haematuria without urological cause or
known polycystic kidney disease or GN.
(Annual U & Es)
• Stage 3  6/12
• Stages 4 & 53/12
Urine tests
• Dipstick urinalysis for protein,
• If +ve  msu to exclude infection & EMU
for ACR(+>30mg/mmol) or PCR(+>45)
• In diabetics, dipstick negativeACR for
microalbuminuria (+>2.5mg/mmolmales,>3.5 in women)
Management –
is easy
• ‘CKD rarely means dialysis’
• Monitor renal function closely- assess rate
of change
• Tight BP control with preferential use of
ACEI or A2RB
• Pay close attention to CV risk
New patient with eGFR<60
• Review previous results ?rate of deterioration
• Review medication ?nephrotoxicity
• Check BP, urine, full clinical assessment eg ?palpable
bladder
• Repeat U&E within 5/7 (?rapid progression)
• Referral criteria- renal function stable monitor
• Stage 4(if stable, monitor) & 5 should be referred
• Stage 3 if deteriorating function
Long term management to delay
progression and reduce CV events
• Life style advise smoking cessation, wt
reduction, exercise, low protein diet
• Aspirins & statins if CVD risk >20%
• (evidence is that all CKD patients are high risk)
• Strict BP control-QOF2 target <140/85,
but renal guidelines best practice target is
130/80
• Check U&Es before starting, 2/52 after & also 2/52 every
dose change of ACEI or A2RBs
Additional management-CKD3
Renal USS if LUTS, refractory HTN,
unexpected fall in GFR
Immunise-influenza, pneumococcus, Hep B
in CKD4&5
If HB<11-exclude other causes, refer for
ESA, iv Fe
Renal osteodystrophy
• Renal failure failure of Vit D
hydroxylation secondary
hyperparathyroidism
• increased # risk due to faulty bone
remodelling & lowered BMD.
• Check PTH levels, if low check 25-hydroxy
Vit D levels
• Rx- ergo or cole-calciferol with calcium
ACEI / A2RB-Rx or the cause
• ACEI/A2RBs improve outcomes but in
some patients can be nephrotoxic
• A slight reduction in GFR (<15%) or
increase in creatinine is a normal
haemodynamic response to ACE inhibition
& is normally not an indication to stop Rx
unless creatinine rises by >30%
Prescribing in CKD
• Avoid NSAIDs, codeine
• Antibiotics, digoxin, metformin etc –
• ‘use with caution’
• (reduce dose or frequency)
What about elderly patients with low
eGFR- how should we manage them?
• The guideline makes no age distinctions
• BMJ2006;it is ageist not to Rx CKD just because
•
•
someone is elderly.
BJGP editorial Dec2006;elderly with CKD still
benefit from CV risk factor intervention and strict
BP control in elderly slows rate of renal decline
Use clinical judgement & patient circumstances
Take - aways…..
• CKD patients have high risks of CV events
and require aggressive management of
vascular risk factors
• Risk of ESRF is very low
• Best practice target BP is 130/80 with
preferential use of ACEI / A2RB
• Consider aspirin and statins
Thank you
‘The enemy of good
is
better’