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CKD-Chronic Kidney Disease ????????????? Becky Allcock What is CKD? • New term for chronic renal failure • Classified into 5 stages according to eGFR Stage Stage Stage Stage Stage 12345eGFR >90 eGFR 60-89 eGFR 30-59 eGFR 15-29 eGFR <15 • Diagnosis requires abnormalities to be present • for at least 3 months. It’s common- 5% have stage 3-5 Where did all this come from? • Guidelines published by committee on renal disease, RCP, Renal association and RCGP Chronic Kidney disease in adults:UK guidelines for identification, management and referral March 2006 • SIGN 97-Feb 2007 • NICE guideline in progress-Due Sept 2008 • QOF points-CKD is one of the new clinical domains What is eGFR? • Estimated glomerular filtration rate • More sensitive marker of CHRONIC renal impairment than creatinine. • Similar to creatinine clearance How do we calculate it? • Thankfully its done for us in Tayside • MDRD formula 86 x (Creat / 88.4)- x (Age)- x (0.742 if 1.154 0.203 female) x (1.210 if black). • On-line calculator www.renal.org • Lab result is better measure than calculation What’s normal? • Trend over time is useful • >90ml/min/1.73m² is normal • 60-90 does not itself indicate CKD unless evidence of kidney damage • Tayside gives numerical value up to 60 • eGFR <60 represents CKD • eGFR decreases with age from 40 by a loss of 1ml/min/year What do we need to do about a low eGFR? • If unexpected look at historic creatinine -if big change or no historic records repeat in 1 week if well -if unwell consider acute renal injury rpt test and discuss with specialist • Check patients blood pressure -target BP is 130/85, if there is proteinuria a lower target is recommended 120/75 -QOF target is 140/85 -Treat with ACEI OR ARB (angiotensin II receptor blockers) -Check potassium before and after two weeks and after dose change -If someone is well controlled on other agents and no proteinuria do not change jut because CKD3 -If BP >150/90 and on three antihypertensives should be referred to appropriate specialist What do we need to do about a low eGFR? • Test for proteinuria dip-stick annually, change in BP, oedema or systemic disease is an indication for dip-stick testing -consider infection -if positive dip stick send white topped plain bottle to lab for total protein:creatinine ratio (TPCR) -Normal TPCR is <15mg/mmol ->45mg/mmol is considered proteinuria -urine -Check for anaemia Hb <11g/dl What do we need to do about a low eGFR? • Manage other cardiovascular risk • Improve control of heart failure and diabetes • Medication review of drugs which impair renal • • • function In men consider prostatic disease causing outflow obstruction Asses stability of disease (by monitoring creatinine every 6-12 months) Identify those that need referral to nephrology Who requires referral to nephrology? • A Summary-further guidance www.renal.org -Those with acute renal failure -Those with significant proteinuria (>1g/day) equivalent to protien:creatinine ratio of 100mg/mmol -Microscopic haematuria (may need urology referral first) -All stage 5 (stage 4 should be discussed) -Those with functional consequence of CKD eganaemia, bone disease, refractory hypertension What info is required for referral? • • • • • • • • • • Dates and results of previous serum creatinine Serum potassium Haemoglobin Past medical history and full drug history Blood pressure Dipstick result and total protein:creatinine ratio if more than trace of protein present ?Renal u/s-local policy If diabetic HbA1c Details of prostate disease Some may not be appropriate for referral How often to measure eGFR • Annually in at risk groups • Stage: 1 and 2 (only diagnosed if renal impairment)-annually • Stage 3: 6/12 on diagnosis, annually when stable • Stage 4: 3/12 on diagnosis, six monthly when stable • Stage 5: Three monthly What QOF points are available? • Practice needs to produce a register of patients • over 18 years of age with CKD 3-5. (6 points) Percentage of those on the register who have a recorded BP in last 15 months (6 points) Percentage of patients on the register in whom last BP reading in last 15 months is <140/85 (11 points) Percentage of patients on CKD register who are treated with an ACEI or ARB unless contraindicated or side effects recorded. (4 points) • • References • CKD Frequently asked questions. April 2007 • www.renal.org • Chronic Kidney disease in adults:UK guidelines for identification, management and referral March 2006 • www.bma.org.uk/ap.nsf/content/gof06 • www.opsi.gov.uk