CKD for GPs

Dr Toni Munno

GP King Street Surgery, Kempston

What does the ‘K’

stand for ??

Kardiovascular risk!

100

90

80

70

60

50

40

30

20

10

30-59 = CKD 3

15-29 = CKD 4

<15 or RRT = CKD 5

60-90 & abnormality = CKD 2

>90 & abnormality = CKD 1

eGFR & CKD

How measure (e)GFR

Clever lab things etc

Formula = MDRD

creatinine, age, sex, race (black or other)

tables

Online calcFrom lab

100

90

80

70

60

50

40

30

20

10

30-59 = CKD 3

15-29 = CKD 4

<15 or RRT = CKD 5

60-90 & abnormality = CKD 2

>90 & abnormality = CKD 1

prevalence

3.3%

3.0%

4.3%

0.2%

0.2%

Prevalence 2006/7

CKDNational prev 2.24%

Local prev 1.51%

Highest in Bedford4.75%

lowest in Bedford0.07%

x67

Eg list size 6000= 285 CKD pts

Eg list size 6000= 4 CKD pts

Work v. points!

Why bother?

x30 – 60 higher all cause mortality x20 more likely to die from CVD than

progress to ESRF

10,000 pts

500 have CKD 3-5(20 = stage 410 = stage 5)

90% have BP

30% have DM

40% have Vasc dis

http://www.rcplondon.ac.uk/pubs/books/CKD/CKDfullGuide.pdf

Step 1. Find them

Screen..contd

Step 2. Make the diagnosis

2 readings three months apart Use the right READ Codes

Step 3. sort them out!

Who do I need to refer?

Need to know: at least

- Blood tests- Urine examination- BP

Referal on basis eGFR

5

4

3

1, 2

4, 5 ref

3 +/-ref

Referal for other reasons…

Urine examination+ve for blood or protein MSU

Exclude infection

+ve for protein(more than a trace)

+ve for blood

Do PCR

>100

45-100

Ref Renal clinic

mAcro mIcromIcro

& protein

Urology2WR

mIcro NO protein

>50 <50

Neg? if egfr<60

Step 4. review medication

Step 5. sort out BP

TargetsWith protein 120/75

(threshold to start Rx is 130/80 if PCR >100, 140/90 otherwise)

Without protein 130/80QOF 140/85 !

Refer if >150/90 and on 3 antiBP rx

Remember 90% will have hypertension

Step 6. should they be on ACEi ?

Yes – if proteinuria Yes – if no protein, as part combination Rx to

get to target Yes – if DM and microalbuminura

No – if no protein and already have good BP control in which case remember Read codes:

8I64 – ACE not indicated

8I6C - A2RB not indicated

BUT don’t exempt them from whole CKD domain!!

Monitoring ACEi

Check creatinine (eGFR) and K Before start medcn 2 weeks after starting 2 weeks after any dose change

Watch for creatinine increase >20%, eGFR decrease >15%If so: ‘repeat creatinine, check K, and refer for

specialist opinion on whether to stop rx or to investigate for renal artery stenosis.’

Step 7. minimize cardiovascular risk

Lifestyle: smoke, wt, excse, alc, salt BP etc

‘If 10 yr CVD risk >20% consider’: Aspirin if BP < 150/90 Lipid lowering drug therapy

Step 8. follow-up

Rem. flu & pneumo jabs

Stage 3 chronic disease model Check eGFR 6mthly

(12mthly if stable, ie < 2ml/min change over 6m) Annual check Hb, K, Ca, phosp BP

Stage 4,5 ?shared care Check eGFR 3mthly

(6mthly if stable CKD4) ? 3mthly bloods,

QOF issues

Prevalence! Role of ACEi Appropriate use exemption codes

‘unsuitable/dissent’ , max tol, drugs

Prevalence of co-existing hypertension ?likely changes next year

Resources:

everything you need to know about CKD, eGFR , treatment and referral pathways can be found online:

www.renal.org

There is a very good recent update (April 2007) about CKD and QOF from NHS Employers and the BMA

FAQs for Chronic Kidney Disease (CKD). This document can be accessed at: -

www.pcc.nhs.uk/77.php