acei in ckd - nhs wales in ckd.pdfsrobertson.pdf · acei are beneficial even in advanced ckd...
TRANSCRIPT
ACE Inhibitors in CKD
Dr Stuart Robertson
Plan
Why does CKD matter?Indications for ACEiIndications for ACEiAssessment & management of proteinuriaMode of actionMode of actionHow to start and monitorRi k f AKIRisks of AKI
CKD
Risk Factor for Death
14.141416
te fr
om
ents
/
11.36
1012
Dea
th R
at10
0 pa
tier)
4.76468
dard
ised
Dus
e (p
er
year
0.76 1.08
024
Age
-sta
ndA
ny C
a
>60 45-59 30-44 15-29 <15
eGFR
A
Risk Factor for Cardiovascular DiseaseCardiovascular Disease
36.63540
of
r100
21.82530
sed
Rat
e o
vent
s (p
er
/ yea
r)
11.29101520
stan
dard
isva
scul
ar E
vpa
tient
s /
2.11 3.65
05
10
Age
-C
ardi
ov
>60 45-59 30-44 15-29 <15
eGFR
CKD as Risk Factor for HospitalisationHospitalisation
144.61140160
of
ents
/
86.75100120
sed
Rat
e o
er 1
00 p
atie
r)
45.26406080
stan
dard
issa
tion
(pe
year
13.54 17.22
02040
Age
-H
ospi
tili
>60 45-59 30-44 15-29 <15
eGFR
CKD is an IndependentRisk FactorRisk Factor
eGFR Death from Cardiovascular HospitalisationAny Cause Event
>60 1.00 1.00 1.0045-59 1.2 1.4 1.130-44 1.8 2.0 1.515-29 3.2 2.8 2.1<15 5.9 3.4 3.1
The analyses were adjusted for age, sex, income, education, use or nonuseof dialysis, and the presence or absence of prior coronary heart disease, priorchronic heart failure, prior ischemic stroke or transient ischemic attack, priorperipheral arterial disease, diabetes mellitus, hypertension, dyslipidemia, cancer,a serum albumin level of 3.5 g per deciliter or less, dementia, cirrhosis orchronic liver disease, chronic lung disease, documented proteinuria, and prior
CKD is Treatable
ACE Inhibitors & ARBs
Indications
Heart Failure
Indications
Hypertension
Indications
Proteinuria
NICE - Proteinuria
Proteinuria Assessment
Microalbuminuria screening in diabetes ACRMicroalbuminuria screening in diabetes – ACR
Quantification of proteinuria PCRQuantification of proteinuria – PCR
LogicLogic– ACR more sensitive but 6x more expensive– PCR is a meaningful numberPCR is a meaningful number
• PCR 150mg/mmol = 1500mg/day protein
Proteinuria & Mortality
Proteinuria - Renal Decline
Importance of Proteinuria
More proteinuria = more rapid decline in renal function
Better BP control reduces declineBetter BP control reduces decline at any amount of proteinuria
ACEi vs Others
ACEi vs Others
ACE Benefit NON-DM patients with Proteinuriawith Proteinuria
“Benazepril for Advanced Chronic R l F il ”Renal Failure”
Non-diabetic patients with proteinuria
Group1 Creat 130 – 265Group1 Creat 130 265 Group2 Creat 265 - 440
Endpoint=Creatx2 ESRF or death
NICE
ACEi – Mode of Action
Renal Autoregulation
Titration of ACEi
B li GFRBaseline eGFRStart ACEi
eGFR at 7-10 days
eGFR stable eGFReGFR stable eGFR>20%eGFR
<20%
Titrate ACEi ↑ Stop ACEiTitrate ACEi ↑ Stop ACEiMonitor weekly
Deteriorating eGFRSt bl GFR Deteriorating eGFRStable eGFR
Advice Leaflet
Risk of AKI
What Did He Say?
ACEi are indicated in hypertension heart failure &ACEi are indicated in hypertension, heart failure & proteinuric renal disease (DM & non-DM)ACEi are beneficial even in advanced CKD withACEi are beneficial even in advanced CKD with appropriate monitoringAvoid addition of NSAIDs to ACEi & diureticAvoid addition of NSAIDs to ACEi & diureticPathophysiology of decline in renal function related to ACEiCommend the patient advice leaflet to reduce ACEirelated AKI
Enjoy Lunch!