Cardiovascular Hot topicsCardiovascular Hot topics‘CKD’‘CKD’

Dr Saqib MahmudDr Saqib MahmudMBBS, MD,MBBS, MD, MRCP(UK), MRCPS(Glasg), MRCP(UK), MRCPS(Glasg),

MRCGPMRCGP

CKDCKD

• The introduction of routine reporting The introduction of routine reporting of of

eGFR has led to 3 outcomes in primary eGFR has led to 3 outcomes in primary care;care;

• ‘‘Worried patients, Increased workloadWorried patients, Increased workload

& confused clinicians’.BMJ2006& confused clinicians’.BMJ2006

(Referral rates remain high due to uncertainty (Referral rates remain high due to uncertainty how to manage newly diagnosed CKD cases)how to manage newly diagnosed CKD cases)

Why has CKD been selected as a Why has CKD been selected as a quality indicator?QOF2 2006quality indicator?QOF2 2006

• Patients with CKD have very high rates of Patients with CKD have very high rates of vascular disease & require aggressive vascular disease & require aggressive management of vascular risk factors. management of vascular risk factors. (early (early CKD risk of death from CVD>ESRF)-low GFR predicts CV CKD risk of death from CVD>ESRF)-low GFR predicts CV diseasedisease

• Its incidence is rising dramatically. Its incidence is rising dramatically. (doubled (doubled in last 10yrs,5% adult population)in last 10yrs,5% adult population)

• S Cr does not rise until GFR has fallen by S Cr does not rise until GFR has fallen by 50-70%50-70%

• Early interventions in CKD improve cardiac Early interventions in CKD improve cardiac & renal outcomes& renal outcomes

eGFR-eGFR-bestbest estimate of renal functionestimate of renal function

• Based on S Cr, age, sex & ethnic origin.Based on S Cr, age, sex & ethnic origin.• Does not apply to children, ARF, Does not apply to children, ARF,

pregnant women, oedematous & pregnant women, oedematous & malnourished.malnourished.

• eGFR falls after eating meat, ideally eGFR falls after eating meat, ideally fasting sample or avoid eating cooked fasting sample or avoid eating cooked meat day before.meat day before.

• CKD-diagnosed 2 eGFRs 3/12 apart, not CKD-diagnosed 2 eGFRs 3/12 apart, not on the basis of single eGFRon the basis of single eGFR

CKD-classificationCKD-classificationCKD CKD stagestage

eGFReGFR

11 Kidney damage, Kidney damage,

normal eGFRnormal eGFR>90>90

22 Kidney damage, Kidney damage, reduced eGFRreduced eGFR

60-8960-89

33 Moderate CKDModerate CKD 30-5930-59

44 Severe CKDSevere CKD 15-2915-29

55 ESRFESRF <15 or <15 or

on dialysison dialysis

Clinical Signs & SymptomsClinical Signs & Symptoms

• TirednessTiredness• Anorexia, nausea, vomitingAnorexia, nausea, vomiting• Generalized pruritisGeneralized pruritis• Nocturia, frequency, oliguria, Nocturia, frequency, oliguria,

haematuriahaematuria• Frothy urineFrothy urine• Loin painLoin pain• Pallor, peripheral & pulmonary oedemaPallor, peripheral & pulmonary oedema• Pleural effusion & SOBPleural effusion & SOB• leuconychialeuconychia

QOF 2006 – CKD registerQOF 2006 – CKD register

• CKD1- register of pts>18 with CKD3-5CKD1- register of pts>18 with CKD3-5

• CKD2-(90%) on register with record of BP CKD2-(90%) on register with record of BP in last 15/12in last 15/12

• CKD3-(70%) on register with BP<140/85CKD3-(70%) on register with BP<140/85

• CKD4-(80%) patients on ACEI/A2RB-or CICKD4-(80%) patients on ACEI/A2RB-or CI

• Worth 27pts=£3,364/-Worth 27pts=£3,364/-

Conditions with risk of developing Conditions with risk of developing CKDCKD

• HypertensionHypertension

• DiabetesDiabetes

• Heart failureHeart failure

• Vascular diseaseVascular disease

• Urinary outflow obstructionUrinary outflow obstruction• Multi-system diseases Multi-system diseases eg;RA, SLE,eg;RA, SLE, vasculitisvasculitis

• APKD or reflux nephropathyAPKD or reflux nephropathy• Long term Drugs-Long term Drugs-lithiumlithium, ,

cyclosporin,NSAIDs,mesalazinecyclosporin,NSAIDs,mesalazine

Monitoring renal functionMonitoring renal function

• Stage 1 & 2 requires evidence of Stage 1 & 2 requires evidence of renal damage eg; Proteinuria, renal damage eg; Proteinuria, microalbuminuria, haematuria microalbuminuria, haematuria without urological cause or known without urological cause or known polycystic kidney disease or GN. polycystic kidney disease or GN. (Annual U & Es)(Annual U & Es)

• Stage 3 Stage 3 6/12 6/12

• Stages 4 & 5Stages 4 & 53/123/12

Urine testsUrine tests

• Dipstick urinalysis for protein, Dipstick urinalysis for protein,

• If +ve If +ve msu to exclude infection & EMU msu to exclude infection & EMU for ACR(+>30mg/mmol) or PCR(+>45)for ACR(+>30mg/mmol) or PCR(+>45)

• In diabetics, dipstick negativeIn diabetics, dipstick negativeACR for ACR for microalbuminuria microalbuminuria (+>2.5mg/mmol-(+>2.5mg/mmol-males,>3.5 in women)males,>3.5 in women)

Management – Management – is easyis easy

• ‘‘CKD rarely means dialysis’CKD rarely means dialysis’

• Monitor renal function closely- assess Monitor renal function closely- assess rate of changerate of change

• Tight BP control with preferential use Tight BP control with preferential use of ACEI or A2RBof ACEI or A2RB

• Pay close attention to CV riskPay close attention to CV risk

New patient with eGFR<60New patient with eGFR<60

• Review previous results Review previous results ?rate of deterioration?rate of deterioration

• Review medicationReview medication ?nephrotoxicity ?nephrotoxicity

• Check BP, urine, full clinical assessment eg ?palpable Check BP, urine, full clinical assessment eg ?palpable bladderbladder

• Repeat U&E within 5/7 (?rapid progression)Repeat U&E within 5/7 (?rapid progression)

• Referral criteria- Referral criteria- renal function stablerenal function stable monitor monitor

• Stage 4(if stable, monitor) & 5 should be referredStage 4(if stable, monitor) & 5 should be referred

• Stage 3 if deteriorating functionStage 3 if deteriorating function

Long term management to Long term management to delay progression and reduce delay progression and reduce CV eventsCV events• Life style adviseLife style advise smoking cessation, smoking cessation,

wt reduction, exercise, low protein dietwt reduction, exercise, low protein diet

• Aspirins & statins if CVD risk 15-20%Aspirins & statins if CVD risk 15-20%• (evidence is that all CKD patients are high risk)(evidence is that all CKD patients are high risk)

• Strict BP control-QOF2 target <140/85, Strict BP control-QOF2 target <140/85, but renal guidelines best practice but renal guidelines best practice target is 130/80 target is 130/80 --UK CKD&JBS2 guidelines.UK CKD&JBS2 guidelines.

• Check U&Es before starting, 2/52 after & also 2/52 Check U&Es before starting, 2/52 after & also 2/52 every dose change of ACEI or A2RBsevery dose change of ACEI or A2RBs

• Aspirin->BP<150/90, target TC<4,LDL<2Aspirin->BP<150/90, target TC<4,LDL<2

Additional management-Additional management-CKD3CKD3

Renal USS if LUTS, refractory HTN, Renal USS if LUTS, refractory HTN, unexpected fall in GFRunexpected fall in GFR

Immunise-influenza, pneumococcus, Immunise-influenza, pneumococcus, Hep B in CKD4&5Hep B in CKD4&5

If HB<11-exclude other causes, refer If HB<11-exclude other causes, refer for ESA, iv Fefor ESA, iv Fe

Renal osteodystrophyRenal osteodystrophy• Renal failureRenal failure failure of Vit D failure of Vit D

hydroxylationhydroxylation secondary secondary

hyperparathyroidismhyperparathyroidismincreased # risk due to faulty bone increased # risk due to faulty bone

remodelling & lowered BMD.remodelling & lowered BMD.

• Check PTH levels, if low check 25-Check PTH levels, if low check 25-hydroxy Vit D levelshydroxy Vit D levels

• Rx- ergo or colecalciferol with Rx- ergo or colecalciferol with calcium/bisphosphonatescalcium/bisphosphonates

Bone disease in CKDBone disease in CKD

• Recent Irish study found 76% of Recent Irish study found 76% of osteoporosis cases in CKD patientsosteoporosis cases in CKD patients

• Patients with CKD 4&5 had significantly Patients with CKD 4&5 had significantly lower BMD at hip & spine + high bone lower BMD at hip & spine + high bone turnoverturnover

• 2 fold increased risk of vertebral 2 fold increased risk of vertebral fracturesfractures

• Statins - known to have beneficial effect Statins - known to have beneficial effect in prevention of osteoporosis as well as in prevention of osteoporosis as well as decreased incidence of sepsis in CKD!decreased incidence of sepsis in CKD!

ACEI / A2RB-ACEI / A2RB-RxRx or the causeor the cause

• ACEI/A2RBs improve outcomes but in ACEI/A2RBs improve outcomes but in some patients can be nephrotoxicsome patients can be nephrotoxic

• A slight reduction in GFR (<15%) or A slight reduction in GFR (<15%) or increase in creatinine is a normal increase in creatinine is a normal haemodynamic response to ACE inhibition haemodynamic response to ACE inhibition & is normally not an indication to stop Rx & is normally not an indication to stop Rx unless creatinine rises by >30%unless creatinine rises by >30%

• Heart failure-rise in CR upto 50% baseline Heart failure-rise in CR upto 50% baseline or 200umol/l is acceptable-(NICE)or 200umol/l is acceptable-(NICE)

Renal artery stenosisRenal artery stenosis• GFR- difference b/w flow of blood into GFR- difference b/w flow of blood into

glomeruli via afferent arteriole & flow out glomeruli via afferent arteriole & flow out via efferent arteriolevia efferent arteriole

• This is not dependent on AT II normally This is not dependent on AT II normally but kidneys can increase GFR by local but kidneys can increase GFR by local production of AT II which vasoconstricts production of AT II which vasoconstricts efferent arterioleefferent arteriole

• In In RAS-GFR is -GFR is dependentdependent on AT II on AT II mediated efferent arteriole mediated efferent arteriole vasoconstrictionvasoconstriction

Renin- Angiotensin systemRenin- Angiotensin system

RAS-contRAS-cont

• RAS is likely if rise in S Cr in absence of RAS is likely if rise in S Cr in absence of significant drop in BP significant drop in BP

• ‘‘Flash pulmonary oedema’-bilateral Flash pulmonary oedema’-bilateral RAS predisposes to episodic RAS predisposes to episodic catastrophic pulmonary oedema-often catastrophic pulmonary oedema-often misdiagnosed as LVF until ACEI Rx misdiagnosed as LVF until ACEI Rx causes rapid rise in S Crcauses rapid rise in S Cr

• Renal function usually reverts to Renal function usually reverts to baseline on stopping ACEIbaseline on stopping ACEI

• Small kidneys in Renal USS-strong Small kidneys in Renal USS-strong indicatorindicator

RAS-contRAS-cont

Rx in RASRx in RAS

•Ca channel blockers Ca channel blockers (dihydropyridines)-Rx of choice in (dihydropyridines)-Rx of choice in RASRAS

•Also indicated when ACE Is are not Also indicated when ACE Is are not toleratedtolerated

•Targeting BP lowering aggressive is Targeting BP lowering aggressive is more important than choice of Rx- more important than choice of Rx- ALHAT studyALHAT study

Prescribing in CKDPrescribing in CKD

•Avoid NSAIDs, codeineAvoid NSAIDs, codeine

•Withold ACEIs in hypovolaemic Withold ACEIs in hypovolaemic states-gastroenteritis etcstates-gastroenteritis etc

•Antibiotics, digoxin, metforminAntibiotics, digoxin, metformin etc – etc –

• ‘‘use with caution’use with caution’

•(reduce dose or frequency)(reduce dose or frequency)

What about elderly patients with What about elderly patients with low eGFR- how should we manage low eGFR- how should we manage them?them?

• The guideline makes no age distinctionsThe guideline makes no age distinctions• BMJ2006;it is ageist not to Rx CKD just BMJ2006;it is ageist not to Rx CKD just

because someone is elderly.because someone is elderly.• BJGP editorial Dec2006;elderly with CKD BJGP editorial Dec2006;elderly with CKD

still benefit from CV risk factor still benefit from CV risk factor intervention and strict BP control in intervention and strict BP control in elderly slows rate of renal declineelderly slows rate of renal decline

• Use clinical judgement & patient Use clinical judgement & patient circumstancescircumstances

Key points…..Key points…..

• CKD patients have high risks of CV events CKD patients have high risks of CV events & so CVD prevention should be & so CVD prevention should be fundamental to the management of CKDfundamental to the management of CKD

• Risk of ESRF is very lowRisk of ESRF is very low(ckd3-1.1%:24.3% CV death-(ckd3-1.1%:24.3% CV death-5yr)5yr)

• Best practice target BP is 130/80 with Best practice target BP is 130/80 with preferential use of ACEI / A2RBpreferential use of ACEI / A2RB

• Consider aspirin and statins Consider aspirin and statins

• Life style advise & low protein dietLife style advise & low protein diet• Consider Bisphosphonates & Ca for CKD assoc bone Consider Bisphosphonates & Ca for CKD assoc bone

diseasedisease

• ACEIs not necessary for all CKD ptsACEIs not necessary for all CKD pts

Thank Thank you-you-questionsquestions??????

‘ ‘The enemy of good The enemy of good

is is better’ better’