CKD and risk management : NICE guideline

2008-2014

Shahed Ahmed

Consultant Nephrologist

shahed.ahmed@rlbuht.nhs.uk

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Key points :

• Changing parameters of CKD and NICE guidance

• CKD and age related change of GFR

• Nice guidance on lipid management with CKD

• CKD Vs AKI

• Community AKI project

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Defining CKD

• CKD is present when either:

The MDRD-derived estimated glomerular filtration rate (eGFR) is less than 60ml/min on at least two occasions over a period of no less than 90 days

Or,

The urine ACR is >30mg/mmol

(or, PCR is > 50mg/mmol)

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Classification of CKD, based on NICE 2008

Stage of CKD Estimated GFR KIDNEY FUNCTION

Stage 1 >90ml/min with urine abnormality or abnormal renal anatomy

Normal

Stage 2 60-89ml/min with urine abnormality or abnormal renal anatomy

Mild Reduced

Stage 3a 45-59ml/min Mild to moderate reduced

Stage 3b 30-44ml/min Moderate reduced

Stage 2 15-29ml/min Severe reduced

Stage 5 <15ml/min or dialysis dependant Kidney failure

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WHY CKD is a high risk disease ? CV disease mortality : General Population vs. ESRD Dialysis Patients

Foley RN, et al. Am J Kidney Dis.

1998;32:S112-S119.

0.001

0.01

0.1

1

10

100

25-34 35-44 45-54 55-64 66-74 75-84 >85

GP Male

GP Female

GP Black

GP White

Dialysis Male

Dialysis Female

Dialysis Black

Dialysis White

Age (years)

An

nu

al C

VD

Mo

rtality

(%

)

Prevalence of Chronic Kidney Disease (CKD) Stages by Age Group in NHANES 1988-1994 and 1999-2004

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CV

events

N Engl J Med. 2004 Sep 23;351(13):1296-305, Go et al, Kaiser Permanente

Northern California

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CKD- However,

The majority of patients with CKD 1-3 do not progress to ESRF.

Their risk of cardiovascular death is higher than their risk of progression.

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Patients with CKD are more likely to die than go onto dialysis

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No DM /

CKD

DM No

CKD

CKD No

DM

DM and

CKD

Dialysis

Death

ESRD/D

Event Free

Adapted from Collins, Adv Studies in Med, (3C) 2003, Medicare Cohort 1998-99

25% 30% 40%

15% 9%

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In CKD – early identification is essential !

NICE: Chronic kidney disease Early identification and management of chronic kidney

disease in adults in primary and secondary care – Issue date: September 2008

The Challenges: • However, because of a lack of specific symptoms, CKD are often not diagnosed,

or diagnosed late. • 30% of people with advanced CKD disease are referred late, causing increased

mortality and morbidity.

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CKD – How we diagnose ? Serum Cr Vs GFR

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eGFR: Practical Implementation Issues

• Apply only to age > 18

(MDRD ages: 18-70)

• Not Validated - AKI

Transplant

Pregnancy

• Ease of use . Good fit with data at lower GFR

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GFR = 170 x [Pcr]-0.999 x [Age]-0.176 x [0.762 female] x [1.180 black race] x [SUN]-0.170 x [Alb]+0.318

Modified Equation 7:

GFR = 186 x [Pcr]-1. 154 x [Age]-0.203 x [0.742 female] x [1.212 black race]

Estimate GFR from Serum

Creatinine:, AS. Levey, et al;

Ann Intern Med.

1999;130:461-470.

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Age & GFR • Functional changes

–Renal plasma flow 10%/decade

– Longitudinal study,

mean reduction CCL 0.75ml/min/yr (92 out 0f 254 no reduction)

• Lindeman, R. D., Tobin, J., and Shock, N. W.

(1985). Longitudinal studies on the rate of decline in renal function with age.Journal of the American Geriatrics Society

NICE CKD 2008: Did we overkill CKD diagnosis ?

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Group in NHANES 1988-1994 and 1999-2004

WHATS NEW NICE CKD 2014

The new and updated areas include:

Classification of CKD and identification of people at risk of CKD complications and progression

The relationship between acute kidney injury and CKD

Self-management of CKD

Pharmacotherapy for CKD.

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Classification of chronic kidney disease

• Classify CKD using a combination of GFR and ACR categories and be aware that:

a. Increased ACR is associated with increased risk of progression

b. Decreased GFR is associated with increased risk of progression

c. Increased ACR and decreased GFR in combination multiply the risk of progression.

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Identification and investigation of people who have or are at risk of developing CKD

• Consider using eGFR cystatin C to confirm the diagnosis of CKD in people with :an eGFR creatinine of 45–59 ml/min/1.73 m2, sustained for at least 90 days and no proteinuria (albumin:creatinine ratio)ACR less than 3mg/mmol)

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CKD : aim of Rx

CV risk reduction:

Target BP control Rx of hyperlipidaemia

Control of proteinuria Target primary disease: ex.- good control of diabetes

Specific Rx for CKD

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Blood pressure and progression of CKD

Jafar et al, Ann Intern Med 2003;139:244-252

Ad

just

ed

re

lati

ve r

isk

of

pro

gre

ssio

n t

o C

KD

(9

5%

CI)

Meta-analysis of 11 randomised controlled trials with or without ACEi

1860 patients with non-diabetic kidney disease

Systolic BP (mmHg)

0

0.5

1

1.5

2

2.5

3

3.5

<110 110-119 120-129 130-139 140-159 160+

MEDLINE Database

3.14

2.08

1.83

1.23

1.00

2.48

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Blood pressure targets

NICE CKD Guidance

• If CKD, blood pressure target: • <140 mmHg SBP (130-139) • < 90 mmHg DBP (80-89)

•If diabetes and CKD or ACR ≥ 70 mg/mmol, blood

pressure target: • < 130 mmHg SBP • < 80 mmHg DBP

NICE Management of CKD: NICE 2008

NICE CKD 2014

Overview: management of CKD in primary care

• Identify those at risk by eGFR and proteinuria measurement

• Explain to people they have the condition and encourage self-management

• Control blood pressure

• manage cardiovascular risk

• Medicine management

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Cont..

Do not offer a combination of renin-angiotensin system antagonists to people with CKD

And do not offer a renin-angiotensin system antagonist to people if pretreatment serum potassium is >5.0mmol/litre

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Key priority:

Promoting self-management of CKD

• BP control: Explain that reducing raised BP is a

key factor in preventing the progression of CKD

• BP monitoring: Advise people to monitor their own BP at home

• Smoking cessation

• Blood sugar control (if they have diabetes) • Diet: To avoid processed, high-salt and high-fat

foods

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Key priority: Assess & control

cardio-vascular risk

• Statins: • Use statins for primary prevention of cardiovascular

disease in same way as in people without CKD • Offer statins for secondary prevention of CVD

irrespective of lipid values

• Offer antiplatelet drugs to people with CKD for

the secondary prevention of CVD (but the risks of bleeding may be increased with multiple antiplatelet drugs)

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NICE guideline: Lipid modification Feb 2014

• prevention of CVD in primary care, use a systematic strategy to identify people aged 40-74 who are likely to be at high risk

• Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD (more than 10% , 10 year CVD risk on assessment)

• Offer statin treatment for the primary prevention of CVD with atorvastatin 20 mg.

• Start statin treatment in people with established CVD, type 1 diabetes or type 2 diabetes with atorvastatin 80 mg. s ahmed, 2014

NICE guideline: Lipid modification Feb 2014

63. In people with stage 1 or stage 2 CKD treat as primary prevention and initiate treatment with atorvastatin 20 mg if there is no evidence of CVD and more than 10% CVD risk on assessment with QRISK2. [new 2014] 64. In people with stage 1 or stage 2 CKD and evidence of CVD, start treatment with atorvastatin 20 mg and increase dose if a greater than 40% reduction in non-HDL cholesterol is not achieved. [new 2014] 65. In people with stage 3 CKD start high-intensity statin treatment with atorvastatin 20 mg. Increase the dose if a reduction in non-HDL cholesterol of greater than 40% is not achieved. [new 2014] 66. In people with CKD stage 4 or greater start treatment with atorvastatin 20 mg and agree the use of higher doses with a renal specialist. [new 2014]

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Case

• 32 Year old lady , generally feeling unwell. H/O- HTN, depression

• On Lisinopril 20 mg, Furosemide 40 mg

• INV- S Cr 250/ eGFR 29

• Urine dip – NAD

• BP, HR , RR – normal limit

• Rx:

1. Urgent Renal O/P ref for CKD 4

2. Stop ACEI / repeat U&E , then consider referral

3. Urgent hospital Referral for AKI

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AKI : Background

• Up to 18% of all hospital admissions have AKI

• Inpatient AKI-related mortality is between 25 and 30%

• Between 20 and 30% of cases of AKI are preventable.

Prevention could save up to 12,000 lives each year

• NHS costs related to AKI are between £434 and £620 million per year

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Cost of AKI 23 June 2011 Health Service Journal supplement 1

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e-AKI alert: Early Diagnosis of AKI

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e-AKI alert

Community Acute Kidney Injury (AKI) Guideline

→

→

.

**Discuss with AKI team / on call renal Registrar if required and appropriate

AKI stage 1 AKI stage 3

New Diagnosis of AKI (Stage 1 / Stage 2/ Stage 3)

(Electronic AKI alert)

- Treat underlying probles

(dehydration, sepsis,

medication review etc.)

-To arrange Hospital

admission in appropriate

cases3**

- Repeat U & Es – 24 hours if

treated in community5

-

-Treat underlying problems (dehydration, infection, medication

review etc.)

- Repeat U & Es in 24- 48 hours

- Hospital admission if

progressive /in appropriate cases3

AKI stage 2

Patient Details:

Date:

Baseline Cr/ date:

Latest Creatinine (Cr):

Urine dip test:

To arrange patient review (To exclude CKD) and medication review

To repeat U & E within 24-48 hours (i.e, as per AKI stages as below)

-Treat underlying problems (dehydration, infection,

medication review etc.)

- Consider Hospital admission in

appropriate cases3**

- Repeat U & Es in 24 hours if

treated in community5

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Referral Nephrology:

Discuss AKI management with a nephrologist/paediatric nephrologist as

soon as possible (and within 24 hours) if one of the following is present:

Potential diagnosis requiring

specialist treatment (for example,

vasculitis or glomerulonephritis)

AKI with no clear

cause

Inadequate treatment

response

Complications associated with AKI Stage 3 AKI

eGFR is less than < 30

ml/min/1.73 m2 after

AKI episode

Patients with renal transplant and

AKI

CKD stage 4 or 5

Renal replacement therapy:

Refer adults, children and young people immediately for RRT if any of the

following are not responding to medical management:

Hyperkalaemia Metabolic

acidosis

Symptoms or complications

of uraemia such as

pericarditis or

encephalopathy

Fluid overload

+/- pulmonary

oedema

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Summary 1: CKD - aim of Rx First, Identify CKD

CV risk reduction:

Target BP control / Rx of hyperlipidaemia

Control of proteinuria – ACEI/ARB Target primary disease: ex.- good control of diabetes Specific Rx for CKD – anaemia / bone disease CKD vs. AKI

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Thank you

Any Question ?

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