Chronic kidney disease (ckd) 22nd June 2017

Andrea Fox – teacher, university of Sheffield

Andrew Plant – renal patient

ThinkKidneys/Ipsos MORI 2014

Anatomy of the Kidney

• Situated in the middle of the back, just below ribcage, either side of the spine.

• Bean shaped, about the size of your fist.

• Receive about 25% of the blood pumped by the heart.

Nephron

• Nephron is the functioning unit of the kidney.

• Approx. one million in each kidney.

• Processes involved in urine formation are filtration, reabsorption and secretion.

What is Chronic kidney disease (CKD)?

• CKD – gradual decline in kidney function over months or years

• Kidney function deteriorates naturally from the age of 40!

• Do elderly have CKD or just normal age-related deterioration?

• CKD is not a diagnosis in itself – indicator of how well the kidneys are working

Measuring renal function

• Glomerular Filtration Rate (GFR) is best indicator of kidney function

• eGFR measured using estimation formulae GFR Estimator

• Not entirely reliable

• A low eGFR rarely leads to clinically significant renal disease. (Lewis 2009)

• Low eGFR greater indicator for CVD

CKD strongly associated with CVD

US Renal Data System report (2011)

Classification of CKD

Stages of Kidney disease

Stage Description GFR mL/min/1.73m2

1 Kidney damage with normal or ↑GFR ≥90

2 Kidney damage with mild ↓GFR 60-89

3A Moderate ↓GFR 45-59

3B Moderate ↓GFR 30-44

4 Severe ↓GFR 15-29

5 Kidney failure <15 or dialysis

ThinkKidneys/Ipsos MORI 2014

Causes of Renal Failure

• Diabetes http://www.youtube.com/watch?v=ikGl7DPXUK0

• Hypertension

• Renovascular disease

• Infections

• Kidney stones

• Cancer

• Genetic

• Hypotension

• Drugs

• Toxins

• Part of a disease process, eg.lupus

• Trauma

Key Learning points:

• Kidneys have numerous functions and don’t just produce urine.

• CKD is the gradual decline in renal function.

• Measured using eGFR.

• CKD is classified into 5 stages

• CKD has many different causes, with diabetes and hypertension being the most common.

CKD in Primary Care

• Quality Improvements in CKD. Over 900,000 patients in general practice, criterion for CKD register was 2 consecutive eGFR results at least 3 months apart.

• Estimated prevalence of CKD 3-5 is 5.41% of entire population

• This means approximately 2.81 million people have CKD 3-5

• 97% of these have CKD 3

(de lusignan et al 2011)

Human and Financial Costs

• 40,000-45,000 premature deaths a year in people with CKD

• 7000 extra strokes and 12,000 extra heart attacks each year among people with CKD

• CKD costs the NHS more than breast, lung, colon and skin cancer combined.

• CKD costs the NHS £1.4billion per year

• CKD and its complications cost the NHS in England £1 in every £77 spent.

• Estimated costs for tests and consultations in primary care related to CKD are £143,000,000. • Kerr, M et al (2012)

Screening for CKD

• Diabetics

• Cardiovasular disease or CVD risk factors (IHD, chronic heart failure, peripheral or cerebral vascular disease)

• Hypertension

• Acute kidney injury • Structural renal tract disease, recurrent kidney stones or prostatic hypertrophy

• Family history of CKD 5 or genetic predisposition

• Multi system diseases eg. Lupus, myeloma

• Opportunistic /Persistent detection haematuria or proteinuria (NICE CG 182, 2014)

• Nephrotoxic drugs

Identifying CKD

• Minimum of 2 eGFR measurements over no less than 90 days

• New result of reduced eGFR repeat within 2 weeks to exclude AKI

• Accelerated progression of CKD defines as:

– Sustained increase in GFR of 25% or more and a change in GFR category within 12 months OR

– Sustained decrease in GFR of 15mls/min/1.73m per year

• Focus particularly on those whose decline at current rate would likely lead to needing dialysis

O Hare AM et al. J Am Soc Nephrol

Age impacts on outcomes in CKD 210,000 subjects, eGFR<60mls/minute/1.73m², outcomes at 3.5 years

Death – the key outcome in CKD 27,998 CKD patients – outcomes at 66 months

•Keith DS et al. Arch Intern Med. 2004

1.1

19.5

1.3

24.3

19.9

45.7

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5

10

15

20

25

30

35

40

45

50

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ts

2 3 4

CKD Stage

ESRD

Death

Proteinuria

• To detect and identify proteinuria, NICE recommend ACR

• Urine ACR sensitive for low levels of proteinuria.

• For quantification and monitoring of proteinuria, PCR can be used.

• If initial ACR is between 3 - 70mg/mmol and, confirm with subsequent early morning sample.

• Confirmed ACR of 3mg/mmol or more should be viewed as clinically significant.

Importance of Proteinuria in CKD

Interpretation Explanation

Marker of kidney damage

Spot urine ACR >30 mg/g or PCR>200 mg/g for >3 months defines CKD

Risk factor for adverse outcomes

Higher proteinuria predicts faster progression of kidney disease and increased risk of CVD.

Effect modifier for interventions

Strict BP control and ACE inhibitors are more effective in slowing kidney disease progression in patients with higher baseline proteinuria.

Focus of care?

• Focus particularly on those whose eGFR decline would lead to the need for renal replacement therapy within their lifetime. (NICE Guideline 182, 2014)

• Diabetics who develop CKD have a substantial increase in risk of mortality. Individuals with diabetes and no CKD mortality risk was 11.5%. With diabetes and CKD risk increases to 31.1.%.

• Patients with cancer, heart failure and CKD had a significantly higher risk of avoidable readmission. Need close follow-up and monitoring in post discharge period. (Danze et al 2013)

CKD MANAGEMENT – PRIMARY CARE

• Information and education:

• Inform patient of CKD diagnosis

• Investigate the cause of CKD

• Support self management and shared decision making

• Give access to medical data, including results PatientView

• Lifestyle advice – exercise, stop smoking, weight management

• Manage cardiovascular risk - Blood pressure control

Obesity, diet and CKD

• Don’t screen for CKD due to obesity • Higher the BMI, more rapid and significant decline in renal function

(Grubbs et al 2013) • Yamahara et al (2013) found a direct link between obesity and kidney cell

damage • NICE (2014) Do not offer low protein diets to people with CKD • Moderately increase exercise and eat no more than 2200 cals per day

decreases the risk of developing kidney stones. (Sorenson et al 2013) • Eating more vegetable protein than animal protein reduces risk of dying of

CKD by 14% for every 10g increase in intake. Unclear as to whether this prolongs life of CKD patients. (Chen et al 2013)

Cardiovascular risk management and CKD

• Prescribe statins as per NICE CG 181 (2014)

• Anti-platelet medications

• Systolic BP 120 – 139mmHg

• Diastolic BP below 90mmHg

• In people with CKD and diabetes or ACR 70mg/mmol or more, systolic BP should be 120-129mmHg and diastolic BP below 80mmHg

• Follow Hypertension NICE CG 127 (2011) if CKD, hypertension and ACR of less than 30mg/mmol and not diabetic

BP control - SPECIFIC ADVICE

• ACE inhibitor or Angiotensin receptor blocker (ARB) should be prescribed if:

Diabetic and ACR of more than 3mg/mmol

Hypertension and an ACR of more than 30mg/mmol

ACR greater than 70mg/mmol

• Monitor GFR and potassium 1-2 weeks after starting ACEi/ARB

General CKD management

• Monitor regularly according to cause, rate of progression, comorbidities, changes to medications, conservative management

• Check for anaemia CKD stages 3B, 4 and 5

• Monitor calcium, phosphate and PTH levels in CKD stages 4 and 5.

Referral to Nephrology

• GFR less than 30mls/min (CKD stages 4 and 5) • ACR of more than 70mg/mmol • Decrease in GFR of 25% or more and a change in CKD category or

decrease in GFR of 15mls/min or more within 12 months • Poorly controlled hypertension despite the use of at least 4 anti-

hypertensives • Known or suspected rare or genetic causes of CKD • Suspected renal artery stenosis • Discuss with patient their wishes and preferences and take into

account comorbidities

Key learning points

• Only screen those at risk according to NICE guideline

• Monitor regularly, checking serum eGFR and urine ACR

• Manage cardiovascular risk

• Provide information and support

• Email advice for referrals to Sheffield : sht-tr.CKDEnquiry@nhs.net.

Ckd progression Uraemia

High blood pressure

Headaches

CVA

Heart failure

Blood/ protein in urine

Fluid retention

Oedema

Breathlessness

Anaemia

Loss of libido

Tiredness

Lack of energy

Confusion

Apathy

Itching

(Pruritus)

Cramp

Restless legs

Altered Taste

Nausea and vomiting

Loss of appetite

Weight loss

Malnutrition

Acidosis

Hyperkalaemia

Decreased calcium/ raised phosphate

levels

Increased risk of infection

Blood clotting problems

Pre treatment phase

• CKD Stage 4

• Increasing symptoms

• Common medications – anti-hypertensives, phosphate binders, sodium bicarbonate, diuretics, erythropoetin injections, intravenous iron

• Treatment options: dialysis, transplantation or conservative management

• Planning of access for dialysis

• Transplant list/live donor

Conservative Management

• Specific term relating to those with advanced renal disease, who choose not to have dialysis or a transplant.

End stage renal disease - ckd stage 5

• eGFR less than 15mls/min

• Diet and fluid restrictions

• Psychological, social and financial impact

Key learning points

• Not everyone will choose to have dialysis or a transplant

• Not everyone will be on diet and fluid restrictions

• Preserve residual function

• Consider changes to medications

• Seek support from: Renal dieticians, Renal social workers, psychologists, Kidney Care

Renal replacement therapy

• Peritoneal dialysis

• Haemodialysis

• Transplant

PD Key Learning Points

• Carried out by the patient in their own home

• Performed via a Tenckhoff catheter that is surgically inserted

• Catheter needs to anchored securely when not in use

• Performed daily

• Observe for signs and symptoms of infection

YouTube - How Does Hemodialysis Work?

Arteriovenous fistula (avf)

Arteriovenous graft (avg)

Vascular catheter

HD – THINGS TO REMEMBER

• Dialyse 3 times a week usually for 3 – 4 hours

• Hospital HD runs to timed slots

• Don’t give antihypertensive medication prior to dialysis

• Access must only be used for dialysis

• Some medications can be dialysed out

Key learning points

• Haemodialysis removes blood from the body, removes waste water and solutes and puts it back

• 3 forms of access: AV Fistula, graft and central venous catheter

• Only use access for dialysis

• HD can be performed in hospital or at home by the patient

Why Transplant?

Physical Benefits

• Lower mortality

• Lower morbidity – Cardiovascular

– Access related infection

• Increased fertility

• Increased “Vitality”

Non-Physical Benefits

• Less time receiving treatment – Haemodialysis sessions

– PD exchanges

• Capacity to spend more time at work

• More cost effective

Transplant Operation

• Incision made in lower abdomen.

• Right or left iliac fossa is the normal site for a transplant.

• Kidney is attached to the the external iliac artery and vein.

Transplant – things to remember….

• Transplant – treatment not a cure

• ‘Waiting list’

• Medications

• Vaccinations and travel

• Skin care

Conservative Management

• Specific term relating to those with advanced renal disease, who choose not to have dialysis or a transplant.

• But what about those deteriorating despite dialysis, and dialysis withdrawal?

Recommended Terminology

NHSIQ

Aims of Conservative Management (cm)

• Treat and control symptoms of ESRD without dialysis or transplantation

• Slow progression of CKD

• Maintain optimal quality of life

• Enable a good quality death

• Enable effective communication and decision with patient and family members

• Advanced care planning

Choosing CM

• Viable option in the elderly and those with multiple comorbidities where dialysis doesn’t offer a survival advantage.

• Patients with ischaemic heart disease were least likely to see a survival benefit from dialysis

• Consider burden of dialysis

• CM patients 4 times more likely to die at home or in a hospice.

(O’Connor & Kumar 2012)

Symptom management

• Renal anaemia – EPO, Intravenous iron

• Phosphate binders

• BP control

• Pain – Fentanyl patches, Tramadol, methadone

• Diet and fluid restrictions

• Dialysis

• Constipation – lactulose, docusate, senna, bisacodyl

• Nausea and vomiting – metoclopramide, ondansetron, haloperidol, levomepromazine

• Pruritis – creams, antihistamines

• Restless legs - Clonazepam

End if Life Trajectories

Recognising EoL in renal patients

• ‘Surprise’ question ‘

• Would you be surprised if this patient died within next 6-12 months?

• Intractable infection

• Increasingly severe symptoms needing more complex management

• Multiple admissions

• Patient withdrawing

Recognising EoL in renal patients

• Unintentional weight loss

• Needs help with 3 or more activities of daily living

• Increasingly bedbound

• Evidence of skin breakdown

• Swallowing difficulties

• Dialysis related – increasing difficulty with access

• Recurrent and problematic hypotension on HD

• Loss of ultrafiltration on PD

• Patient frequently refusing dialysis or states they want to stop

Recognising EoL in renal patients – DISEASE RELATED

• Recurrent chest pain at rest or on dialysis

• Arrhythmias

• Chest pain resulting from physical activity

• Worsening PVD leading to amputation

• Recurrent cerebralvascular events resulting in worsening functional ability

• Gut ischaemia

• Malignancy

• COPD

• Progressive dementia

• Presence of any other condition with less than 6 months prognosis and no treatment possible

Key learning points

• Conservative management is not the ‘no treatment’ option

• Recognising end of life in renal patients can be challenging but look for key indicators

• Medication dose is often reduced in patients with advanced renal disease

Useful links and support

• www.britishrenal.org

• www.ckdonline.org • Think Kidneys

• Kidney Care (formerly known as BKPA) • www.renal.org

• www.kidneypatientguide.org.uk

• www.kidney.org.uk

• Chronic Kidney Disease (Chronic Renal Failure) | Doctor | Patient UK

• British Journal of Renal Medicine

Contacts:

• Andrea Fox, Teacher, School of Nursing, University of Sheffield

• Email: andrea.fox@Sheffield.ac.uk

• Tel: 0114 2222079

• Louise Wild, AKI Nurse Educator, Renal Unit, STHFT

• Email: louise.wild@sth.nhs.uk

• Tel: 0114 2714460

What is Acute Kidney Injury (aki)

• AKI is now the universal term used to describe sudden deterioration of renal function, and it replaces the previous term know as Acute Renal Failure (ARF)

• AKI is detected by monitoring creatinine blood levels, and urine output

• AKI is a common condition amongst hospital inpatients and affects mortality and length of stay

AKI is common and Serious

Prevention, Recognition and early management

Risk Factors • Patients age is 65 and over • Patient has heart failure, liver disease

or diabetes • Chronic kidney disease – adults with an

estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 are at particular risk

• History of AKI • Multiple Myeloma

Insults • Hypotension (absolute

relative) • Sepsis • Use of iodinated contrast

agents (contrast scan) within the past week.

• Use of drugs with nephrotoxic potential such as:

• non-steroidal anti-inflammatory drugs (NSAIDs)

• aminoglycosides, e.g. Gentamicin

• angiotensin-converting enzyme (ACE) inhibitors, e.g. Ramipril

• angiotensin II receptor antagonists (ARBs), e.g. Losartan

• and diuretics

Identification Reduced urine output: • < 0.5mls/kg/hr for 6

hours (half body weight) Blood creatinine rise from baseline: • 26mmols rise within 48

hours • > 50% rise within

previous 365 days

Management Plan Screen for Sepsis Toxins avoid/stop; • Review medication Optimise B/P –assess volume status; • Regular SHEWS monitoring • Urine output monitoring • IV fluids • Hold antihypertensive’s • Consider vasopressors Prevent Harm • Identify cause/urinalysis • Treat complications • Review medications/fluid • Daily U&Es, additional checks

following surgery or invasive procedures

• Patients identified as having AKI; “renal profile”, allows monitoring of bicarbonate in addition to creatinine and electrolytes

Key Learning Points

• AKI Risk Factors! Prevent

• Urine output! Identify

• Creatinine blood tests! Identify

• Finding and treating the underlying cause in a timely manner! Early management prevents long term consequences

• Identify and Treat life threatening complications

• Hydration! Prevent/treat

• Medication review! Prevent/treat

• Patients! Inform/empower