CHRONIC KIDNEY DISEASE (CKD) 3RD OCTOBER 2019 ANDREA FOX – TEACHER, UNIVERSITY OF SHEFFIELD

WILL HAMILTON– 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.

EFFECTS OF AGEING ON THE KIDNEYS

• Kidney function reduces as we age, from

about the age of 40

• Smaller and lighter

• Reduction in surface area of glomeruli

• Thickening of glomerular basement membrane

• Cardiac output decreases affecting perfusion

• Older kidneys less sensitive to ADH

• Renin production decreases

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 CHRONIC KIDNEY DISEASE*

• Diabetes (44%)—the number

one cause of kidney failure in

the US, especially type 2

diabetes

• High blood pressure (29%)—

also called hypertension, is the

second leading cause of kidney

failure

• Glomerular disease (7%)—

causes damage to the blood

vessels that filter blood in the

kidneys

• Polycystic kidney disease

(1.6%)—causes a buildup of

cysts in the kidneys, leading to

CKD

• Other (18.4%)—medication or

drug abuse, immune system

diseases (HIV, AIDS), lupus,

cancer and severe infection * Percentages are based on US stats

1. Fresenius Medical Care. Available from https://www.freseniuskidneycare.com/about-chronic-kidney-disease/whos-at-

risk/Causes#tabs

DIAB-1242435-0007

January 2018

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.

• Kidney function deteriorates naturally as we age – all the more important to look

after our kidneys

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

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

0

5

10

15

20

25

30

35

40

45

50

% o

f p

ati

en

ts

2 3 4

CKD Stage

ESRD

Death

• 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.

PROTEINURIA

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, 2015)

• 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 (2016)

• 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 136 (2019) 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

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 – check local policy for

recommended medications

• 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

• 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

AKI RISK FACTORS AND INSULTS

• Age over 65 years old

• Chronic kidney disease, diabetes, heart failure, liver failure

• Sepsis

• Deteriorating early warning scores

• History of AKI

• Neurological or cognitive impairment

• Hypovolaemia

• Nephrotoxic medications and recreational drugs

• Urological obstruction

• RISK FACTORS + INSULTS = HIGH AKI RISK

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 from baseline: lowest value

within 7 days, median value within 365

days

MANAGEMENT OF AKI – S.T.O.P.

• Screen for Sepsis

• Toxins avoid/stop;

• Review medication

• Optimise B/P –assess volume status;

• Regular EWS monitoring

• Urine output monitoring

• IV fluids

• Hold antihypertensive’s

• 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 Management

• Hydration! Prevent/treat

• Medication review! Prevent/treat

• Patients! Inform/empower