Section 6: Management in primary care

Particular emphasis on nurse practitioner’s role

Effects of age on eGFR• The “normal” eGFR is age-related• In normal “healthy” individuals, the eGFR will fall

by one percent for every year after 40 years of age

• An 80 year old man will have an expected eGFR of 50-60 ml/min

• Not all patients with reduced eGFR need active management

1 14

7 8

1720

34

38

5351

64

0

10

20

30

40

50

60

70

<45 45-55 55-65 65-75 75-85 >85

Age bands

% subjects with "CKD 3" by age

Male Female

%

% subjects with CKD stage 3 by age and gender East Kent Data

Age bands<45 45-54 55-64 65-74 75-84 >85

70

50

%30

10

de Lusignan et al 2005

0

50

100

150

20 30 40 50 60 70 80 90

F

EDTA

“Normal” inulin GFR declines with age

CKDStage 1

CKD 2

CKD 3

CKD 4

CKD 5

Which individuals with abnormal eGFR should we to worry about?

• Those with very poor function for age• Those with deteriorating function• Those who may have reversible/treatable cause

(unexplained proteinuria/haematuria)• Those with functional consequences of CKD

(anaemia, renal bone disease, persistent hyperkalaemia)

2008 NICE guidance for CKD – focus on vascular risk

• Lifestyle modification• Attention to known CV risk factors

– smoking– statins for secondary prevention regardless

of lipid level– Anti-platelet drugs for secondary prevention

• Medicines management• BP targets

NICE 2008: recommendations for BP control in CKD

No diabetes or proteinuria 120-140/70-90

Diabetes or ACR>30 120-130/70-80

NICE 2008: Diagnosis of CKD

• Proteinuria=ACR>30 or PCR>50 (NOT dipstick)• 3 eGFR estimations <60 over a period not less

than 90 days• Progressive decline defined as eGFR falling by

>5mls/min/year• Focus on those whose observed rate of decline

would necessitate RRT ‘within their lifetime’

NICE: 2008 Classification of CKDwaking up to the impact of proteinuria

• Stage 1: GFR>90 + abnormal urinalysis • Stage 2: GFR 60-89 + abnormal

urinalysis• Stage 3A: GFR 45-59• Stage 3B: GFR 30-44• Stage 4: GFR 15-29• Stage 5: GFR <15 or dialysis dependent

Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)

QOF indicators for CKD 2009

Register of patients over 18 with CKD 3-5 6

Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months

6 40-90%

Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less

11 40-70%

Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded)

4 40-80%

Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months

6 40-80%

Monitoring of CKD

• Each assessment should include– Review of symptoms and fluid status – Blood pressure– Medication review (metformin, NSAIDs)– Urine ACR or PCR– Blood test for renal and bone status– FBC in advanced CKD

Frequency of monitoring

Newly diagnosed Stable

Stage 3 6/12 annual

Stage 4 3/12 6/12

Stage 5 3/12 3/12

What data is required for effective referral?

• Current creatinine and eGFR• Previous creatinines (tracing back to last normal)• Blood pressures (recent and historical)

• Urine dip for blood, ACR/PCR• FBC, Ca, Pi • Renal US only if :-

• stage 4• resistant HT• lower tract symptoms