If I had Chronic Kidney Disease:What would I want my Doctor to Know…..

Liam PlantDepartment of Renal Medicine, Cork University Hospital

Department of Medicine, University College Cork School of Medicine

Conceptual Framework

What happens when kidneys fail?

• Conceptually best viewed as loss of nephrons

• Conceptually best viewed as not having any dysfunction of the myriad functions of the renal epithelial cells

Where?

(One of the) Central Mechanism(s)

Prevalent ESKD patients (n)

3505 patients

42% HD 5% Home 53% TX

786 p.m.p.

6 Year Increase in Dialysis Prevalence

31/12/03 – 31/12/09

647 patients64% All

78% HD

2% PD

Mean(95%C.I.)

108 (65,151) All

107 (72,142) HD

1 (-17,19) PD

Identify the Gold Standard

Sensible Default

Who gets CKD?

• Risk Groups10% of adults (3-4% CKD 3+) 60% male Older adults Racial Groups Diabetes/Vascular Disease/Other

• How detectedScreening – which groupsOpportunisticIntercurrent IllnessPrimary presentation

NeoErica project: 112,215 patients (12 practices)

[Creat] in last 10 years - 27.4% – 74% in last 2 years Proteinuria recorded in 9.1%

24.9% had eCrClr <60ml/min (C&G)

At least 5.1% of UK population CKD 3-5 (NHANES-III 4.7% of US population CKD 3-5)

Any CKD in adults – up to 10%

Issues

What would I fear…………………………………..

How would I be evaluated…………………………

How would I alter my lifestyle……………………..

What treatments would I wish………………………

How would I wish to be monitored and by whom………

What would I fear………..?

• Premature death from non-renal complications• Career, financial, family plans

• Badly organised care pathways

• Pain• ‘Uraemia’• Renal Replacement Therapy

Theoretical Construct

Complications

DeathESKDGFRCKDRISK HI-RISK

How would I be evaluated..?

• Define presence of CKD

• Stratify stage of CKD; estimate rate of progression

• Identify underlying cause (specific measures)

• Target objectives

Chronic Kidney Disease

• One or more of:

• Proteinuria

• Haematuria (not urological)

• Radiological abnormality

• Histological abnormality

5 Key data points

1. Stage of CKDGFRHypertensionProteinuria

2. Complications

3. Rate of Progression

4. Comorbidities

5. Cause of CKD

K/DOQI Stratification

Stage GFR (ml/min/1.73m2)

Comment

1* >90 HypertensionStructural problem

2* 60-89 HypertensionStructural problem

3 30-59 ComplicationsProgression/Referral

4 15-29 More ComplicationsReferral/Preparation

5 0-14 RRT/Conservative

Proteinuria

• Dipstick for Screening• 24hr collection if nothing better (worse!) to do

• Protein/Creatinine or Albumin/Creatinine ratios• Express as mg/mmol (x0.0088 for 24h)

(divide by 100!)

• <3.0 Normal• 3.0 – 34.0 Microalbuminuria• >34.0 Proteinuria

How would I alter my lifestyle..?

• Stop smoking

• Continue drinking

• Sensible, healthy diet; passage to ‘elite’ diet only in special circumstances

• A BMI target to remember……………..

What treatments would I wish..?

• Conservative treatment• Specific treatment

• Dialysis therapies• Transplantation

• Palliative care

What treatment is appropriate for these patients?

  Review medications. Stop NSAID’s. Adjust other medications if needed because of level of CKD.

·  Treat BP to a target of <130/80. This may require multiple medications. ACEi/ARB are 1st choice therapies.

·   If PCR >300mg/mmol – treat to target of <125/75.·   

If 10year CV risk estimate is >20% - consider anti-platelet agent/statin.

·      Encourage smoking cessation, exercise, weight loss.

·       Immunise against influenza and pneumococcus.

Stage 4-5 drugs

• Erythropoeisis-stimulating agents

• Drugs for secondary hyperparathyroidism

• Anti-rejection drugs

How monitored and by whom..?

• Conservative treatment• Specific treatment

• Dialysis therapies

• Transplantation

April 2006 Corrigan Club

‘New Good Practice’

Renal function expressed as eGFR4-point MDRD Formula

CKD classified as Stage 1-5K/DOQI Classification

Protein to Creatinine; Albumin to Creatinine ratio

Detection, monitoring, referral criteria www.renal.org/CKDguide/ckd.html

Non-visit-based Specialist advice service

Martinez-Ramirez HR, et al. Am J Kidney Dis 2006; 47: 78-87

Martinez-Ramirez HR, et al. Am J Kidney Dis 2006; 47: 78-87

1 year outcomes in DN

42

17

43

4

39

-7-11

27

-20

-10

0

10

20

30

40

50

Nephrology Primary Care

ACEIARBStatinNSAID

Conclusion

Levey AS, et al. Chronic kidney disease as a global public health problem: Approaches and positions – a position statement from Kidney Diseases Improving Global Outcomes. Kidney Int 2007; 72: 247-59.

Taal M, Tomson S. UK Renal Association Clinical Practice Guidelines, 4th Edition 2007.

www.renal.org/guidelines/module1.html

Irish Nephrology Society. Irish CKD Guidelines. www.nephrology.ie