CKD

CKD
eGFR:
Flow of blood through the kidney
CKD =
each minute
• a reduction in kidney function

• or structural damage
• or both
• present for more than 3 months
• with associated health implications
ACR:
Leakiness in kidneys
The amount of protein in urine
NB NOT the same as positive urine
dip
DIAGNOSIS
• Made if any of the following present:
– eGFR <60 on 2 occasions 3 months apart
– ACR >3 (with any eGFR)
– Structural kidney disease (even if eGFR is normal)
BEWARE:
eGFR and meat
ACR and orthostatic proteinuria
AKI (if this is a concern repeat sooner)
ACR
• When to send:
• Adults with eGFR <60
• Children with a high creatinine (above age-adjusted norm)
• Adults and children with diabetes (type 1 or type 2)
• Strong clinical suspicion
• Incidental finding of proteinuria on dipstick (this should prompt us to check both ACR and
eGFR)
• In hypertension - checking for end-organ damage
• Interpretation:
• If ACR is >70, it does not need repeating.
• If ACR is between 3 and 70, the sample should be repeated on an early morning sample
WHO TO SCREEN
• NICE say screen those who are at increased risk
• Who’s at increased risk?
Renal/urological risk Comorbidities
Incidental finding of protein or blood in urine dip •Diabetes (types 1 and 2)
Previous AKI (we should monitor for at least 3 years after AKI, even after •Hypertension
eGFR normalises) •Cardiovascular disease
Prostatic hypertrophy → obstructive uropathy •Gout
secondary care review: •Multisystem disease with potential
• Structural renal tract disease or recurrent renal tract stones to affect renal function, e.g. SLE –
• FHx of end-stage renal disease or hereditary kidney disease likely under secondary care
Children:
• Solitary functioning kidney
• Low birth weight (<2.5kg)
• Structural cardiac disease in children
How often to screen?
No specific guidelines unless…
General symptoms:
Lethargy, Itch, breathlessness
cramps (often worse at night) sleep
disturbance
bone pain, loss of appetite
vomiting, weight loss
taste disturbance (often present with end-
stage disease)
SYMPTOMS?
Urinary Symptoms:
polyuria (tubular concentrating ability is
impaired)
Oliguria, nocturia (due to impaired solute
diuresis or oedema)
or anuria (due to AKI, obstructive uropathy
causing urinary retention; or end-stage renal
disease
CLASSIFICATION
SO THEY HAVE
CKD
WHAT NEXT?
INVESTIGATIONS
• Dip urine – if not already done so
– Check for haematuria
– Check for infection
• Bloods:
– U+Es, FBC, bone profile, LFTs
– NB NICE guidelines doesn’t specify who these tests should be done for
• Renal USS:
– Accelerated progression of CKD
• sustained decrease in eGFR of 25% or more and a change of eGFR category within 12 months OR
• a sustained decrease in GFR over 15 per year
– Haematuria (visible or non-visible persistent)
– Symptoms of urinary obstruction
– Family history of polycystic kidneys once aged >20y
– eGFR <30
MONITORING
• Ultimately NICE recommends testing frequency be agreed with the patient and this should be
documented in the notes
WHEN TO WORRY?
• Sudden drop in eGFR
– Is this an AKI?
– Repeat in 2/52
• >/= 25% fall in eGFR over past year WHICH RESULTS IN A CHANGE IN
CKD STAGE
• OR
• A SUSTAINED FALL in eGFR of >15 per year
= markers of increased risk of progression to end stage renal disease
MANAGEMENT
THINK ALPHA!
A FOR ATORVASTATIN
• In primary prevention:
• DON’T use QRISK2 to assess the need for statins
• offer a statin (providing no contraindications)
• In secondary prevention
• starting dose of atorvastatin is 20mg (in those without CKD, it is usually 80mg)
• because of the lack of evidence around high-dose statins in CKD
• For primary prevention and secondary prevention:
• Offer ATORVASTATIN 20mg to all
• Do NOT base decision on risk assessment tool score (e.g. QRISK) in primary
prevention
• If eGFR ≥30, increase dose if <40% fall in non-HDL cholesterol
• If eGFR <30, increase dose only in consultation with renal team
L FOR LIFESTYLE
P FOR PERSISTENT PROTEINURIA
• NICE says ACEi/ARBs and gliflozins if indicated
• For those WITHOUT diabetes, ACEi/ARB are used to manage proteinuria if the ACR is ≥70
• For those WITH diabetes, ACEi/ARB are used to manage proteinuria if the ACR is ≥3
• Gliflozins can be used for renoprotection in type 2 diabetes if:
– ACR 3–30: gliflozins should be ‘considered’
– ACR >30: gliflozins should be ‘offered’
• RENOPROTECTION and dapagliflozin (DAPA-CKD trial):

– Those with T2DM if eGFR25-75
– Those WITHOUT DM if they have an eGFR 25-75 and ACR>/= 22.6
THIS IS AN ADD ON TO ACEi/ARB

WHY NO
GLIFLOZINS
IN T1DM?
H FOR HYPERTENSION
NB
IF 80YRS OR OLDER
AND T1DM THEN
TARGET BP 150/90
A FOR ANAEMIA
• Simply NICE say we should Ix and manage!
• eGFR >60:
– Unlikely to be cause of anaemia
• eGFR 30-60:
– Ix for other cuases
– Use clinical judgement
– Could be cause
• eGFR <30:
– Often the cause
– But Ix for other potential causes
WHEN TO REFER?
• QRISK for kidneys:
• 4-variable kidney failure risk equation
• = 5-year risk of needing renal replacement therapy
• Refer if >5%
• CKD + renal outflow obstruction
– Refer to urology
• ACR ≥70 (unless caused by diabetes and already treated)
• ACR >30 with haematuria
• Those with progressive CKD (when to worry?)
• Those with poorly-controlled hypertension despite the use of at least 4 antihypertensive drugs
• Known genetic or rare causes of CKD, including renal artery stenosis
• Tools and resources | Chronic kidney disease: assessment and management | Guidance | NICE
Atorvastatin
Lifestyle
Proteinuria (persistent)
Haematuria
Anaemia
QUESTIONS
Carol is 78yrs old. She has mild COPD and still smokes a few
cigarettes daily. She has an eGFR of 48, her ACR is 6 and her BP is
137/85. she is non-diabetic and is not anaemic. Her BMI is 28.9
Shane is 68yrs old. He has T2DM – diagnosed 25 years ago. BMI is 22, most recent HBA1C was
50. recent bloods also showed eGFR 48, no anaemia and urine ACR 4. BP 139/88. He is an ex-
smoker.
In the management of chronic kidney disease (CKD), which is the SINGLE MOST
appropriate reason to refer to a specialist? Select ONE option only.
Select one:
A. A reduction in estimated glomerular filtration rate of 5 mL/min/1.73m2 in two years
B. Blood pressure of 160/95 mm/Hg despite three antihypertensive drugs
C. One episode of microscopic haematuria
D. Stage 3b CKD
E. Suspected renal artery stenosis

RENAL ARTERY STENOSIS
Criteria for referral:

• Estimated glomerular filtration rate (eGFR) less than 30 ml/min/1.73 m2 (category
G4 or G5), with or without diabetes
• ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already
appropriately treated
• ACR of 30 mg/mmol or more (ACR category A3), together with haematuria
• Sustained decrease in eGFR of 25% or more, and a change in eGFR category or
sustained decrease in eGFR of 15 ml/min/1.73 m2 or more within 12 months
• Hypertension that remains poorly controlled despite the use of at least 4
antihypertensive drugs at therapeutic doses
• Known or suspected rare or genetic causes of CKD
• Suspected renal artery stenosis

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• a reduction in kidney function

• RENOPROTECTION and dapagliflozin (DAPA-CKD trial):

THIS IS AN ADD ON TO ACEi/ARB

A. A reduction in estimated glomerular filtration rate of 5 mL/min/1.73m2 in two years

B. Blood pressure of 160/95 mm/Hg despite three antihypertensive drugs

C. One episode of microscopic haematuria

E. Suspected renal artery stenosis

Criteria for referral:

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