AKI and CKD: Top ten facts for primary care physicians

Richard Smith

KIDNEYS

CKD: Does it really matter?

Richard SmithConsultant Nephrologist

www.renal.org/CKDguide/ckd.html http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4101902

Significant biochemical changes have no ‘immediate’ clinical correlate

CKD(3) and AKI are associated with significant risk

Recognise the patient at risk and manage this

CKD(3):Confers significant cardiovascular risk and risk of AKIProgression to RRT is rare (1.3%)Progression to worse CKD (and therefore worse cardiovascular and AKI risk) is common

The talk in one slide: Risk management

RRT

60

50

40

30

20

10

eGFR

CKD3CKD3

CKD4CKD4

X

CKD: Does it really matter?

RRT

60

50

40

30

20

10

eGFR

CKD3

CKD4

X

CKD3: Does it really matter?

Risks associated with CKD

Cardiovascular Risk

(N=1,120,295)

1.0

1.4

2.0

2.8

3.4

Ha

zard

ra

tio fo

r C

V e

ven

t

0

1

2

3

4

Reduced kidney function is associated with a higher risk of CV events

≥60 45-59 30-44 15-29 <15

eGFR (mL/min/1.73m2)

Go et al. N Engl J Med 2004 351: 1296–1305 Tonelli et al. J Am Soc Nephrol 2006 17: 2034–2047Eeg-Olofsson et al. J Internal Medicine 2010 268: 471–482 Khaw Nature Reviews Endocrinology 2009 5: 130-131

8.0-8.9

9.0-9.9

CKD3

Age-related glomerulosclerosis is amplified by systemic atherosclerosis

Kasiske BL. Kidney Int 1987; 31: 1153-1159

Risk factors for cardiovascular disease

Risk factors for chronic kidney disease

Hypertension

Smoking

Obesity

Diabetes

Dyslipidaemia

Reduced GFR

Proteinuria

Hypertension

Smoking

Obesity

Diabetes

Dyslipidaemia

Atherosclerosis

Heart failure

SHARP: Major Atherosclerotic Events5-year benefit per 1000 patients

http://www.ctsu.ox.ac.uk/~sharp/

Hemmelgarn BR. Kidney International 2006: 29: 2155

10,184 community-dwelling subjects aged 66 or over

Decline in eGFR greatest in diabetic patients (2.1 and 2.7 ml/min/1.73m2/year in F and M respectively)

Decline in eGFR in non-diabetic patients: 0.8 and 1.4 ml/min/1.73m2/year in F and M respectively

Decline more likely if baseline eGFR <30

Risk of decline of GFR in elderly people

CKD progression

Steps to identify progressive CKD

Obtain a minimum of three eGFR over not less than 90 days

In new cases of reduced eGFR repeat within 2 weeks

to exclude acute deterioration

Slow progression by treating BP

In CKD >140/90 mmHg

In CKD and diabetes or ACR 70mg/mmol > 130/80 mmHg

Risks associated with CKD

Acute Kidney Injury

NICE Guidance 28th August 2013

The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care

Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year

Inadequate assessment of risk factors in 24% of patients admitted with AKI

Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia

RRT

60

50

40

30

20

10

eGFR

CKD3

CKD4

X

CKD3: Is it really CKD?

Do not ignore eGFR 30-59ml/min until know direction of travel and

significant causes ruled out

Diagnostic Criteria for Primary Care

A rise in serum creatinine of ≥26.5 μmol/L in 48 hoursA rise in serum creatinine of ≥50% in 7 days

AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or 1.5-1.9 × baseline

AKI stage 2: a rise in creatinine of 2.0-2.9 × baseline

AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L

776 AKI spells over 12 monthsNo differences between practices19% of patients die in hospital24% have diabetes20% have diabetes and are >65 yrs old

Case note review:

Presentation usually with ‘other’ diagnosis

Also500 new referrals at Ipswich Hospital

Kidney medicine in primary care: BaNES

48 yr old man. Routine health check. Found to have eGFR of 35ml/minReferred for investigation of his “CKD 3”

No previous eGFRProtein ++++ No haematuriaBP 122/74

Case 1

Renal biopsy demonstrated FSGS

Mrs MA 74 year old eGFR 46ml/min/1.73m2

USS demonstrated ‘normal’ size kidneys

Serum electrophoresis revealed a paraprotein with urinary BJP

Case 2

Dipstick of urine revealed + protein

Fact 1: Haematuria and proteinuria are

flags for further investigation

Fact 2: Combined renal length <20cm

makes CKD likely Still need to exclude A/CKD

Mr PS 80 year old ‘Stable’ IHD Not diabetic No ACEI

Acutely SOB with possible rigor

Few crackles L base

Clarithromycin prescribed

Case 3

24 hours later confused and hypotensive

Emergency admission

Treated as CAP according to hospitalprotocol

Rx Vancomycin 1g x 2Gentamicin 160mg x 2

48 hours later AKI diagnosedBaseline eGFR 42ml/min/1.73m2

4 week hospital admission

Probably avoidable with recognition that patient likely to have CKD and risk conferred by this CKD

Admission eGFR 22ml/min/1.73m2

‘48h’ eGFR 12ml/min/1.73m2

74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease

Most recent HbA1c 7.4%

First thoughts?

Case 4

Rx Ramipril 5mg daily and Metformin 500mg bd

74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease

Rx Ramipril 5mg daily and Metformin 500mg bd

Pyrexial. BP 130/74. Euvolaemic

WCC 10.6x109/l CRP 48ng/ml

eGFR 42ml/min with a potassium of 4.2mmol/l

Case 5

92 year old is seen in clinic having been found by GP to have ‘CKD4’

She is well with an eGFR of 26ml/min

Rest of biochemistry is safe, urine reveals neither blood nor protein

What do I do?

Case 6

USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction

eGFR was 28ml/min in 2008

Fact 1: Haematuria and proteinuria are flags for further

investigation

Fact 2: Direction of travel is everything!

Fact 3: Risk factors for AKI include age >65, diabetes, CVD and

ACEI/ ARB

Fact 4: Infection is a trigger for AKI in at risk patients even if not

involvingurinary tract

Case 7

A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.

What do I do?

Case 7

A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.

What do I do

Dipstick of urine revealed blood ++ and protein ++

Fact 1: Dipstick of urine is your get out of jail free card.

Particularly if hypertension.

78 year old with stable CKD3. Rx Ramipril 5mg daily

eGFR June 2011 47ml/min April 2014 41ml/min

Cares for terminally ill husband therefore deferred R hip replacement

What pain killers would you recommend?

Case 8

Pharmacist recommended Ibuprofen 400mg daily

4th July 2014 16ml/min

Stopped Brufen

14th July 2014 39ml/min

Fact 5: NSAID/COX inhibitors/COX-2 inhibitorsXFact 6: Consider stopping ACEI/ARB

Even in patient with stable kidney function if ‘at risk’

Fact 7: Restart ACEI/ARB when acute event resolved

Patients who need ACEI/ARB should not be deprived of them because of undue concerns about AKI

Fact 8: Stop metformin if risk of AKI

Fact 9: Metformin can be used in CKD3

Avoid in CKD3b if significant risk of AKI

Recognition and Prevention of AKI

Is this an at risk patient?Age >65 yearsVascular diseaseDMACEI/ARBCKD

Is glomerular perfusion threatened ?Hypotension or sepsisNSAID/COXi/COX-2i

Kidney medicine in primary care: 7 minutes

Fact 10: Slides and more info available at www.clinimeded.co.uk Wales Deanery CPD for

GPs

http://gpcpd.walesdeanery.org/Clinical

Acute Kidney Injury

Quiz: http://www.doctors.net.uk