CKD updateCKD update

Dr Saqib MahmudDr Saqib MahmudMRCP(UK),MRCGPMRCP(UK),MRCGP

Chronic kidney diseaseChronic kidney disease

Defined by a reduced Defined by a reduced eGFR, proteinuria, eGFR, proteinuria, haematuria and/ or haematuria and/ or

structural abnormalities structural abnormalities persistent for more than persistent for more than

90 days90 days

IntroductionIntroduction

• Prevalence – over 13% of Prevalence – over 13% of population; rising as a population; rising as a consequence of DM & Obesityconsequence of DM & Obesity

• Primarily a marker of CV riskPrimarily a marker of CV risk• Stage 3 CKD – 40 – 100% Stage 3 CKD – 40 – 100%

increased risk of CV eventsincreased risk of CV events• Minority at risk of progressive Minority at risk of progressive

decline in renal functiondecline in renal function

ClassificationClassification

• Stage 1 : GFR>90 Stage 1 : GFR>90 (presence of kidney damage (presence of kidney damage with N or raised GFR)with N or raised GFR)

• Stage 2 : GFR 60 – 89 Stage 2 : GFR 60 – 89 (presence of kidney (presence of kidney damage with mildly reduced GFR)damage with mildly reduced GFR)

• Stage 3A : GFR 45 – 59Stage 3A : GFR 45 – 59• Stage 3B : GFR 30 – 44 , Stage 3B : GFR 30 – 44 , moderately moderately

reduced GFRreduced GFR

• Stage 4 : GFR 15 – 29 Stage 4 : GFR 15 – 29 , , severely reduced GFRseverely reduced GFR

• Stage 5 : GFR <15 , Stage 5 : GFR <15 , end-stage RFend-stage RF

Basic investigationsBasic investigations

• Repeat U&E, eGFR (within 3/12)Repeat U&E, eGFR (within 3/12)• FBSFBS• FBCFBC• Dipstick urine for haematuriaDipstick urine for haematuria• Urine ACR or TPCRUrine ACR or TPCR• Ca, PO4Ca, PO4

Further investigationsFurther investigations

• Hypercalcaemia – inv for myelomaHypercalcaemia – inv for myeloma• LUTS, deteriorating renal function – LUTS, deteriorating renal function –

renal tract USSrenal tract USS• Significant proteinuria +/- Significant proteinuria +/-

haematuria –> primary glomerular haematuria –> primary glomerular disease or vasculitis– autoimmune disease or vasculitis– autoimmune screen/referscreen/refer

ManagementManagement

• Main aims ; slow deterioration of renal Main aims ; slow deterioration of renal function – tight control of BPfunction – tight control of BP

• Reduce CV risksReduce CV risks• Maintain SBP at 129-139, DBP below 80Maintain SBP at 129-139, DBP below 80• SBP below 100 – 110 may be SBP below 100 – 110 may be

detrimentaldetrimental• ACEI / ARB confer additional benefit, ACEI / ARB confer additional benefit,

slow decline of renal function & slow decline of renal function & proteinuriaproteinuria

MonitoringMonitoring

• U&E post ACEI mandatoryU&E post ACEI mandatory• Stable CKD3A & B – U&Es 6/12, Stable CKD3A & B – U&Es 6/12,

CKD4 -3/12CKD4 -3/12• d/c ACEI if SCr rises >30%, eGFR d/c ACEI if SCr rises >30%, eGFR

falls>15% baselinefalls>15% baseline• Thiazide diuretics lose their efficacy Thiazide diuretics lose their efficacy

in Rx of HTN in CKD as GFR decline in Rx of HTN in CKD as GFR decline – loop diuretics Rx of choice– loop diuretics Rx of choice

Drug administrationDrug administration

• Certain drugs CI, require dose Certain drugs CI, require dose adjustment adjustment

• d/c metformin if eGFR <30d/c metformin if eGFR <30• Insulin dose may need to be Insulin dose may need to be

reducedreduced

ReferralReferral

• Most CKD patients managed in primary Most CKD patients managed in primary carecare

• Consider referral; younger patients with Consider referral; younger patients with CKD any stageCKD any stage

• Deteriorating renal functionDeteriorating renal function• Significant protienuria >1g/d or Significant protienuria >1g/d or

proteinuria + haematuria>1+proteinuria + haematuria>1+• Poorly controlled HTN despite 4 drugsPoorly controlled HTN despite 4 drugs• Renal anaemiaRenal anaemia