Cardiovascular Hot topics ‘CKD’

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Cardiovascular Hot topicsCKD

• Dr Saqib Mahmud
• MBBS, MD, MRCP(UK), MRCPS(Glasg), MRCGP

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CKD

• The introduction of routine reporting of
• eGFR has led to 3 outcomes in primary care
• Worried patients, Increased workload
• confused clinicians.BMJ2006
• (Referral rates remain high due to uncertainty
  how to manage newly diagnosed CKD cases)

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Why has CKD been selected as a quality
indicator?QOF2 2006

• Patients with CKD have very high rates of
  vascular disease require aggressive management
  of vascular risk factors. (early CKD risk of
  death from CVDgtESRF)-low GFR predicts CV disease
• Its incidence is rising dramatically. (doubled in
  last 10yrs,5 adult population)
• S Cr does not rise until GFR has fallen by 50-70
• Early interventions in CKD improve cardiac
  renal outcomes

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eGFR-best estimate of renal function

• Based on S Cr, age, sex ethnic origin.
• Does not apply to children, ARF, pregnant women,
  oedematous malnourished.
• eGFR falls after eating meat, ideally fasting
  sample or avoid eating cooked meat day before.
• CKD-diagnosed 2 eGFRs 3/12 apart, not on the
  basis of single eGFR

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CKD-classification
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Clinical Signs Symptoms

• Tiredness
• Anorexia, nausea, vomiting
• Generalized pruritis
• Nocturia, frequency, oliguria, haematuria
• Frothy urine
• Loin pain
• Pallor, peripheral pulmonary oedema
• Pleural effusion SOB
• leuconychia

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QOF 2006 CKD register

• CKD1- register of ptsgt18 with CKD3-5
• CKD2-(90) on register with record of BP in last
  15/12
• CKD3-(70) on register with BPlt140/85
• CKD4-(80) patients on ACEI/A2RB-or CI
• Worth 27pts3,364/-

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Conditions with risk of developing CKD

• Hypertension
• Diabetes
• Heart failure
• Vascular disease
• Urinary outflow obstruction
• Multi-system diseases egRA, SLE, vasculitis
• APKD or reflux nephropathy
• Long term Drugs-lithium, cyclosporin,NSAIDs,mesala
  zine

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Monitoring renal function

• Stage 1 2 requires evidence of renal damage eg
  Proteinuria, microalbuminuria, haematuria without
  urological cause or known polycystic kidney
  disease or GN. (Annual U Es)
• Stage 3 ? 6/12
• Stages 4 5?3/12

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Urine tests

• Dipstick urinalysis for protein,
• If ve ? msu to exclude infection EMU for
  ACR(gt30mg/mmol) or PCR(gt45)
• In diabetics, dipstick negative?ACR for
  microalbuminuria (gt2.5mg/mmol-males,gt3.5 in
  women)

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Management is easy

• CKD rarely means dialysis
• Monitor renal function closely- assess rate of
  change
• Tight BP control with preferential use of ACEI or
  A2RB
• Pay close attention to CV risk

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New patient with eGFRlt60

• Review previous results ?rate of deterioration
• Review medication ?nephrotoxicity
• Check BP, urine, full clinical assessment eg
  ?palpable bladder
• Repeat UE within 5/7 (?rapid progression)
• Referral criteria- renal function stable? monitor
• Stage 4(if stable, monitor) 5 should be
  referred
• Stage 3 if deteriorating function

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Long term management to delay progression and
reduce CV events

• Life style advise? smoking cessation, wt
  reduction, exercise, low protein diet
• Aspirins statins if CVD risk 15-20
• (evidence is that all CKD patients are high risk)
• Strict BP control-QOF2 target lt140/85, but renal
  guidelines best practice target is 130/80 -UK
  CKDJBS2 guidelines.
• Check UEs before starting, 2/52 after also
  2/52 every dose change of ACEI or A2RBs
• Aspirin-gtBPlt150/90, target TClt4,LDLlt2

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Additional management-CKD3

• Renal USS if LUTS, refractory HTN, unexpected
  fall in GFR
• Immunise-influenza, pneumococcus, Hep B in CKD45
• If HBlt11-exclude other causes, refer for ESA, iv
  Fe

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Renal osteodystrophy

• Renal failure? failure of Vit D hydroxylation?
  secondary hyperparathyroidism
• ?increased risk due to faulty bone remodelling
  lowered BMD.
• Check PTH levels, if low check 25-hydroxy Vit D
  levels
• Rx- ergo or colecalciferol with
  calcium/bisphosphonates

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Bone disease in CKD

• Recent Irish study found 76 of osteoporosis
  cases in CKD patients
• Patients with CKD 45 had significantly lower BMD
  at hip spine high bone turnover
• 2 fold increased risk of vertebral fractures
• Statins - known to have beneficial effect in
  prevention of osteoporosis as well as decreased
  incidence of sepsis in CKD!

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ACEI / A2RB-Rx or the cause

• ACEI/A2RBs improve outcomes but in some patients
  can be nephrotoxic
• A slight reduction in GFR (lt15) or increase in
  creatinine is a normal haemodynamic response to
  ACE inhibition is normally not an indication to
  stop Rx unless creatinine rises by gt30
• Heart failure-rise in CR upto 50 baseline or
  200umol/l is acceptable-(NICE)

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Renal artery stenosis

• GFR- difference b/w flow of blood into glomeruli
  via afferent arteriole flow out via efferent
  arteriole
• This is not dependent on AT II normally but
  kidneys can increase GFR by local production of
  AT II which vasoconstricts efferent arteriole
• In RAS-GFR is dependent on AT II mediated
  efferent arteriole vasoconstriction

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Renin- Angiotensin system
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RAS-cont

• RAS is likely if rise in S Cr in absence of
  significant drop in BP
• Flash pulmonary oedema-bilateral RAS
  predisposes to episodic catastrophic pulmonary
  oedema-often misdiagnosed as LVF until ACEI Rx
  causes rapid rise in S Cr
• Renal function usually reverts to baseline on
  stopping ACEI
• Small kidneys in Renal USS-strong indicator

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RAS-cont
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Rx in RAS

• Ca channel blockers (dihydropyridines)-Rx of
  choice in RAS
• Also indicated when ACE Is are not tolerated
• Targeting BP lowering aggressive is more
  important than choice of Rx- ALHAT study

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Prescribing in CKD

• Avoid NSAIDs, codeine
• Withold ACEIs in hypovolaemic states-gastroenterit
  is etc
• Antibiotics, digoxin, metformin etc
• use with caution
• (reduce dose or frequency)

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What about elderly patients with low eGFR- how
should we manage them?

• The guideline makes no age distinctions
• BMJ2006it is ageist not to Rx CKD just because
  someone is elderly.
• BJGP editorial Dec2006elderly with CKD still
  benefit from CV risk factor intervention and
  strict BP control in elderly slows rate of renal
  decline
• Use clinical judgement patient circumstances

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Key points..

• CKD patients have high risks of CV events so
  CVD prevention should be fundamental to the
  management of CKD
• Risk of ESRF is very low(ckd3-1.124.3 CV
  death-5yr)
• Best practice target BP is 130/80 with
  preferential use of ACEI / A2RB
• Consider aspirin and statins
• Life style advise low protein diet
• Consider Bisphosphonates Ca for CKD assoc bone
  disease
• ACEIs not necessary for all CKD pts

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Thank you-questions???

• The enemy of good
• is better