The management of renal problems in primary care
Hugh Gallagher
Consultant Nephrologist
St Helier Hospital
• The “epidemic” of CKD
• What is a typical CKD patient?
• A role for increasing primary care involvement?
• How can we achieve this?
• The “epidemic” of CKD
• What is a typical CKD patient?
• A role for increasing primary care involvement?
• How can we achieve this?
Nephrology workload
• “High” maintenance– Dialysis (HD/PD)– Predialysis– Acute renal failure– Acute transplantation– “Special”, eg vasculitis
• “Low” maintenance– CKD– Long term transplant
follow up– Hypertension– Others
Patient Volumes (1994-2003)
0
50
100
150
200
250
300
350
400
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Txps
CA
PD
HD
0
500
1000
1500
2000
2500
3000
3500
Nep
hrol
ogy
HD TXP CAPD NEPH
“Local health organisations can work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of glomerular filtration rate (eGFR), calculated and reported automatically by all clinical biochemistry laboratories.”
Renal NSF Part 2, Dept of Health, 2004
• MDRD formula– Age– Sex– Creatinine– Ethnicity (black vs. non-black)
• Cockcroft-Gault formula– Age– Sex– Creatinine– Weight
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150 46
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150 46
80 M 60 170
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150 46
80 M 60 170 26
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150 46
80 M 60 170 26
80 F 60 170
Age Sex Weight(kg)
Serumcreatinine(μmol/L)
EstimatedGFR
(ml/min)
60 M 70 150 46
80 M 60 170 26
80 F 60 170 22
K-DOQI Classification of CKD
Stage GFR(ml/min)
Description
1 > 90 1 Kidney damage withnormal or GFR
2 60-89 1 Kidney damage withmild GFR
3 30-59 Moderate GFR4 15-29 Severe GFR5 < 15 Kidney failureChronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging
K-DOQI Classification of CKD
Stage GFR(ml/min)
Description Prevalence(%)
1 > 90 1 Kidney damage withnormal or GFR
3.3
2 60-89 1 Kidney damage withmild GFR
3.0
3 30-59 Moderate GFR 4.34 15-29 Severe GFR 0.25 < 15 Kidney failure 0.2Chronic kidney disease is defined as either kidney damage or GFR < 60 ml/min for > 3 months. 1 Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in urinalysis or imaging
Prevalence of Unreferred CKD in East Kent
• East Kent population 601,000• Small ethnic population• Study period Oct 2000 - Sept 2002• Using opportunistic serum creatinine
– Monthly screening of Chemical Pathology Database
– Review after two months
• Males serum creatinine 180 mol/L
• Females serum creatinine 135 mol/l
• Approximate to GFR < 30-40ml/min/1.73m2
CKD definition
Prevalence 5554pmpMedian Age 82 (18-103)Median GFR 28.0 (3.6-42.8)41.8% Male17.8% diabetes
CRF PopulationCRF Population
Calculated GFR (mls/min)
40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5
N
umbe
r of
cas
es1600
1400
1200
1000
800
600
400
200
0
Prevalence 0.55%Median Age 82 (18-103)Median GFR 28.0 (3.6-42.8)41.8% Male17.8% diabetes
CKD population
Unreferred CRF population Unreferred CRF population
Median Age 83 (18-103)Median GFR 28.5 (4.1-42.8)39.2% Male17.7% Diabetes
Calculated GFR (mls/min)
40 - 4535 - 4030 - 3525 - 3020 - 2515 - 2010 - 155 - 100 - 5
N
umbe
r of
pat
ient
s1400
1200
1000
800
600
400
200
0
Prevalence 0.47%Median Age 83 (18-103)Median GFR 28.5 (4.1-42.8)39.2% Male17.7% Diabetes
Unreferred population
<0.0128.5
(4.1-42.8)
23.4
(4.8-39.8)eGFR (ml/min/1.73m)
<0.0160.843.8Women (%)
<0.0183 (18-103)70 (18-91)Age (yrs)
4708846Prevalence (pmp)
PUnreferredKnown
John et al AJKD 2004;43:825-835DOD/0604-04
Comparison of known and unreferred populations
In real money...
• GP practice 10,000 patients– Stage 3 CKD: 500 patients– Stage 4 CKD: 20 patients– Stage 5 CKD: 20 patients– Unreferred stage 4 and 5: 28 patients
• Renal unit, serving 1.8 million population– Unreferred stage 4 and stage 5: 5,100 patients
• The introduction of eGFR will facilitate early recognition of CKD
• It will also result in increased awareness of advanced CKD previously not recognised as such
• A “coping” strategy needs to be developed before eGFR reporting is introduced
• The “epidemic” of CKD
• What is a typical CKD patient?
• A role for increasing primary care involvement?
• How can we achieve this?
Causes of CKD in the elderly
25%
15%
20%
15%
10%
15%
Diabetes
Hypertension
Aetiology unknow n
Renovascular
Outf low obstruction
Other
Functional consequences of CKD
• Hypertension
• Anaemia
• Disorders of Ca/Pi/PTH metabolism– renal osteodystrophy– vascular calcification
Snapshot of a CKD population in primary care
• GFR estimated on patients from 12 practices in Surrey, Kent and Greater Manchester
• 19% of sample (5% population) stage 3-5 CKD• mean age 74 years (control 57 years)• 75% stage 3-5 (22% control) co-existing
circulatory disease• 25% stage 3-5 (men) prostatic disease• 15% stage 3-5 anaemic by WHO (4% requiring
treatment by European Best Practice guidelines)• 3% recorded as having a renal disease
Comorbidities in CKD
0%
20%
40%
60%
80%
100%
All cardiovascular
disease
Diabetes Ischaemic heart
disease
Heart failure Peripheral vascular
disease
Hypertension
No CKD
Stage 3 CKD
Stage 4 CKD
Stage 5 CKD
• The “epidemic” of CKD
• What is a typical CKD patient?
• A role for increased primary care involvement?
• How can we achieve this?
Most CKD patients are stable
Rate of GFR decline (ml/min/1.73m2/year) <2.0 2.0-2.9 3.0-3.9 4.0-4.9 >5.0 Age (years) <70 (%) 82 4 5 5 5 70-80 (%) 80 5 4 3 7 >80 (%) 77 6 3 4 10 All (%) 79 5 4 4 8
Cardiovascular diseases in CKD
Damage to the heart(Uraemic cardiomyopathy)
Damage to the arteries(Uraemic arteriopathy)
Uraemic Cardiomyopathy
•Thickening of the wall•Dilation of the heart•Myocardial scarring•Calcification•Conduction defects
Uraemic Arteriopathy
•Thickening of the wall•Atherosclerosis•Stiffening of the artery•Calcification
25-34 35-44 45-54 55-64 65-74 75-84 >85
Age
Ann
ual m
orta
lity
(%)
Adapted from Levey AS et al. Am J Kidney Dis 1998; 32: 853-906.
Cardiovascular Mortality Rates are Higher among Dialysis Patients
General population: maleGeneral population: female
Dialysis: maleDialysis: female
10
100
1
0.01
0.1
0.001
Go, A. S. et al. N Engl J Med 2004;351:1296-1305
Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization among 1,120,295 Ambulatory Adults, According to the Estimated GFR
• Most renal patients die of CV causes well before they reach ESRD
• Their management is therefore that of their CV risk
Risk factors
• CVS DISEASE– Hypertension– Dyslipidaemia– Smoking– Obesity– Lack of exercise
• PROGRESSION– Hypertension– Dyslipidaemia– Smoking– Obesity– Lack of exercise
Patient choice…..
“No added value” consultations
• “The BP today was too high at 160/90. I have not made any changes today but suggest you repeat it in 2 weeks….”
• Where are blood tests performed?
• Protocol-based nurse-led clinics
• IT support
• GMS contract
• The “epidemic” of CKD
• What is a typical CKD patient?
• A role for increasing primary care involvement?
• How can we achieve this?
Principles
• Collaborative approach between primary and secondary care
• Concise practice guidelines for referral and management
• Role for practice and community-based specialist nurses
• Support from nephrologists for all stages• Dedicated nephrology care for predialysis and
deteriorating
Dangers
• Late referral• Missing ARF• Undertreatment of renal anaemia and
abnormalities of bone biochemistry• Issues around clinical responsibility• Workload
Short-term goals
• Education• Pilot and issue guidelines for
– management of newly discovered abnormal eGFR in primary care
– management of CKD (including indications for referral) in primary care
• Implement eGFR reporting by St Helier laboratories
• Link the management of CKD to that of CV risk
Longer-term goals
• Specialist nurse-led community based renal clinics
• Protocol-based approach for management of renal anaemia and bone disease in the community
• Renegotiation of GMS contract• Commissioning arrangements
The nephrologist’s view
The GP’s view