CKD:

the primary/secondary care

interface
Daniel Ford
Consultant Renal Physician
UHCW

Overview
Background
History, classification and controversies!

Complications
CVD, CKD progression, other complications

CKD Management
Management of CKD: role of primary and secondary care

Referral guidelines
Who to screen and when to refer

Discussion

Overview
Background
History of CKD
Classification
Model of CKD

History of CKD
Chronic renal failure/impairment
NKF/KDOQI CKD guidelines
Terminology
Definition/classification
MDRD eGFR
Association of level of kidney function with
complications
Risk factors for progression
[AJKD Suppl. Feb 2002]

CKD Classification

www.NICE.org.uk/guidance/CG73

Model of CKD

Levey AS, et al. KI 2007; 72(3): 247-259

Overview
Background
Complications of CKD
Cardiovascular disease
Hypertension
Anaemia
Bone-mineral metabolism
Poor nutritional and functional status
Progression of CKD

Complications of CKD

Complications of CKD
Hypertension
80% HD patients, 50%
PD patients
CKD progression
associated with HTN
HTN associated with
level of eGFR

Buckalew VM, et al. AJKD 1996; 28: 811-821

Complications of CKD
Anaemia

NHANES III

Complications of CKD
Cardiovascular disease

Go et al. NEJM 2004; 351:1296-1305

Overview
Background
Complications of CKD

Management of CKD
Diagnosis
Managing complications
Progression of CKD
Pre-ERF planning
Primary vs. secondary care management

Diagnosis
CKD classification does not mandate a
diagnosis
Generic management of CKD
Disease-specific management

Diagnosis of patients starting

RRT during 2011
Diagnosis

Percentage of patients

Diabetes

24.8

Glomerulonephritis

13.3

Pyelonephritis

7.1

Hypertension

7.0

Polycystic kidney disease

7.2

Renal vascular disease

6.9

Other

16.3

Uncertain

17.3

UKRR 15th Annual Report

CKD Progression
What is significant progression?
What risk factors are associated with
progression?
Why is progressive CKD important?

CKD Progression
What is significant progression?
Most patients with CKD will not progress to
ERF
How many patients in the UK have CKD?
How many start RRT each year?

CKD Progression
What is significant progression?
Most patients with CKD will not progress to
ERF
How many patients in the UK have CKD?
4.94 million (8% of 61.8M)

How many start RRT each year?

6,730
i.e. 0.13% of CKD patients per year

Stevens et al. KI 2007;72:92-99

ONS 2009 estimates
UKRR 13th Annual Report (2009 data)

CKD Progression
What is significant progression?

CKD Progression
What is significant progression?
eGFR decline >5ml/min/1.73m/year
Or >10ml/min/1.73m in 5 years

CKD Progression
What is significant progression?
eGFR decline >5ml/min/1.73m/year
Or >10ml/min/1.73m in 5 years

What risk factors are associated with

progression?

What risk factors are associated

with progression?
Hypertension
Diabetes mellitus
Albuminuria

Cardiovascular
disease
Smoking
Ethnicity
NSAIDS

CKD Progression
What is significant progression?
What risk factors are associated with
progression?
Why is progressive CKD important?

Overview
Background
Complications of CKD

Management of CKD
Diagnosis
Managing complications
Progression of CKD
Pre-ERF planning
Primary vs. secondary care management

(Dialysis) planning
Consequences of late presentation
Rate of late presentation

Consequences of late presentation

Higher mortality, morbidity,

hospital stay, cost
Due to poorer clinical state at
presentation, lack of vascular
access
No possibility of pre-emptive
transplantation

Winkelmayer WC. J Am Soc Nephrol 2003; 14: 486-492.

Rate of late presentation

250 patients starting RRT
96/250 (38%) referred within < 4 months
43/96 (43%) of late referred patients were avoidable
Known raised serum creatinine
Risk factors for progressive renal disease, e.g. diabetic
nephropathy
Late referral as likely from hospital as from GP

Roderick P. Q J Med 2002; 95: 363-370

UKRR 13th Annual Report

Planning
All children, young people and adults approaching established renal
failure are to receive timely preparation for renal replacement
therapy so the complications and progression of their disease are
minimised, and their choice of clinically appropriate treatment
options is maximised
People with established renal failure receive timely evaluation of their
progress, information about the choices available to them, and for
those near the end of life a jointly agreed palliative care plan, built
around their individual needs and preferences

Renal NSF part 1. www.dh.gov.uk

Renal NSF part 2. www.dh.gov.uk

Planning
Dialysis
Haemodialysis (hospital, satellite, home)
Peritoneal dialysis (CAPD, APD)

Transplantation
Deceased-donor transplant
Living-donor transplant (including pre-emptive)
Other options (e.g. kidney-pancreas, paired-exchange,
desensitisation)

Conservative care

Overview
Background
Complications of CKD

Management of CKD
Diagnosis
Managing complications
Progression of CKD
Pre-ERF planning
Primary vs. secondary care management

CKD Management

Identification
(Renal) diagnosis
Progression
eGFR monitoring
BP control
ACE/ARB if appropriate

CVD risk management

BP control

Anaemia management
Bone mineral metabolism
Nutrition
RRT planning/education

CKD Management in primary care

Identification
(Renal) diagnosis
Progression
eGFR monitoring
BP control
ACE/ARB if appropriate

CVD risk management

BP control

Anaemia management
Bone mineral metabolism
Nutrition
RRT planning/education

CKD Management in primary care

8% of UK population has CKD 3-5
Stevens et al. KI 2007; 72: 92-99

Primary care

Renal care

CKD 3

84.6%

1.5%

CKD 4

62.7%

25.1%

CKD 5

30.0%

61.1%

Richards et al. NDT 2008; 23: 556-561

CKD 1:

QoF

The practice can produce a register of patients aged 18 years and over with CKD (US
National Kidney Foundation: Stage 3 to 5 CKD).

CKD 2:
The percentage of patients on the CKD register whose notes have a record of blood
pressure in the previous 15 months.

CKD 3:
The percentage of patients on the CKD register in whom the last blood pressure reading,
measured in the previous 15 months, is 140/85 or less

CKD 5:
The percentage of patients on the CKD register with hypertension and proteinuria who are
treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor
blocker (ARB) (unless a contraindication or side effects are recorded).

CKD 6:
The percentage of patients on the CKD register whose notes have a record of a urine
albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months

Overview
Background
Complications of CKD
Management of CKD

Referral guidelines
Who should be tested?
Frequency of testing
Who should be referred?
What information is required?

Who should be offered testing for

CKD?

Diabetes (type 1 and 2)

Hypertension
Cardiovascular disease
Receiving nephrotoxic drugs (NSAIDS, lithium)
Structural renal disease (stones, prostatic hypertrophy)
Relevant multisystem diseases (e.g. SLE)
Family history of CKD5 or hereditary disease

Who should be offered testing for

CKD?

Diabetes (type 1 and 2)

Hypertension
Cardiovascular disease
Receiving nephrotoxic drugs (NSAIDS, lithium)
Structural renal disease (stones, prostatic hypertrophy)
Relevant multisystem diseases (e.g. SLE)
Family history of CKD5 or hereditary disease

If neither diabetes nor hypertension is present, do not use obesity as a risk

marker
If none of the above is present, do not use age, gender or ethnicity as risk
markers

Overview
Background
Complications of CKD
Management of CKD

Referral guidelines
Who should be tested?
Frequency of testing
Who should be referred?
What information is required?

How often to test for progression?

Overview
Background
Complications of CKD
Management of CKD

Referral guidelines
Who should be tested?
Frequency of testing
Who should be referred?
What information is required?

NICE CKD Guidelines Sep 2008

Referral algorithm, p 19-21
www.NICE.org.uk/guidance/CG73

People with CKD in the following groups should usually be

referred for specialist assessment:

Stage 4 & 5 CKD (with/without DM)

Heavy proteinuria (ACR>70mg/mmol)
Proteinuria (ACR>30) and haematuria
Rapidly declining eGFR
5ml/min in 1 year
10ml/min in 5 years
Poorly controlled hypertension (4 agents)
Rare or genetic causes of CKD
Suspected renal artery stenosis

Considerations
Consider discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the
person with CKD to be seen by the specialist.
Once referral has been made and a plan jointly agreed, it may be
possible for routine follow-up to take place at the patients GP
surgery rather than in a specialist clinic. If this is the case, criteria for
future referral or re-referral should be specified.
Take into account the individuals wishes and comorbidities when
considering referral.
People with CKD and renal outflow obstruction should be referred to
urological services, unless urgent medical intervention is required,
e.g. for treatment of hyperkalaemia, severe uraemia, acidosis or
fluid overload.

Overview
Background
Complications of CKD
Management of CKD

Referral guidelines
Who should be tested?
Frequency of testing
Who should be referred?
What information is required?

What information is required?

Reason for referral
Latest blood results
Rate of progression
Serial creatinine results

Risk of progression
uACR/PCR

Likely diagnosis/need for tissue diagnosis

Other co-morbidities/ complications
Drug history (OTC meds & relevant changes)

Summary

Why these guidelines were introduced

How to manage patients with CKD
Who, when & how to refer
Where to find further information on CKD
www.renal.org/CKDguide/ckd.html
www.nice.org.uk/guidance/CG73