Chronic Kidney Disease Pathway D by pengxiang

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									Chronic Kidney Disease Pathway


Document Description

Document Type          Clinical Pathway
Service Application    Clinicians Included in the Management of Renal
                       Disease
Version                2.0
Ratification date      October 2009
Review date            October 2011

Lead Author(s)
Name                   Position within the Organisation
                       CVD/Renal Disease Lead nurse
                       Pharmaceutical Advisor


Presented for discussion, approval and ratification to


Core Policies and Procedures Group



Change History

Version    Date        Comments
1.0        Dec. 2007   Chronic Kidney Disease Register Validation Toolkit
1.1        July 2009   Draft of CKD pathway circulated for consultation
1.2        Sept 2009   Amendments agreed following consultation process
2.0        Oct. 2009   Chronic Kidney Disease Pathway ratified

Link with Standards for   C6:Clinical and Cost Effectiveness
Better Health Domains

Link with Trust Purpose   We will work to continuously improve services
and Values statements     We will support and empower people to
                          contribute to improving their health and that of
                          their community



                                                                             1
Summary Sheet

This pathway is intended to provide information on the management of people
with Chronic Kidney Disease (CKD) to reduce their risks and to identify, prevent
or delay the progression of associated co-morbid vascular and metabolic
conditions. It is also intended to identify people who are deemed to be at high risk
of developing CKD, to promote active screening of these people and to reduce or
eliminate individual risk factors to reduce their overall level of risk.
This policy applies directly to all staff members employed by NHS Dudley and
Dudley Community Services who are involved in the management of people with
CKD and is recommended as good practice guidance for each of the
independent contractor professions. National and local guidance, policies, reports
and/or papers which this particular document should be read in conjunction with:

Local Guidance:
   • Best practice Guidelines for Lifestyle Assessment
   • Cardiovascular Risk pathway
   • Hyperlipidaemia Guidelines
   • Dudley Guidelines for the Pharmacological Management of Hypertension

National Guidance: NICE Guidelines for:
   • Management of Chronic Kidney Disease
   • Secondary Prevention of Myocardial Infarction
   • Management of Patients with Heart Failure
   • Management of Hypertension
   • Lipid Modification
   • Management of Obesity

National Service Frameworks for:
   • Coronary Heart Disease
   • Renal Services Part II
   • Diabetes

This document will be subject to formal review in October 2011 led by the
Vascular Programmes Local Implementation Team.




                                                                                  2
Pathway for the Identification and Management of



Chronic Kidney
Disease
In the Primary Care Setting




Implementation date: October 2009
Review date: October 2011




Pathway overview




                                                   3
This CKD pathway has been produced by the CKD pathway group, a sub-group
of the Dudley Renal LIT. It is intended to be used by practice and community
teams, GPs, practice nurses, HCAs and administrative/I.T staff to:
     • Build and validate accurate CKD registers in line with the Quality and
        Outcomes Framework of the GMS contract and nationally expected
        prevalence rates.
     • Promote an awareness of CKD and the need for reduction of risk, early
        identification and diagnosis.
     • Inform the management of people with CKD in line with best practice as
        demonstrated in local and national guidelines
     • Support the appropriate referral to acute services and/or promotion of
        joint working with acute and community services to provide optimum
        outcomes in terms of management and patient choice.

Consultation has included:

          •   Renal LIT
          •   Diabetes DIP
          •   Vascular LIT
          •   Nephrologists at DGoH
          •   Diabetologists at DGoH
          •   Consultant Chemical Pathologist
          •   Dudley Clinical Commissioning Forum (DCF)
          •   Dudley Clinical Executive Team
          •   Community Diabetes Team
          •   Renal Dieticians
          •   Dudley Kidney Patients’ Association


This pathway may be used wholly electronically by downloading onto the practice
system, or in paper form. Practices may wish to use the pathway in either way, or
may wish to download certain sections only.


For further information on the development of the CKD pathway please contact:

Cardiovascular and Renal Disease Lead Nurse                 Tel. 01384 366880
Falcon House                                                Fax. 01384 366460
The Minories                                                Mob. 07786 338072
Dudley
DY2 8PG                                                            Courier 114




                                                                                 4
Contents
Introduction ……………………………………………………………………….7

Renal Pathway Overview ……………….……………………………………. ..9

High Risk Groups ……………………………………………………………….10

Read Codes ……………………………………………………………………..12

Identification of CKD in patients not in a High Risk Group …………………14

Acute Renal Failure …………………………………………………………….15

Contact Details ……………………………………………….. ………………. 17

Diagnosis of CKD ……………………………………………………………... 18

CKD Stages ……………………………………………………………………. 19

Prevalence of CKD ……………………………………………………………. 20

Practice Action Plan Template ………………………………………………. .21

Stages 1 and 2 …………………………………………………………………. 30

      Patient information ……………………………………………… 30

      Cardiovascular risk ……………………………………………… 31

      Hypertension …………………………………………………….. 33

      Initiating ACE Inhibitor …………………………………………… 36

      Salt intake ………………………………………………………… 36

      Nephrotoxic drugs ……………………………………………….. 36

      Renal Artery Stenosis …………………………………………… 37

      Urinalysis …………………………………………………………. 40

      Diet ………………………………………………………………... 44

      Diabetic Control …………………………………………………. .45

      Hepatitis B ……………………………………………………… 48



                                                                       5
     Influenza/Pneumococcal Vaccination ……………………….. 49

     Follow-up ……………………………………………………….. 50

Stage 3 …………………………………………………………………………… 51

     Anaemia ……………………………………………………….. 51

Stage 4 …………………………………………………………………………… 54

     One-Stop Renal Clinic ………………………………………. 54

     Bone Metabolism …………………………………………….. 56

     Annual Review ……………………………………………….. 57

Stage 5 ………………………………………………………………………….. 59

     Referral ……………………………………………………….. 60

     Renal Ultrasound ……………………………………………. 61

Abbreviations …………………………………………………………………… 62


Appendix 1:

Calcium and Phosphate Balance pathway …………………………………. 63




                                                          6
Introduction

Chronic kidney disease (CKD) describes abnormal kidney function and/or
structure. It is common, frequently unrecognised and often exists together with
other conditions (for example, cardiovascular disease and diabetes). When
advanced, it also carries a higher risk of mortality. The risk of developing CKD
increases with increasing age, and some conditions that coexist with CKD
become more severe as kidney dysfunction advances. CKD can progress to
established renal failure in a small but significant percentage of people.

CKD is usually asymptomatic, but it is detectable, and tests for detecting CKD
are both simple and freely available. There is evidence that treatment can
prevent or delay the progression of CKD, reduce or prevent the development of
complications and reduce the risk of cardiovascular disease. However, because
of a lack of specific symptoms, people with CKD are often not diagnosed, or
diagnosed late when CKD is at an advanced stage.
http://www.nice.org.uk/nicemedia/pdf/CG073NICEGuideline.pdf

Normal Kidney Ageing

A normal estimated glomerular filtration rate (eGFR) is about 100 ml/min in young
adults. However, this may be somewhat lower, some young adults with normal
kidneys may have an eGFR as low as 75 ml/min. Normal kidney function
deteriorates with age and falls by about 1 ml/min per year. Therefore as people
get older, many healthy people aged 75+ may have an eGFR of < 60 ml/min.

Recent research suggests that 1 in 10 of the population may have chronic kidney
disease (CKD), but it is less common in young adults, being present in 1 in 50
people. In those aged over 75 years, CKD is present in 1 out of 2 people.
However, many elderly people with an eGFR < 60 mls/min may not have
‘diseased’ kidneys, but have normal ageing of their kidneys. Although severe
kidney failure will not occur with normal ageing of the kidneys, there is an
increased chance of high blood pressure and heart disease or stroke.

It is recommended that all patients with CKD stage 1 – 5, including elderly
patients are added to the CKD register for the GMS Contract Quality and
Outcomes Framework and undergo annual screening to monitor the rate of
progression, blood pressure, proteinuria and development of associated
cardiovascular risk factors.

http://www.kidney.org.uk/Medical-Info/ckd-info/index.html

Late referral of patients with CKD requiring renal replacement therapy (RRT) to
specialist renal services is associated with significant cost and poor clinical
outcomes. On average 30% of people with advanced kidney disease are
referred late to nephrology services from both primary and secondary care,
causing increased mortality and morbidity.
http://www.nice.org.uk/nicemedia/pdf/CG073NICEGuideline.pdf


                                                                                   7
The great majority of patients starting RRT have progressed from earlier stages
and most could therefore have been identified, managed and referred more
appropriately at an earlier stage from primary care. Early CKD is common
however and referral of all patients with early CKD would completely overwhelm
existing specialist services. The great majority of patients with early CKD do not
progress to end-stage renal disease (ESRD), but do have a substantially
increased risk of cardiovascular morbidity and mortality. Optimal management of
the risk factors for cardiovascular disease, such as hypertension and proteinuria
will reduce the risk of progression from early CKD to ESRD and can be managed
effectively in primary care.

CKD Stages According to Established Estimated Glomerular Filtration Rate
(eGFR)


     CKD Stage                            Description


          1         Normal eGFR > 90 mL/min/1.73m2
                    *With other evidence of chronic kidney damage present


          2         Mild Impairment - 60-89 mL/min/1.73m2
                    *With other evidence of chronic kidney damage present


          3         Moderate Impairment - 30-59 mL/min/1.73m2
                               3A        45 - 59
                               3B        44 - 30


          4         Severe Impairment – 15-29 mL/min/1.73m2


          5         Established Renal Failure (ERF)
                    < 15 mL/min/1.73m2 or on dialysis


*Other Evidence of Chronic Kidney Damage
   • Persistent microalbuninuria, proteinuria or haematuria (after exclusion of
      other causes)
   • Structural abnormalities seen on X-ray (e.g. polycystic kidney disease)
   • Biopsy proven chronic glomerulonephritis




                                                                                  8
                                CKD Pathway
     Ensure annual assessment         Introduction         Suspicion of Chronic Kidney Disease
D   of people in high risk groups                           (CKD) following investigation for other
I                                                                    unrelated condition
A
G
N                   1. Confirm diagnosis                                         Is it Acute Renal
O                   2. Identify CKD stage 1 - 5                                        Failure?
S                   3. Enter onto practice system with appropriate
I                      read code compatible with GMS contract to form
S                      register.                                                    Urgent
                    4. Check register prevalence                                   Admission
                    5. Consider use of practice action plan template


    CKD stage 1 and 2.                     Stage 3 (3A 3B)
    Patient information and                  As stage 1 and 2
    education                                      plus:
                                             Management of
M   Address progressing factors:-                anaemia
A   CV risk                                   ESA pathway
N   Hypertension
                                                                          CKD stage 5
A   lifestyle
                                                                         Urgent referral
G   Initiation of ACE/ARB
                                                                           if clinically
E   Drugs with high salt content
                                                                          appropriate
M   Nephrotoxic/renally excreted
                                        CKD stage 4                       exceptions
    drugs, inc. OTC medication
E                                       As I, 2 and 3 plus shared
    Renal Artery Stenosis
N                                       care plan initiation. Refer to
T   Urinalysis
                                        "One-Stop" Renal clinic
    Diet in CKD                                                                             Annual
                                             Bone metabolism
    Glycaemic control                          Pathway for the                             review in
    Flu/pneumo vac                                                                          primary
                                         Management of Calcium
    Hepatitis B immunisation                                                                 care
                                         and Phosphate Balance
    Follow-up



R
E    Criteria for referral to
F    Specialist Nephrology            Information to include             Seeking Advice from
E           services                       with referral                 Nephrologist / Renal
R      Renal Ultrasound                                                     Dept. DGOH
R                                                                        Contact information
A                                                                         Frequently asked
L                      Palliative care trust protocol                         questions
                Prescribing /symptom control in advanced
                                renal disease


                                                                                       9
High Risk Groups

Renal function should be measured and recorded annually for all patients who
fall into a high risk group. This is measured by Estimated Glomerular Filtration
Rate (eGFR). Measurement of eGFR is available from the pathology department
at Dudley Group of Hospitals. It accompanies the report following any request for
Urea and Electrolytes (U+E), being calculated from the serum creatinine assay.
Patients in the high risk groups are considered to be at a higher than normal risk
of developing renal impairment due to co-morbities and/or medical history.
Ethnicity also increases risk with black and minority ethnic (BME) groups in the
U.K having up to 4 times greater risk of developing CKD.
http://www.britishrenal.org/conferences/brs2007/posters/CKD%20General-48.doc
The high risk groups fall into 3 main categories, morbidity, drug related and
urinary.

Morbidity:
   • Patients with Vascular disease
         o Coronary Heart disease
         o Stroke
         o Peripheral Vascular disease
   • Heart Failure
   • Hypertension
   • Diabetes
   • Multi-system diseases which involve the kidney, e.g. systemic lupus
      erythematosus, rheumatoid arthritis.
   • A first-degree relative with CKD stage 5.
Drug related:
   • Patients on ACE inhibitors or angiotensin receptor blockers (ARBs)
   • Patients on NSAIDs, including COX II
   • Patients on diuretics
   • Patients on lithium carbonate
   • Mesalazine and other 5-aminosalicylic drugs
   • Calcineurin inhibitors (cyclosporin, tacrolimus)
Urinary:
   • Recurrent Urinary Tract Infections
   • Bladder outflow obstruction
   • Recurrent kidney stones (>1/year) or predisposing condition, e.g. primary
      hyperoxaluria
   • Neurogenic bladder
   • Past surgical urinary diversion
   • Polycystic kidney disease
   • Reflux nephropathy
   • Biopsy proven chronic glomerulonephritis
   • Persistent proteinuria
   • Urologically unexplained persistent haematuria




                                                                               10
Kidney function deteriorates naturally with age. However the conditions above
may cause the kidneys to deteriorate more rapidly. Careful management of
progressing factors (see pathway) could ensure a normal or close to
normal/expected pattern of deterioration.
Kidney function by eGFR measurement should be monitored annually in the high
risk groups identified above.

Frequency of monitoring of Kidney function in CKD is indicated by the table
below.

Frequency of Monitoring of Kidney Function in Established CKD

  K/DOQI          eGFR                            Frequency
   Stage         mls/min
     1             > 90                             Annually
     2           60 - 89                            Annually
     3           30 - 59                            Annually
                                (6 monthly if newly diagnosed or progressive**)
     4            15 - 29                          6 monthly
                                (3 monthly if newly diagnosed or progressive**)
     5             < 15                            3 monthly

   Stable kidney function is defined as a change of < 2mls/min in 6 months
** Progressive kidney function is defined as a change of > 2mls/min in 6 months

Any patient assessed with a progressive condition should receive assessment of
progressing factors and discussion/referral to nephrology services.

Stage 3 Classification

The UK Consensus Conference on early CKD has recommended that the Kidney
Disease Outcomes Quality Initiative (KDOQI) classification should be modified by
dividing CKD stage 3 into CKD 3A and 3B and that a suffix “p” should be used for
all stages to denote patients with urine protein to creatinine ratio >100mg/mmol,
who are at increased risk for progression and/or the development of
cardiovascular disease e.g. CKD stages 2p, 3Bp.

CKD stage 3 is sub-classified into 2 groups, 3A and 3B.



               Stage          eGFR          Progression to ESRD
                3A            45 - 59            Lower risk
                3B            44 - 30            Higher risk




                                                                              11
Using the existing classification at least 4% of the adult population have stage 3
CKD, many of whom are elderly. They are at increased risk of cardiovascular
disease but most will not progress to end stage kidney disease. The priority
should therefore be to identify those at risk of kidney disease progression.

Persistent proteinuria (protein:creatinine ratio (PCR) > 100 mg/mmol) is the
best indicator of risk of progression to ESRD.

In diabetic patients urinary albumin /microalbumin estimations should be used.

It is recommend that all patients with suspected early CKD should have a urine
dipstick for proteinuria and, if positive, quantification of the PCR. This is included
in the Quality and Outcomes Framework. Urine albumin:creatinine ratio (ACR)
should be used in line with national guidelines in people with diabetes.

 (Patients undergoing dialysis have the suffix D added to their CKD stage, e.g.
5D. Those who have had a transplant should be classified according to eGFR but
have the suffix T added, e.g. 3T)

Read Codes

1Z15.         CKD stage 3A
1Z16.         CKD stage 3B

1Z17.         CKD stage 1 with proteinuria / 1P
1Z18.         CKD stage 1 without proteinuria

1Z19.         CKD stage 2 with proteinuria / 2P
1Z1A.         CKD stage 2 without proteinuria

1Z1B.         CKD stage 3 with proteinuria / 3P
1Z1C.         CKD stage 3 without proteinuria

1Z1D.         CKD stage 3A with proteinuria / 3AP
1Z1E.         CKD stage 3A without proteinuria

1Z1F.         CKD stage 3B with proteinuria / 3BP
1Z1G.         CKD stage 3B without proteinuria

1Z1H.         CKD stage 4 with proteinuria / 4P
1Z1J.         CKD stage 4 without proteinuria

1Z1K.         CKD stage 5 with proteinuria / 5P
1Z1L.         CKD stage 5 without proteinuria

http://www.renal.org/CKDguide/consensus.html
References



                                                                                    12
Joint Speciality Committee - Royal College of Physicians, The Renal Association
(2006) Chronic Kidney Disease in Adults, UK Guidelines for Identification,
Management and Referral.
http://www.renal.org/CKDguide/full/CKDprintedfullguide.pdf

University Hospital – Leicester (2005) Renal Guidelines Adults with Chronic
Kidney Disease http://www.britishrenal.org/Other/RenalGuideline.pdf

Department of Health (2005) The National Service Framework for Renal
Services: Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life
Care.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_4101902

Return to overview




                                                                              13
Identification of CKD in Patients who are not in a High Risk Group

There are few specific signs or symptoms which would alert suspicion to the
possibility of CKD in groups who are not routinely tested due to the presence of
morbidities which would put them at high risk. As a result these patients often
present at a late stage. Another reason for this would be the lack of
understanding of clinical staff on the significance of kidney function testing when
relying only on measurements of serum creatinine concentration. It is therefore
recommended that eGFR be requested as this gives a more accurate picture of
decline in kidney function than rising serum creatinine alone. Currently at Dudley
Group of Hospitals any request for urea and electrolytes (U+E) will automatically
have eGFR calculated and will accompany the results.

Any patient with an eGFR of < 60 mls/min should be investigated following
the renal pathway.

An eGFR of > 60 without other evidence of renal disease should not be
considered significant and these patients should not be subject to further
investigation. However, a diagnosis of Acute Renal Failure should be considered.

In many cases the possibility of renal impairment only comes to light when a
patient receives routine monitoring at a well person clinic, insurance medicals or
during routine investigations for acute illness or any assessment which involves
the monitoring of serum creatinine and/or U+E and/or urinalysis. It is worth
remembering that the majority of these patients will feel well and therefore the
diagnosis of renal impairment will be unexpected, especially if it comes to light as
part of a routine assessment.



Joint Speciality Committee - Royal College of Physicians, The Renal Association
(2006) Chronic Kidney Disease in Adults, UK Guidelines for Identification,
Management and Referral.
http://www.renal.org/CKDguide/full/CKDprintedfullguide.pdf


Return to overview




                                                                                 14
Acute Renal Failure

Acute Renal Failure (ARF) is a medical emergency as deterioration can be rapid
and fatal in many cases. Prognosis for recovery of kidney function is dependent
on the time delay between presentation and diagnosis. It is therefore extremely
important that people with suspected ARF are identified and investigated
promptly to ensure best possible outcomes. These patients should receive
prompt admission to acute nephrology services/emergency department.

ARF is characterised by rapid deterioration in renal function over a period of
hours or days. It should be suspected in the presence of an acute illness with
the following signs/symptoms:

   • A 50% rise in serum creatinine concentration
   • A 25% fall in eGFR (if baseline unknown, assume 75mls/min)
     N.B. eGFR should be interpreted with caution as it should be calculated in
     stable creatinine concentrations
   • Oliguria (urinary output <0.5mls/kg/hour)


Recognition of Acute Renal Failure in Newly Diagnosed Renal Impairment
eGFR < 60mls/min

ARF must be excluded in patients with newly diagnosed renal impairment. In
patients diagnosed at stages 3, 4 and 5, previous serum creatinine
concentrations should be investigated and compared, and eGFR calculated using
the 4-variable MDRD formula to assess the rate of deterioration to date.
http://www.renal.org/eGFRcalc/GFR.pl

Any patient found to have an eGFR of < 60mls/min without known Chronic
Kidney Disease (CKD) should be considered to have ARF until proven otherwise,
due to the emergency nature of the acute disease. These patients require the
following:

   •   Repeat measurement of serum creatinine and eGFR within a maximum of
       5 days. Further deterioration marked by a rise in serum creatinine of 50%
       or fall in eGFR of 25%, should prompt urgent referral to nephrology
       services.
   •   Clinical assessment for underlying conditions such as sepsis, heart failure,
       hypovolaemia.
   •   Clinical examination for bladder enlargement
   •   Urinalysis – proteinuria and/or haematuria suggest glomerulonephritis,
       which may also be rapidly progressive
   •   Review of medication, especially recent additions/nephrotoxic or renally
       excreted drugs, such as; NSAIDs, diuretics, ACE/ARBs, not forgetting
       “over the counter” (OTC) medication/therapies.



                                                                                15
     Management of a Previously Undiagnosed Patient with eGFR <
     60mls/min




      YES
   Is the patient acutely unwell?                 YES                Manage illness as appropriate.
                                                                     Repeat eGFR within 1-5 days
                                                                                (Go to *)

              NO



       Symptoms of outflow                        YES                     Palpate for bladder
         obstruction?**                                                 Urgent renal ultrasound
                                                                    (Renal ultrasound scan if history
                                                                    suggestive of urological disease)

              NO


                                                                   Check previous eGFR results.
* Has a reduced eGFR (< 60mls/min) or                              Calculate eGFR using the 4-
                                                  YES
   raised creatinine been measured                                 variable MDRD formula from
              previously?                                          previous creatinine results.
                                                                   Compare results and track rate of
                                                                   progression chronologically.
                                                                   Suspect ARF if there is:
              NO                                                       • A fall in eGFR of 25%
                                                                       • A rise in Creatinine of 50%
                                                                       • eGFR < 30 ml/min
 Repeat eGFR within 5 days                                             • Blood and Protein in urine
 Suspect ARF in the presence of
 any of the following:
 eGFR < 30 ml/min                                                                  URGENT
 eGFR fall of 25%                                                                 ADMISSION
 Creatinine rise of 50%                                                            Refer to/
 Blood and Protein in urine                                                      Discuss with
                                                                                 nephrologist.
                                                                                Contact details

     **People with CKD and renal outflow obstruction should normally be referred to urological
     services, unless urgent medical intervention is required.




                                                                                                 16
Next Steps

Any patient suspected to have ARF should be admitted urgently to nephrology
services/emergency department with as much information as possible, including
all previous results available for:

    • Creatinine
    • eGFR
    • Blood pressure
    • Urinalysis
    • HbA1C (if diabetic)
To include a list of current medication (including OTC) and any relevant medical
history.

Further information upon which to make a clinical decision should be sought
urgently by contacting the nephrology department.

Contact details:

On call renal consultant:               01384 244432 (direct line)
(Advice/Urgent admission)               (or 01384 456111 to switchboard at
                                        RHH and ask for on-call renal
                                        consultant)

Fax./urgent paper referral              01384 244543

Haemodialysis                           01384 244384
(Nursing Station Renal Unit)

CAPD                                    01384 244388
(Nursing Station Renal Unit)



                                                              Return to overview




Diagnosis of CKD


                                                                               17
The diagnosis of CKD is made by assessment of kidney function using estimated
Glomerular Filtration Rate (eGFR). eGFR is calculated from serum creatinine
levels, but depends on the method of creatinine assay used by each pathology
department. Therefore independent calculations of eGFR from previous
creatinine results will not give reliable results, as a correction factor needs to be
applied for the method used by Dudley group of hospitals pathology dept.

There is no need for 24-hour urine collection to measure creatinine clearance in
primary care.

The method for calculating eGFR is the 4-variable MDRD formula:

eGFR (mL/min/1.73m2)= 186 x [Serum Creatinine (umol/L) x 0.0113]-1.154 x
Age(years)-0.203 (x 0.742 if female) and 1.21 if African Caribbean.

An online calculator can be downloaded from:
http://www.renal.org/eGFRcalc/GFR.pl

N.B. The 4-variable MDRD formula:

   •   Is suitable for adults only (>17 years of age)
   •   Results are unreliable for eGFR > 60 mL/min/1.73m2.
   •   Results will NOT reflect true GFR if patient is receiving dialysis therapy.
   •   The formula has not been validated for Asian people.
   •   Results may deviate from true GFR values with extremes of body
       composition, dietary intake or severe liver disease.
   •   The formula has NOT been validated for drug dosing. Use the Cockcroft
       and Gault formula


Diagnosis of CKD should be made during a period of wellness by
measurement of eGFR.
Advise the person not to eat meat for at least 12 hours before the eGFR blood
test.

If the eGFR is < 60 mls/min then the guidance in this pathway should be followed
to exclude acute renal failure.

   A diagnosis of renal impairment should not be made on the basis of
  one result; at least 2 results should be considered which should be at
                            least 3 months apart.


If both of the results are< 60 mls/min then the patient should be considered to
have CKD and be added to the practice register. The patient should then be
managed following the guidance in this pathway.



                                                                                     18
Return to overview

CKD Stages


       CKD Stage                           Description


           1         Normal eGFR > 90 mL/min/1.73m2
                     With other evidence of chronic kidney damage


           2         Mild Impairment - 60-89 mL/min/1.73m2
                     With other evidence of chronic kidney damage


           3         Moderate Impairment - 30-59 mL/min/1.73m2
                                3A        45 - 59
                                3B        44 - 30


           4         Severe Impairment – 15-29 mL/min/1.73m2


           5         Established Renal Failure (ERF)
                     < 15 mL/min/1.73m2 or on dialysis



*Other Evidence of Chronic Kidney Damage

   •    Persistent microalbuminuria
   •    Persistent proteinuria
   •    Persistent haematuria (after exclusion of other causes)
   •    Structural abnormalities seen on X-ray (e.g. polycystic kidney disease)
   •    Biopsy proven chronic glomerulonephritis

Patients found to have an eGFR of 60-89 mls/min without one of the markers
above should not be considered to have CKD as these levels are considered
normal and therefore should not be subject to further investigation unless there
are additional reasons to do so, e.g. belonging to a high risk group.


Prevalence of CKD

The prevalence of CKD in at stage 3-5 in the UK based on neoErica data is
4.9%1


                                                                                   19
(Where stage 4 = 0.7%, and stage 5 = 0.2%)

Screening of patients with hypertension, diabetes and > 55 would yield approx.
93% of the CKD register, with this approach being the most effective strategy to
detect patients with CKD2.

Based on an expected prevalence of 4.9%:

   •   For a practice population of 2000:
       The approx. number of patients with CKD       =   94
       (4 pts. at stage 4 and 4 pts. at stage 5)

   •   For a practice population of 5000
       The approx. number of patients with CKD       =   245
       (10 pts. at stage 4 and 10 pts. at stage 5

   •   For a practice population of 10 000
       The approx. number of patients with CKD       =   490
       (20 pts. at stage 4 and 20 pts. at stage 5)

For guidance on building and validating a practice CKD register see practice
action plan - compiling a chronic kidney disease register.



References

   1. de Lusignan S, Chan T, Stevens P, O'Donoghue D, Hague N, Dzregah B,
      Van Vlymen J, Walker M and Hilton S. Identifying patients with chronic
      kidney disease from general practice computer records. Family Practice
      2005; 22: 234–241
      http://fampra.oxfordjournals.org/cgi/content/full/22/3/234


   2. Hallan S et al. Screening strategies for chronic kidney disease in the
      general population: follow-up of cross sectional health survey BMJ
      2006;333(7577):1047. http://www.bmj.com/cgi/con


Return to overview




                                                                               20
Practice Action Plan
Compiling a Chronic Kidney Disease Register


Name of Practice …………………………………………………………………………………………………………………………

Aim: To build a register of patients with Chronic Kidney Disease to meet the requirements of the Quality and
    Outcomes Framework of the GMS contract: CKD1



This action plan sets out the method and rationale behind each action in a step wise approach, assigning responsibility to
each part of the task. Practice expected prevalence should be calculated, allowing for assessment of the completeness of
the final register.


Support for completing these actions is available from the Cardiovascular and Renal Disease Lead Nurse, (address
below)
Shelagh.cleary@dudley.nhs.uk Tel. 01384 362754

Please sign below and send a copy of this front sheet to:

Cardiovascular and Renal Disease Lead Nurse
Service Development Dept. 5th Floor, Falcon House, The Minories, Dudley. DY2 8PG. Courier no. 114, Fax 01384 366460


Signed ………………………………………………. Position ………………………………………...

Print …………………………………………………. Date ……………………………………………




                                                                                                                        21
Practice Demographics

Population size                                                              ……………………………….

Estimated CKD prevalence at stage 3-5 = 4.9%
Stage 4 = 0.7%, and stage 5 = 0.2%
(Based on UK figures from NeoErica1 )

Estimated practice prevalence of CKD stage 3-5 =                             ……………………. patients
(Stage 4 = ………. patients
 Stage 5 = ……….. patients)




Number on practice system with read coded CKD diagnosis                      ……………………………….
(Read codes compatible with QoF)

This information can be found from population manager or clinical audit facility on the practice system. Or a practice query
can be run as outlined on p.4




                                                                                                                         22
Action                                              Rationale                                        Responsible
Run a search on the practice system to identify     To identify all patients who may possibly
all patients with an eGFR <60mls/min since          have a diagnosis of CKD 3-5 using pathology
1.4.06, excluding any patient who has a read        lab results who do not appear on the register.
coded diagnosis of CKD 3-5.                         N.B. The method for creatinine assay used
Include:                                            by the pathology dept. at RHH has been
All patients with 451E (eGFR) 59mls/min and         upgraded and so a correction factor is
below between 1.4.06 – 30.7.07                      applied when using the 4 variable MDRD
Exclude:                                            formula to calculate eGFR (eGFR results
1Z12 - CKD 3                                        have been available from 1.4.06). Therefore
1Z13 - CKD 4                                        individual calculations from previous
1Z14 - CKD 5                                        creatinine levels will not give an accurate
                                                    result.

Check each patient for validation of CKD            To build validated register.
diagnosis ensuring ethnicity correction factor is
applied and enter appropriate read code where
diagnosis is confirmed (p.7).
There will be 4 outcomes:
   1. Diagnosis confirmed.                             1. CKD 3-5 can be diagnosed by eGFR
Where there are 2 readings <60mls/min at least 3          readings alone.
months apart
   2. Diagnosis needing confirmation                   2. There must be at least 2 readings
Where there is 1 reading <60mls/min requiring a           <60mls/min at least 3 months apart.
second test.
   3. Diagnosis not confirmed.                         3. Both readings must be <60mls/min.
Where there are 2 readings, but only one of the           Recheck eGFR in a period of
readings is <60mls/min.                                   wellness.
   4. Diagnosis unclear                                4. Concurrent illness such as infection
Where there are multiple readings with at least          can affect eGFR which may account for



                                                                                                                   23
one <60mls/min.                                         isolated low results. Recheck eGFR in
                                                        a period of wellness.
Build a search for the practice CKD register       To check amended practice prevalence
Include:
Practice population with CKD diagnostic read
code compatible with QoF:
1Z12 - CKD 3
1Z13 - CKD 4
1Z14 - CKD 5
Or
Use population manager to check the number of
patients included on the register.
(This will also give denominator populations to
show patients not included in the indicators for
CKD 2,3 and 4)

If prevalence is not at least achieving Dudley QMAS average of 3.0% (approx. ………… patients) contact Cardiovascular
Disease Lead Nurse, contact details p1.


An example of a worksheet using the action plan follows.




                                                                                                                24
eGFR <60mls/min Since 1.4.06 With No CKD Diagnosis - Worksheet


   EMIS No.                       Results                                         Action
     12                     14.8.06 eGFR = 45              Needs second test
     38                      5.4.07 eGFR = 57              Needs second test
     43                     9.12.06 eGFR = 43              Needs second test
    2039                    28.6.06 eGFR = 61              Previous creatinine results checked for presence of
                             9.3.07 eGFR = 53              trend. Trend not seen. Needs second test to confirm.
     105                     9.6.06 eGFR = 54              Patient c/o frequent UTI. The 2 readings <60 fall on
                            21.7.06 eGFR = 66              the occasion of infection treated with antibiotics.
                             1.9.06 eGFR = 65              Dipstick urine tests reveal haematuria but no protein.
                            20.9.06 eGFR = 68              As there is a concurrent gynae complaint, it is not
                            23.7.07 eGFR = 54              clear as to the origin. The patient is also slightly
                                                           anaemic, where Hb has shown a continued
                                                           downward trend over the period.
                                                           Suggest renal ultrasound.
                                                           Frequent monitoring of eGFR. Add to register as
                                                           appropriate according to action plan.
     2356                   13.11.06 eGFR = 46             Added to register. CKD stage 3.
                            15.1.07 eGFR = 47              Last BP within audit standard 119/70
                            20.4.07 eGFR = 52              On ACE
                            20.7.07 eGFR = 52              Achieving all 4 clinical indicators.
     108                    11.7.06 eGFR = 22              Has read coded diagnosis on system but it is not
                             9.1.07 eGFR = 17              compatible with QoF business rules v.10. Read code
                            11.7.06 eGFR = 17              changed to include patient in QoF, CKD stage 4
     4718                    13.4.07eGFR = 57                                 Needs second test
     111                    18.6.07 eGFR = 59                                 Needs second test
     116                    26.6.07 eGFR = 57                                 Needs second test
     122                    16.10.06 eGFR = 34                Diagnosis confirmed CKD 3. Added to register.




                                                                                                              25
        3.1.07 eGFR = 35                    Last BP 139/71
       26.1.07 eGFR = 41                       On ACE
        3.3.07 eGFR = 38          Achieving all 4 clinical indicators.
4741   30.6.06 eGFR = 50    Diagnosis confirmed CKD 3. Added to register.
       10.10.06 eGFR = 56                   Last BP 144/70
       22.5.07 eGFR = 46                     Not on ACE
                                      Achieving CKD 1,2 and 3




                                                                            26
CKD Stages


    CKD Stage                             Description            Read Code


        1        Normal GFR > 90 mL/min/1.73m2
                 *With other evidence of chronic kidney damage


        2        Mild Impairment - 60-89 mL/min/1.73m2
                 *With other evidence of chronic kidney damage


        3        Moderate Impairment - 30-59 mL/min/1.73m2         1Z12


        4        Severe Impairment – 15-29 mL/min/1.73m2           1Z13


        5        Established Renal Failure (ERF)                   1Z14
                 < 15 mL/min/1.73m2 or on dialysis

                 eGFR                                              451E
                 (estimated glomerular filtration rate)



*Other Evidence of Chronic Kidney Damage
   • Persistent microalbuminuria
   • Persistent proteinuria



                                                                             27
   •   Persistent haematuria (after exclusion of other causes)
   •   Structural abnormalities seen on X-ray (e.g. polycystic kidney disease)
   •   Biopsy proven chronic glomerulonephritis

Patients found to have an eGFR of 60-89 mls/min without one of the markers above should not be considered to have
CKD and should not be subject to further investigation unless there are additional reasons to do so, e.g. belonging to a
high risk group.


References

 de Lusignan S, Chan T, Stevens P, O'Donoghue D, Hague N, Dzregah B, Van Vlymen J, Walker M and Hilton S.
Identifying patients with chronic kidney disease from general practice computer records. Family Practice 2005; 22: 234–
241 http://fampra.oxfordjournals.org/cgi/content/full/22/3/234


Return to overview




                                                                                                                           28
References



Joint Speciality Committee - Royal College of Physicians, The Renal Association
(2006) Chronic Kidney Disease in Adults, UK guidelines for Identification,
Management and Referral.
http://www.renal.org/CKDguide/full/CKDprintedfullguide.pdf

Department of Health (2005) The National Service Framework for Renal
Services: Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life
Care.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_4101902

University Hospital Leicester (2005) Renal Guidelines – Adults with Chronic
Kidney Disease http://www.britishrenal.org/Other/RenalGuideline.pdf

British Medical Association (2007) Chronic Kidney Disease Frequently Asked
Questions. NHS Employers
http://www.primarycarecontracting.nhs.uk/uploads/QOF/june_07/qof__faq_in_chr
onic_kidney_disease.pdf


Return to overview




                                                                              29
Stages 1 and 2
Patient Information and Education

The following websites are useful for downloading information and materials for
patients and for use in clinics.
It is worth noting however, that a diagnosis at stage 3/4 CKD may have been
made on blood test results alone. The patient will most likely have not had any
symptoms and therefore will not be expecting the diagnosis.

Kidney Patient Guide

Web: www.kidneypatientguide.org.uk

The Kidney Patient Guide provides web-based patient information for renal
patients, their families, health professionals and others interested in kidney
disease. The site is described as follows: "It includes information not only on
physical aspects of kidney failure - how the kidneys function, what happens when
they don't, and the treatments available - but also on wider issues such as
emotional, social and financial implications.

The site is designed primarily with a UK focus but will be of value to anyone who
is affected by the condition." Information is included on the following topics.

   •   What patients say.
   •   The physical aspects of kidney failure.
   •   The treatment of kidney failure.
   •   Emotional effects.
   •   Diet.
   •   Financial implications.
   •   Holidays.
   •   Carers, partners, family & friends.
   •   Support groups.

Kidney Health Information

http://www.kidneyresearchuk.org/index.php?option=com_content&task=view&id=
15&Itemid=32

Kidney Health Information is a service for kidney patients, their families and
carers, as well as medical professionals and researchers. The service is provided
by Kidney Research UK and the information is available to everyone at no
charge. It has a downloadable factfile section.

Return to overview




                                                                               30
Cardiovascular Risk

All patients with CKD have a greatly increased risk of developing heart disease
and other diseases of blood vessels, including strokes. For many, this is more
important than the danger of progressing to end-stage renal disease due to the
10 fold increase in cardiovascular events and mortality at CKD stage 3.
Furthermore, when events occur, mortality is higher for people with CKD and
they have less favourable outcomes from intervention such as angioplasty. This
increased risk begins at the very earliest stages, for example when there is
microalbuminuria without a reduced eGFR. The prevalence of CKD at stage 3-5
in the population is currently approximately 4.9%. However the prevalence of
CKD at stages 4-5 is approximately 0.9%. The chief reason for the reduction of
the numbers of people going on to stage 4 or 5 is due in the most part to their
cardiovascular mortality at an earlier stage. For this reason reducing
cardiovascular risk is of crucial importance to impact on mortality and as a
progressing factor for further renal deterioration.

For this reason, CVD risk calculators, including JBS2, are not recommended for
use in calculating risk in patients with CKD. CKD at stage 3-5 is in itself a marker
for CVD, therefore no calculation is needed and these patients should be
considered high risk.


Dyslipidaemia

Patients with established macrovascular disease should receive treatment for
hyperlipidaemia according to the current PCT Hyperlipidaemia Guidelines. Treat
with simvastatin 40mg, aim for cholesterol of < 4mmol/l.
Patients with diabetes and CKD but no established macrovascular disease
should be offered lipid-lowering drug treatment according to the current PCT
Hyperlipidaemia Guidelines.

Patients with CKD who do not have diabetes and who do not have established
macrovascular disease should be offered the options of lipid-lowering treatment
according to the current PCT Hyperlipidaemia Guidelines if estimated 10-year
risk of cardiovascular disease is ≥20%.

Health Economy Formulary Drug of Choice - simvastatin 40mg.

For further information see Dudley Guidelines for the Drug Treatment of
Hyperlipidaemia. http://joint.dudley.nhs.uk/cmsextra/documents/cms/222-2008-2-
22-5663216.pdf

It would follow that patients with CKD should receive lipid therapy if they are
considered to be at high risk. However, studies evidencing benefit from the use



                                                                                  31
of statins such as HPS and ASCOT excluded patients with CKD therefore
reliable evidence is not available. The Study of Heart and Renal Protection
(SHARP) with a cohort of over 9000 patients will hopefully provide the evidence
required. Until then, patients with CKD and no cardiovascular disease or diabetes
should be treated with a statin if their 10 year CVD risk is > 20% (Renal
Association). However, tables for calculating risk of CVD are not recommended
for use in patients with CKD, but it would follow that due to their presenting
condition, they would be considered at high risk of cardiovascular disease.


Antiplatelet therapy

Aspirin should be considered for all patients with an estimated 10 year risk of
Cardiovascular (CVD) disease of >20%, so long as blood pressure is <150/90
mm Hg.

There is limited evidence on the role of prophylactic antiplatelet therapy in
patients with CKD due to the fact that most of the large studies excluded people
with renal impairment. Too few CKD patients have been included in trials to
evaluate the risks and benefits reliably. Recommendations from the Renal
Association are to follow the advice from the British Hypertension Society.
Therefore:

Aspirin is recommended, “providing there are no contraindications and blood
pressure is < 150/90 mmHg and stable” in:

   •   Secondary prevention of CVD
   •   Primary prevention of CVD in patients who are
          o Hypertensive
          o Aged > 50
          o Calculated to have a 10 year CVD risk of > 20%


Health Economy Formulary Drug of Choice - aspirin dispersible 75mg OD

See Aspirin Initiation Protocol

Also see:

Hypertension
Lifestyle
Primary Prevention of Cardiovascular Disease Protocol


Return to overview




                                                                                  32
Hypertension

Blood pressure should be measured by a health care professional who has
undergone training, using a machine which is regularly serviced and calibrated.
The patient should be seated comfortably and relaxed with:
• arm supported at chest level
• ensuring correct cuff size is used ie. inner bladder fits 80 – 100% of the
   circumference of the upper arm.

On the first visit:
   •       BP should be measured in both arms and the arm with the higher
           reading used. This arm can then be noted and used for each
           subsequent visit.
   •       At least 2 readings should be taken, with an interval of at least a
           minute between readings and an average of the readings recorded.
   •       If the BP is above treatment threshold, (either systolic, diastolic, or
           both) check the BP again at the end of the consultation or after a short
           interval of 5 – 10 minutes, where patient remains seated comfortably.


Target BP Range in CKD

Aim for: Systolic of <140 and diastolic of <90 mmHg in a range of

                                     120 - 139
                                       <90

In CKD and diabetes:                 120 - 129
                                       <80

For elderly and diabetic patients, check sitting and standing BP. A drop in systolic
BP of 10 - 20 mmHg or more on standing may indicate the possibility of postural
hypotension. If postural hypotension is detected, all subsequent monitoring
should record the postural drop to aid consideration of symptomatic hypotension
when hypertensive medication is initiated/titrated.


Hypertension should be meticulously controlled. It is crucially important in
preventing the progression of renal deterioration in many patients with CKD, and
in particular protecting against damage to the heart and arteries. Patients with
renal impairment should be encouraged to carry out regular home monitoring as
long as they are fully empowered to do so. This will provide a more accurate
picture of baselines and response to medication. As targets for hypertension
management are based on office measurements, 10/5mmHg should be added to
average home readings to reflect this when assessing in clinic.




                                                                                 33
If BP is above threshold, check this reading on 2 more visits 2 – 4 weeks apart or
check home readings.
If the BP trend is found to be above the treatment threshold as stated, a decision
on initiating pharmacological management should be made. Inhibition or
blockade of the renin/angiotensin/aldosterone system with ACE inhibitors or
ARBs has been found to confer renal and cardio protection over and above the
effects of their BP lowering effect. For this reason they are recommended as first
line treatment for people with CKD.

See Initiation of ACE/ARB.
See Renal artery stenosis


For non-pharmacological management discuss lifestyle measures as detailed in
the “Best Practice Guidelines for Lifestyle Assessment” with particular attention
to salt content in the diet and also in prescribed or OTC drugs.

Note that in the checklist below for those with CKD the dietary advice differs from
that which is usually recommended:
   • Fruit and vegetables are to be at a maximum of 5 portions a day due to
       their potassium content
   • Oily fish should be one portion only per week due to high phosphate
       levels.

Lifestyle Measures Checklist

   •   Stop smoking
   •   Correct dyslipidaemia
   •   Screen for diabetes
   •   Maintain normal weight for adults (body mass index 20-25 kg/m2)
   •   Avoid central obesity <102cm in men, <88cm in women. (Asians <90cm in
       men, <80cm in women)
   •   Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day)
   •   Limit alcohol consumption to ≤3 units/day for men and ≤2 units/day for
       women
   •   Encourage regular moderate physical exercise for 30 minutes per day,
       ideally on most of days of the week but at least on 5 days of the week
   •   Consume a maximum (due to high potassium content) of five
       portions/day of fresh fruit and vegetables.
   •   Mediterranean diet: reduce the intake of total and saturated fat
       replace saturated fat with monounsaturated fats.
   •   Regular oily fish intake 1 portion a week due to high phosphate levels
       or other source of omega 3 fatty acids.
   •   Immunise against influenza and pneumococcus and consider Hepatitis B
       Immunisation




                                                                                34
 Further information on the pharmacological management of hypertension can be
found in the:
“Dudley Guidelines for the Pharmacological Management of Hypertension”,
http://joint.dudley.nhs.uk/cmsextra/documents/cms/222-2007-12-19-5392411.pdf


For further information on taking blood pressure measurements, guides using
electronic machines and anaeroid and mercury sphygmomanometers may be
downloaded from the british hypertension society www.bhsoc.org


For patients with T2 diabetes, please refer to NICE Guidelines, Inherited
Guideline H “Management of Type 2 Diabetes: Management of Blood Pressure
and Blood Lipids”
http://guidance.nice.org.uk/page.aspx?o=38564




Return to overview




                                                                              35
Initiation of ACE Inhibitor / ARB

ACE inhibitors and ARBs reduce hypertension in renal disease, but also confer
major prognostic benefits over that which can be attributed to the reduction in
blood pressure alone. For this reason they are recommended for use in CKD.

Threshold for initiation – see hypertension

Dual blockade with combinations of ACE and ARB should only be initiated under
specialist supervision.

Serum creatinine and potassium concentration should be checked
   • prior to starting ACE and/or ARB
   • within two weeks of initiation
   • two weeks after any subsequent dose increase
   • during severe intercurrent illness, particularly if there is a risk of
        hypovolaemia
   • annually (or more frequently if indicated, according to kidney function, see
   follow-up.)



 A rise of serum creatinine concentration of >20% or fall in estimated GFR of
     >15% after initiation or dose increase should be followed by a further
                         measurement within two weeks.




   If deterioration in kidney function is confirmed, before the ACE or ARB is
    discontinued, a specialist opinion should be sought (not necessarily by
    formal referral) on whether the drug treatment should be stopped or the
           patient subjected to investigation for renal artery stenosis.


If hyperkalaemia is present (K >6.0 mmol/l)
    • Stop relevant drugs, such as NSAIDs, K sparing diuretics.
    • Check diet, e.g. “low-salt” salt substitute discontinue use.
If hyperkalaemia persists despite these measures, then advice should be sought
from the nephrology dept on management with the ACE/ARB. Contact details


Health Economy Formulary Drugs of Choice
Lisinopril*
Ramipril capsules
Candesartan (not specific CKD licence)


                                                                                  36
Irbesartan*
Valsartan
Losartan*

*Specifically licensed for patients with type 2 diabetes and
nephropathy/microalbuminuria.

ARBs should be used as a second line treatment, only in patients who do not
tolerate ACE inhibitors (usually due to development of persistent dry cough which
does not disappear within two months of starting the ACE – check no other
caveats).

N.B Heart Failure
The commonest fear for not using an ACE/ARB in patients with Heart Failure
(HF) is the potential for worsening renal function. However, although the
CONSENSUS trial demonstrated a 30% rise in Creatinine; the subsequent
follow-up showed 19% returned to baseline and the ACE was generally well
tolerated.

Drug treatment with an ACE or ARB can contribute to hyperkalaemia, which can
also be exacerbated by treatment with spironolactone (indicated in the treatment
of heart failure).Severe hypovolaemia, may complicate the treatment of heart
failure with high dose diuretics, as it may also cause hyperkalaemia in the
presence of CKD, although in the presence of volume overload, diuretic
treatment may be a logical treatment for hyperkalaemia. For these reasons,
working out the cause and appropriate treatment of hyperkalaemia can be
difficult, and a good reason for referral to / advice from a nephrologist.

NSAIDs are associated with worsened outcomes in Heart Failure because they
oppose the benefits of ACE by inhibiting the production of prostacyclin.

Spironolactone should be avoided in patients with a GFR < 30 but can be used
with caution in patients where eGFR is between 30 – 60 ml/min. It should be
withheld in patients with diarrhoea and vomiting, who have heart failure and
CKD, due to dehydration and hyperkalaemia.
Spironolactone, ACE and ARB should be reduced or stopped if the serum
potassium is greater than 6.0 mmol/l. This includes potassium sparing diuretics.

http://www.renal.org/CKDguide/ckd.html




                                                                               37
K/DOQI Recommended Monitoring Intervals




Salt Intake

All patients with hypertension should be advised to reduce dietary sodium intake
to <100 mmol/day. (100mmol = 2.3g sodium = 5.75g salt).

Further information is available from the Food standards agency and BHS. The
approach should be to educate patients to assess the sodium content of foods
rather than providing a comprehensive catch-all list. See diet in CKD.

Salt content in drugs

Many medicines, particularly liquids, contain significant quantities of sodium.
Always take a comprehensive drug history, including OTC medicines. In
particular some antacids, effervescent tablets and intravenous antibiotics have a
high sodium content. Changing to alternatives which do not have the additional
sodium load will improve renal function, considerably in some cases. Further
information can be obtained from the PCT Medicines Management Team.
Salt Content in Soluble analgesics and Indigestion Remedies.
http://joint.dudley.nhs.uk/cmsextra/documents/cms/222-2007-12-19-5415991.pdf


Drugs to be used with caution in renal disease

   •   ACE inhibitors or angiotensin receptor blockers (ARB’s)
   •   NSAIDs


                                                                               38
   •   Diuretics
   •   Lithium carbonate
   •   Mesalazine and other 5-aminosalicylic drugs
   •   Calcineurin inhibitors (cyclosporin, tacrolimus)


For further information see appendix 3 of the BNF.

http://www.bnf.org/bnf/bnf/current/41003.htm

or contact the Dudley Medicines Management team:

       CKD clinical services lead clair.huckerby@dudley.nhs.uk

       P.A. for the team Tel. 01384 366589

Patients with CKD should be offered a 6 monthly medication review by a Practice
Based Pharmacist if on 4 or more medicines. This could be more or less frequent
depending on the needs of the individual patient.
Return to overview

Renal Artery Stenosis

Suspect Atherosclerotic Renal Artery Stenosis (ARAS) in patients whom:

   •   There is a rise in serum creatinine of > 20% or a fall in eGFR of > 15%
       during the first 2 months after initiation of ACE or after any dose increase.

   •   A rise in serum creatinine of > 20% or a fall in eGFR of > 15% in a 12
       month period where there is evidence or suspicion of widespread
       atherosclerosis.

   •   Refractory hypertension – where BP remains >150/90 despite 3
       antihypertensives.

   •   Recurrent episodes of pulmonary oedema despite normal LV function on
       echocardiogram (flash pulmonary oedema)

   •   Unexplained hypokalaemia with hypertension.

These patients should receive referral to nephrology for further investigation and
specialist management.



Return to overview



                                                                                  39
Urinalysis

Protein

No diabetes

Proteinuria is a significant risk factor for progression in renal disease and for
cardiovascular morbidity and mortality. Unlike haematuria, proteinuria almost
always has a renal origin. Management should include assessment of:

   •   Albumin/creatinine ratio (ACR) / Protein/creatinine ratio (PCR)
   •   Haematuria
   •   Serum creatinine and eGFR

To detect and identify proteinuria, use ACR in preference, as it has greater
sensitivity than PCR for low levels of proteinuria. For quantification and
monitoring of proteinuria, PCR can be used as an alternative. ACR is the
recommended method for people with diabetes.
http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf

Urine should be tested for protein annually in stage 3, and 6 monthly in stages 4
and 5 if stable. If protein is detected, exclude infection (only if symptoms suggest)
and retest.

Measurements should not be made during acute illness.

Send an early morning urine specimen for microalbumin and ACR level.

Persistent proteinuria is defined as 2 or more positive tests, ACR > 30
spaced by 1-2 weeks.

A positive ACR test (>30) in the presence of hypertension indicates
initiation of an ACE inhibitor

http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf

However, patients with CKD have an increased risk of CVD mortality.
Consideration should be given to initiating ACE inhibitors in patients with CKD,
positive microalbumin (< 30mg/day) and increased CVD risk, due to their
cardioprotective effect.

http://www.sign.ac.uk/pdf/sign103.pdf




                                                                                    40
Recommendation:

Therefore consider ACE inhibitor therapy regardless of established proteinuria for
patients with CKD and:

   •   Hypertension
   •   Heart failure
   •   Coronary, cerebral or peripheral vascular disease
   •   Diabetes mellitus
   •   Multi-system disease including SLE, rheumatoid arthritis, vasculitis

For many in this patient group, the cardiovascular impact of their renal disease is
more significant than the risk of continuing to end stage renal failure.

http://renux.dmed.ed.ac.uk/edren/Unitbits/CKDmanagement.html

see initiation of ACE/ARB



Protein/creatinine ratio PCR

PCR is the best test to confirm clinical proteinuria at higher levels. ACR at higher
levels (> 45) may be inaccurate. If using PCR, then proteinuria is defined as

Positive results: PCR > 50

In 2 separate specimens spaced by 1-2 weeks.

http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf




                              ACR >70 (PCR <100)

                   Manage as CKD guidelines, according to stage

                              ACR >70 (PCR >100)

                                 Refer to nephrologist.




                                                                                  41
Diabetes

All people with diabetes should receive annual assessment of microalbumin and
albumin/creatinine ratio.

If raised ACR :

   •    ACR >2.5mg/mmol (male)
   •    ACR >3.5mg/mmol (female)

   or

   •    Microalbumin level > 30 mg/day

Repeat test at next two clinic visits over 3–4 months
Microalbuminuria is confirmed if at least one out of two or more results is also
raised. http://www.nice.org.uk/nicemedia/pdf/CG66T2DQRG.pdf

Microalbuminuria with eGFR >60ml/min/1.73m2 is stage 1 / 2 CKD.

In patients with diabetes (type 1 or type 2), microalbuminuria/proteinuria is an
indication for:

   •    Treatment with ACE inhibitors (or Angiotensin receptor blockers if those
        are not tolerated), with titration up to maximum dose or maximum
        tolerated dose irrespective of initial blood pressure
   •    Control of hypertension to target
   •    Tight glycaemic control
   •    Monitoring of ACR, serum creatinine and eGFR.
   •    Consider referral to / discussion with the diabetic team or joint
        diabetic/nephrology clinic for review
   •    Consider referral to Nephrologist. See referral criteria



Blood

Microscopic haematuria without proteinuria, eGFR >60ml/min

   •    Age >50, refer to Urology
   •    Age <50, or >50 with negative urological investigations, treat as CKD
        stage

Microscopic haematuria with proteinuria eGFR >60ml/min

   •    Refer nephrology



                                                                                   42
Lower levels of proteinuria should be monitored annually and patients managed
according to CKD stage.

Macroscopic haematuria

(Use reagent strips and not microscopy)

   •   Fast track Urology referral
   •   If deteriorating function (eGFR), urgent nephrology referral; urgent
       imaging to exclude obstruction
   •   If GFR<60ml/min/, consider nephrology referral.
   •   If urological investigations negative, refer to nephrology.



Glucose

Any patient found with glycosuria who is not known to have diabetes should
have:

   •   urine checked for ketones
   •   observation of the presence of symptoms of diabetes, weight loss,
       polydipsia, fatigue etc.

If either are present this requires urgent management from the practice diabetes
lead clinician. Diagnosis of diabetes is required following Dudley diabetes
diagnostic criteria. Dudley Diabetes Management Guidelines for Adults



Return to overview




                                                                              43
Diet in CKD

Information on nutritional recommendations can be found on EdREN, the
website of the Renal Unit of the Royal Infirmary of Edinburgh.

http://renux.dmed.ed.ac.uk/EdREN/EdRenINFObits/Diet_CRF.html



Summary of Downloads

Keeping salt intake down

Cutting Down Potassium

A short leaflet about Fluid

Controlling phosphate

Increasing your calorie intake

Weight control

Renal Diets for Christmas and other holidays




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                                                                        44
Glycaemic Control

CKD and Diabetes

Diabetes mellitus is the most common cause of chronic kidney disease
worldwide (Burrows-Hudson 2005) (Levy et al 2006) and at least 20-30% of
people with diabetes will have some evidence of the disease (Audit Commission
2002). There is a variation in the incidence of diabetes among racial and ethnic
groups, with people of South Asian, African and African-Caribbean descent
having a higher than average risk of type 2 diabetes (DOH 2001). The risk of
nephropathy is related to the duration of diabetes with microalbuminuria being
the first sign, progressing to albuminuria then nephropathy. The presence of
urine albumin whether microalbuminuria or albuminuria strongly increases the
person’s cardiovascular risk (University Hospital of Leicester 2006). Thereby a
person with diabetes should not be assessed in isolation for kidney disease but
also for lipid lowering, anti-platelet therapy and hypertension in tandem. Optimal
glycaemic control should be the cornerstone of all treatment for diabetes care.
For guidance please see Dudley Diabetes Management Guidelines for Adults
2006.

Persistent hyperglycaemia results in the thickening of the basement membranes
and accumulation of proteins in the glomeruli (Levy et al 2006). Research studies
suggest that intensive glycaemic control can reduce the rate of microalbuminuria,
proteinuria and nephropathy (Gross et al 2005) and improvement in glycaemic
control may reduce the risk of patients with diabetes developing both
macrovascular and microvascular complications (DOH 2001). Studies relating to
hypertension control also suggest similar results in relation to prevention of renal
failure (DOH 2001) recommending the use of ACE inhibitors (Angiotension
Converting Enzyme Inhibitors) or ARBs (Angiotension Receptor Blockers) to
delay the onset of diabetic nephropathy in people with microalbuminuria.




                                                                                 45
       Screening and Management for People with Diabetes

                               Annual urine analysis: Protein or                      Follow
                               Albumin Creatinine Ratio + U&Es                        urology/
                                                                                      nephrology
                                          and eGFR                                    guidelines.

                                  Does patient have
                                persistent haematuria?                  YES


                              NO


                Does patient have proteinuria?                  YES                Present on repeat
                                                                                     test >2 weeks
                                                                                          later?
                              NO
                                                                   NO
                                                                                         YES
                   Does patient have eGFR <60?


                                                                              Treat with ACE/ARB
                       NO                  YES                                regardless of BP
                                                                              Target BP <130/80

                                                                              (Target BP <125/75
                                                                              if protein:creatinine
                      CKD3                          CKD 4&5                   ratio >100)

                                                                              If CKD 4 or 5, refer
                                                                              to Nephrology
                  Assess 6 monthly             Refer Nephrologists
                   And Medicine                   and Medicine                Optimise glycaemic
                    Management                    Management                  control – See Dudley
                   Avoid NSAIDs                                               Diabetes
                                                                              Management
                                                                              Guidelines for Adults
                                                                              2006*
                                                                              Assess and treat
               Is deterioration of                                            CVD risk factors as
               eGFR >15% yearly               YES                             indicated



*Management of women of childbearing age – see p24 of Dudley diabetes management
guidelines for adults – 2006.



                                                                                               46
References

Audit Commission (2002) Testing Times: A Review of Diabetes Services in
England and Wales.

Burrows-Hudson (2005) Chronic Kidney Disease: an overview. American Journal
of Nursing.

DOH (2001) National Standard Framework for Diabetes: Standards. The
Stationary Office. London

Gross J.L., de Azevedo MJ, Silveiro S.P., Canani L.H., Caramori M.L.,
Zelmanovitz T. (2005) Diabetic Nephropathy: Diagnosis, Prevention, and
Treatment. Diabetes Care. 28, 1l 164-176.

Levy J., Pussey C., Singh A. (2006) Fast Fact: Renal Disorders. Health Press,
Oxford

University Hospitals of Leicester NHS Trust (2006)




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                                                                                47
Immunisation Against Hepatitis B


National Guidelines:

“Immunisation against HBV is recommended for patients on dialysis or in
transplantation programmes. Patients with chronic renal failure should be
immunised as soon as it is anticipated that they may require dialysis or
transplantation. Vaccine and, if appropriate, hepatitis B immunoglobulin should
be given to susceptible patients who have been exposed to HBV.”

Department of Health
Good Practice Guidelines for Renal Dialysis/Transplantation Units 2002
Prevention and Control of Blood-borne Virus Infection


 “Patients with CKD in whom dialysis is anticipated, should be screened for
hepatitis B and C as well as HIV infection. Patients who are hepatitis B surface
antigen and hepatitis B surface antibody negative should be immunised and their
antibody levels measured post vaccination.”

UK Renal Association Clinical Practice Guidelines 4th Edition 2007
Clinical Practice Guidelines for the Care of Patients with Chronic Kidney
Disease


Immunisation Programme

   •   Use standard course (0, 1, 6 months) and titre level taken 6 weeks after
       last dose
   •   Recommended dose 40mcg
   •   Intramuscularly in the upper arm



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                                                                                  48
Influenza and Pneumococcal Vaccine

All patients with CKD should be advised to have an influenza vaccine by the
practice at the appropriate time each year. Efforts should be made to target the
patients who appear on the CKD register.

Pnuemococcal vaccine should also be offered to patients who remain
unimmunised. This may be given at the same time as the influenza vaccine, but
patients who have not received pneumococcal vaccine may be immunised at any
time during the year.

Contraindications, criteria and schedule for the flu and pneumococcal vaccine
and can be found in product literature and in the British National Formulary
   • Influenza - http://www.bnf.org/bnf/bnf/current/6509.htm
   • Pneumococcal - http://www.bnf.org/bnf/bnf/current/6490.htm

Guidelines for administration of the flu vaccine can be found in the “green book”,
“Immunisation Against Infectious Diseases”.



Return to overview




                                                                                49
Follow-up


Suggested follow-up plan



  Stage                      Description                    Frequency

       3                eGFR 30 – 59 mls/min                 6 monthly
                                                           (12 monthly if
                                                              stable*)
       4                eGFR 15 – 29 mls/min                3 monthly
                                                           (6 monthly if
                                                             stable*)
       5                 eGFR < 15 mls/min                   6 weekly




*Stability = < 5mls/min fall in eGFR over 12 months



Take the following steps to identify progressive CKD:

   •       Obtain a minimum of three eGFR estimations over a period of not less
           than 90 days.
   •       Define progression as a decline in eGFR of > 5 ml/min/1.73 m2 within
           1 year, or > 10 ml/min/1.73 m2 within 5 years.
   •       Focus particularly on those in whom a decline of eGFR continuing at the
           observed rate would lead to the need for renal replacement therapy within
           their lifetime (eGFR <15 mls) by extrapolating the current rate of decline.
   •       Address any identified progressing factors such as hypertension,
           nephrotoxic drugs.
   •       Consider nephrologist advice/referral




Return to overview




                                                                                    50
Stage 3

        Management at stage 3 should include all of the interventions as
       detailed for stages 1 and 2 plus the following section/s for stage 3.




Management of Anaemia

Lower levels of kidney function have been proven to be associated with lower
haemoglobin levels and a higher prevalence and severity of anaemia.This is
especially true in patients with diabetes and CKD. Anaemia can occur early in
the course of diabetic kidney disease and is associated with inappropriately low
erythropoietin concentrations1.

In patients with chronic renal disease, normochromic normocytic anaemia may
develop from decreased renal synthesis of erythropoietin. The anaemia becomes
more severe as the GFR decreases2. No reticulocyte response occurs, red blood
cell survival is decreased, and there is an associated increased bleeding
tendency due to uraemia-induced platelet dysfunction.

An eGFR of less than 60 ml/min (stage 3 onwards) should trigger investigation
into whether anaemia is due to CKD. When the eGFR is greater than or equal to
60 ml/min (stage 1 and 2) anaemia is more likely to be related to other causes3.


All patients at stage 3 CKD should have an annual measurement of
haemoglobin (Hb)

If the Hb is < 11 g/dl

Not all anaemia in patients with CKD will be ‘renal anaemia’ and causes of
anaemia other than CKD should be actively excluded before a diagnosis of
anaemia associated with CKD can be made3.

Other causes:

   •    Chronic blood loss
   •    Iron deficiency
   •    Vitamin B12 or folate deficiency
   •    Hypothyroidism
   •    Chronic infection or inflammation
   •    Hyperparathyroidism (consider referral for assessment)
   •    Aluminum toxicity


                                                                               51
   •   Malignancy
   •   Haemolysis
   •   Bone marrow infiltration
   •   Pure red cell aplasia

(Iron deficiency anaemia is the most common cause of anaemia either due to
negative iron balance through blood loss (most commonly gastrointestinal or
menstrual), inadequate nutritional intake, or related to poor gastrointestinal
absorption).


Check:
  • full blood count (if not already done)
  • serum ferritin
  • total iron binding capacity
  • B12 and folate
  • Other investigations will be determined by the likely alternative diagnoses
  and cardiovascular effects of anaemia, e.g. thyroid function test,
  echocardiography, cause of GI bleeding


Serum ferritin

Serum ferritin levels may be used to assess iron deficiency in people with CKD.
Because serum ferritin is an acute-phase reactant and frequently raised in CKD,
the diagnostic cut-off value should be interpreted differently to non-CKD
patients4.

Iron-deficiency anaemia should be:
    • diagnosed in people with stage 5 CKD with a ferritin level of less
       than 100 micrograms/l
    • considered in people with stage 3 and 4 CKD if the ferritin level is
       less than 100 micrograms/l.

In people with CKD who have serum ferritin levels greater than100 micrograms/l,
functional iron deficiency, (and therefore those patients who are most likely to
benefit from intravenous iron therapy) should be defined by:
    • percentage of hypochromic red cells greater than 6%, where the
       test is available, or
    • transferrin saturation less than 20%, when the measurement of the
       percentage of hypochromic red cells is unavailable.

Supplements of vitamin C, folic acid or carnitine should not be prescribed
specifically for the treatment of anaemia of CKD.




                                                                                 52
If all other causes for the anaemia have been excluded, (or where diagnosis
is unclear) then referral may be indicated for assessment and possible
initiation of Erythropoietin Stimulating Agent (ESA).

References

 1.    El Achkar et al. Higher prevalence of anemia with diabetes mellitus in
      moderate kidney insufficiency: The Kidney Early Evaluation Program
      (KEEP). Kidney International 2005; 67: 1483-8.

 2.    National Health and Nutritional Examination Survey III (NHANES III) data
       cited in Royal College of Physicians. Anaemia Management in CKD:
       National Clinical Guideline for Management in Adults and Children.
http://www.nice.org.uk/nicemedia/pdf/Anaemia_Management_full_guideline.pdf

 3.   NICE clinical guideline 39: Anaemia Management in People with CKD
      http://www.nice.org.uk/nicemedia/pdf/AMCKD_NICE_guideline_v8.1.pdf

 4.    Royal College of Physicians. Anaemia Management in CKD: National
       Clinical Guideline for Management in Adults and Children.
http://www.nice.org.uk/nicemedia/pdf/Anaemia_Management_full_guideline.pdf



Return to overview




                                                                                53
Stage 4


        Management at stage 4 should include all of the interventions as
      detailed for stages 1, 2 and 3 plus the following section/s for stage 4.



Patients at CKD stage 4 should be referred for specialist nephrology opinion. For
most patients management at this stage can be achieved by a shared care
programme between the nephrology dept. and primary care, with the provision of
a detailed shared care management plan from the nephrology team.
Referral for patients at this stage with no other referral indication should be to the
"One-Stop" renal clinic.


“One-Stop” Renal Clinic

Introduction:

The “one-stop” renal clinic is an innovative and modern concept delivering health
services designed around patients' needs and lifestyles. The clinics are an
integral part of the drive towards building a patient-centred NHS, providing care,
which minimises waits and delays, and removes unnecessary hospital visits.
The service is committed to raising individual and community health status and
awareness through high quality, evidence based screening, advisory, therapeutic
and support services.


A patient referred to a “one-stop” clinic will typically receive a specialist
consultation, undergo diagnostic testing e.g. renal ultrasound, doppler,
blood tests, basic echocardiography etc., receive their results in the clinic
and have treatment initiated where appropriate.


Clinic aims:

•   To provide seamless care and patient flows from primary to secondary care
    and vice versa.
•   Quicker, more convenient and timely diagnosis and investigation. Faster and
    better care, same day diagnostic tests etc.
•   Reduction in the number of hospital visits.
•   Reduction in patient anxiety levels associated with disease.
•   Smoother and quicker access to other specialties and health care
    professionals (eg. renal specialist dietician) if required.


                                                                                   54
Clinic inclusion criteria:

Patients can be referred directly by the GPs (Choose and book or paper
referrals). Patients waiting for conventional appointment may be transferred to
the “one-stop” clinic by the GP or Consultant if appropriate.

The clinic is suitable for:
   • Elderly patients
   • Those with borderline eGFR where diagnosis may be unclear
   • Patients with borderline referral criteria
   • A specialist second opinion requested by the GP
   • A specific question requested rather than a formal referral

Exclusion criteria

The clinic is not suitable for established and/or advanced renal disease,
which requires many diagnostic tests and long-term follow up.

All patients who attend the “one-stop” clinic are sent a leaflet with their
appointment letter explaining the range of tests they may have, how long the
tests will take and when they can expect results. They are informed that they are
very welcome to bring someone with them. The leaflet also contains contact
numbers for the clinic coordinator should patients wish to access any further
information or alter their appointment time.

Patients benefit by completing their outpatient appointment with a timely and
clear understanding of their diagnosis and management plan rather than
experiencing weeks of uncertainty and apprehension whilst waiting for individual
tests and results. Where immediate treatment is not feasible, the patient will be
given a date for a further appointment before they leave and the referring primary
care clinician informed.

The clinic is currently held at Russells Hall hospital twice monthly with future
plans for further expansion.

For housebound patients this service can be requested as a domiciliary visit from
the Community CKD Team, as an outreach service from Dudley Group of
Hospitals. Portable scanning equipment is available for use by the team. It is
recommended that patients are supported by a member of the primary care
team, usually district nursing services, who meet the CKD team in the patient’s
home. An individual shared care management plan is developed by the CKD
team for use by primary care. Referral is by referral letter to Nephrology Services
at Dudley Group of Hospitals.




                                                                                   55
Contact details:

Clinic co-ordinator        Renal Administrative Secretary
                           Tel. 01384 244432, Fax. 01384 244543
                           Claire.miles@dgoh.nhs

Lead Clinician             Senior Consultant Renal Physician
                           Tel. 01384 244432, Fax. 01384 244543
                           Claire.miles@dgoh.nhs

Consultants                Tel. 01384 244432, Fax. 01384 244543
                           Claire.miles@dgoh.nhs

Renal Dieticians           Tel. 01384 244017, Fax. 01384 244017
                           Christine.morgan@dgoh.nhs

Radiology Support          Tel. 01384 456111 ext. 2541
                           Peter.oliver@dgoh.nhs

Out-Patient Manager        Tel. 01384 456111 ext. 2406
                           Rose.tonty@dgoh.nhs



Return to overview

Bone Metabolism

Patients at stage 4 and 5 should have regular calcium, phosphate and
parathyroid hormone (PTH) concentrations measured. Specimens need to be in
path lab within 1 hour. Therefore it would be recommended that the specimens
are taken at the phlebotomy clinic at Russells Hall Hospital. Blood requests
should include:

      Calcium phosphate
      PTH
      Bicarbonate (in selected patients)
      Serum calcium and phosphate plus alkaline phosphatase (in selected
      patients)
      1,25 dihydroxycholecalciferol (in selected patients)


It is recommended that the management of bone metabolism is carried out by
specialist nephrologist, unless practices are confident to do so under advice from
the nephrology dept. Investigations into bone metabolism are included in the
one-stop clinic assessment and in the shared management plan with primary
care.


                                                                                56
Where vitamin D supplementation is indicated:

Stage 1 – 3A
Initiate alfacalcidol 0.25mcg alternate days and titrate according to PTH and
serum calcium and phosphate. Consider adcal / calcichew D3 1 twice daily in
patients at risk of osteoporosis.


Stage 3B - 5
Initiate alfacalcidol, dose titrated according to PTH, serum calcium and
phosphate and continue to monitor calcium and phosphate levels


See Appendix 1 - Pathway for the Management of Calcium and Phosphate
Balance in Chronic Kidney Disease

Osteoporosis – initiate biphosphonates in stages 1 – 3B

Dudley PCT formulary drug of choice - Alendronate 70mg weekly
N.B. Avoid if eGFR <35mls/min – www.bnf.org


Annual Review

Annual review in all stages of CKD should consist of:

      Blood pressure monitoring to target
      Measurement of eGFR and assessment of stability/progression
      Proteinuria testing by measurement of ACR/PCR
      Medication review, including OTC preparations
      Reduction of CVD risk / lifestyle modification
         o Dietary modification including reduction of salt
         o Reduction of obesity
         o Physical activity
         o Smoking cessation
         o CVD risk assessment and possible initiation of statin, see CVD Risk
             pathway
      Education and self care principles

   Plus:

At CKD stage 3 – 5:

      Monitoring of haemoglobin levels



                                                                                57
At CKD stage 4 and 5:

      Measurement of serum calcium, phosphate and PTH levels

   Return to overview




                                                               58
Stage 5


   Patients identified at CKD stage 5 should be referred urgently for
specialist management unless they are already known to the nephrology
dept. Shared management plans should be agreed between primary and
    secondary care, especially for patients who chose to be treated
    conservatively and for those who are being worked up for renal
                          replacement therapy.




Exceptions to Referral

•   Patients with deteriorating kidney function as a consequence of another
    terminal illness
•   Patients for whom further investigation and management is clearly
    inappropriate
•   Patients with stable function with all appropriate investigations and
    interventions completed who have agreed and understood their individual
    care pathway.

Shared care management should include:

•   3 monthly follow-up where serum creatinine, eGFR, Hb, calcium, phosphate,
    PTH are monitored and acted upon including correction of acidosis.
•   Dietary assessment and advice/referral
•   Hepatitis B immunisation
•   Information and support for patient and family in treatment options
•   Timely provision of renal replacement therapy depending on patient choice




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                                                                              59
Referral

Criteria for Referral to Specialist Nephrology Services According to eGFR



 eGFR mls.min                           Indication


     < 15          Urgent referral (exceptions)
    Stage 5

    15 – 29        Referral to “one stop” clinic for assessment, investigations and
    Stage 4        shared management plan


    30 – 59        Routine referral/advice indications:
    Stage 3        • Where condition is not shown to be stable ie. progressive
                      deterioration in kidney function
                   • Microscopic haematuria
                   • PCR >45 mg/mmol (ACR > 70mg/mmol)
                   • Unexplained anaemia (Hb < 11)
                   • Continuing abnormal potassium, calcium or phosphate levels
                      despite advice in this pathway
                   • Suspected systemic illness, e.g. SLE
                   • Uncontrolled hypertension (>150/90 on 3 agents)


     > 60          Referral not required unless other problems present (see below)
 Stage 1 and 2

    Indications    Immediate referral:
 irrespective of   • Accelerated hypertension
      eGFR         • Hyperkalaemia (K > 7.0 mmol/l)
                   Urgent referral
                   • Nephrotic syndrome (proteinuria, oedema and low serum
                      albumin)
                   Routine referral
                   • Dipstick proteinuria present and PCR >100 mg/mmol
                   • Dipstick proteinuria and microscopic haematuria present
                   • Macroscopic haematuria with negative urological testing
                   • People with, or suspected of having, rare or genetic causes
                      of CKD
                   • Suspected renal artery stenosis.




                                                                               60
   Information to include with referral

   •   General medical history and details of co-morbidities
   •   Urinary symptoms
   •   Medication
   •   Current blood pressure reading and all blood pressure readings over the
       last 2-3 years or back to normal levels, in date order, in graph form if
       available. If incomplete, send as much information as available
   •   Current eGFR and serum creatinine levels and all levels over the last 2-3
       years or back to normal levels, in date order, or graph if available. If
       incomplete, send as much information as available.
   •   Examination findings, e.g. oedema, palpable bladder
   •   Urine dipstick results for blood and protein
   •   PCR if proteinuria present. If no proteinuria present, microalbumin for all
       patients, plus ACR for diabetic patients.
   •   U and E, FBC, albumin, calcium, phosphate, cholesterol. HbA1c if
       diabetic.
   •   Results of any renal ultrasound scan if available.


Once a referral has been made and a plan jointly agreed, consider routine
follow-up in primary care rather than in the specialist clinic.
Specify criteria for future referral / re-referral and when to seek advice.


Renal Ultrasound

Renal ultrasound is indicated in:
  • progressive CKD
  • visible or persistent invisible haematuria
  • symptoms of urinary tract obstruction
  • family history of polycystic kidney disease and are aged over 20
  • stage 4 or 5 CKD
  • nephrologist recommendation for renal biopsy.

Advise people with a family history of inherited kidney disease about the
implications of an abnormal result before arranging the scan.



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                                                                                61
Abbreviations
ACE                  Angiotensin Converting Enzyme
ARB                  Angiotensin Receptor Blocker
ARF                  Acute Renal Failure
BP                   Blood Pressure
CAPD                 Continuous Ambulatory Peritoneal Dialysis
CKD                  Chronic Kidney Disease
DGoH                 Dudley Group of Hospitals
DIP                  Diabetes Improvement Partnership
eGFR                 estimated Glomerular Filtration Rate
ERF                  Established Renal Failure
ESA                  Erythropoietin Stimulating Agent
FBC                  Full Blood Count
GI                   Gastrointestinal
GMS                  General Medical Services
Hb                   Haemoglobin
KDOQI                Kidney Disease Outcomes Quality Initiative
LIT                  Local Implementation Team
MDRD                 Modified Diet in Renal Disease
NSAID                Non- Steroidal Anti-Inflammatory Drug
OTC                  Over The Counter
QMAS                 Quality Management and Analysis System
QOF                  Quality and Outcomes Framework
RHH                  Russell’s Hall Hospital
U+E                  Urea and Electrolytes
UTI                  Urinary Tract Infection




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                                                                  62
Appendix 1



The Dudley Group of Hospitals
             NHS Trust

                             Pathway for the Management of Calcium and Phosphate balance in
                                  Chronic Kidney Disease within Dudley Health Economy


   Rationale: Hyperphosphataemia (elevated serum phosphate) is recognised as an important risk factor for many adverse outcomes in dialysis
   patients, including vascular calcification, calciphylaxis, secondary hyperparathyroidism and mortality. Retention of phosphate occurs much earlier in
   the course of CKD. Serum phosphate concentration increases when eGFR falls below 30 mls/minute (CKD 4).

   Aim: To maintain phosphate levels between 0.9-1.5 mmol/L (1) and between 1.1 and 1.8 mmol/L in dialysis patients.



   Dietary Modification: Patients with CKD may need to follow a reduced phosphate diet. Phosphate rich foods include chocolate, nuts, dairy, eggs,
   meat and fish. This needs to be balanced carefully and so referral to a specialist dietitian is essential.


   If phosphate or intact PTH levels cannot be controlled within target range despite dietary phosphate restriction then prescribe a phosphate binder.



 Calcium containing phosphate binders


 1st Line Choice:                                                                                         Non-calcium containing phosphate binder
 Calcium Carbonate (Calcichew®) 1.25g                                                                     chosen 1st line in patients:-
 (Contains 500mg elemental calcium per tablet)                                                            - with CKD stage 4 or 5 and high risk of CVD
 Dose: To be titrated starting at 1 bd up to 2 tds                                                        including diabetes Or
 with meals                                                                                               - on dialysis with a serum phosphate >1.78
 S/E: diarrhoea, hypercalcaemia                                                                           mmols/l and hypercalcaemia with serum
 Alternatives: Adcal ® 1.5g                                                                               calcium > 2.6 mmols/l
 (Contains 600mg elemental calcium per tablet)
 or add D3 in those at risk of Osteoporosis with
 CKD stages 1-3
                                                                                                    SEVELAMER (RENAGEL®) 800mg
                                                             If total daily calcium load            Indication: hyperphosphataemia as monotherapy
                                                             is greater than 2.5g                   or in combination with calcium containing
2nd Line Choice:                                                                                    phosphate binder. May also decrease total and
Calcium Acetate (Phosex®) 1000mg                                                                    LDL cholesterol.
Indication – hyperphosphataemia and                                                                 Dose: 1 tds with meals, titrate dose according to
intolerance to calcium carbonate or contra-                                                         calcium and phosphate balance, max 5 per
indicated.                                                                                          meal.
NB - contains less elemental calcium                                                                SE’s/CI: CI in hypersensitivity,
compared to calcium carbonate for the same                                                          hypophosphataemia, bowel obstruction, young
phosphate binding capacity; this is also                                                            children, gastroparesis, swallowing disorders.
affected less by gastric pH.                                                                        NB – Prescribing should be in line with an ESCA
Dose: 1g tds with meals titrated according to                                                       Sevelamer.doc
serum phosphate levels, max 12 daily.                                                               OR
S/E: nausea and vomiting, constipation.                                                             LANTHANUM (FOSRENOL®)
NB - Prescribing should be in line with an                                                          Indication: hyperphosphataemia
effective shared care agreement (ESCA)                                                              NB – May be beneficial in those who are
Calcium Acetate.doc                                                                                 intolerant to sevelamer or where it is desirable to
                                                                                                    reduce the pill burden.
                                                                                                    Dose: 500mg, 750mg or 1000mg with meals
 * MONITORING                                                                                       titrated to 1500mg or 3000mg daily.
                                                                                                    S/E’s: Abdominal pain, constipation, diarrhoea,
   Parameter       Frequency          Target (KDOQI,                     Action                     nausea and vomiting.
                       of          Renal Association,                                               NB – Prescribing should be in line with an ESCA
                   Monitoring       recommendations                                                 Lanthanum.doc
                                   for stages of CKD)
 Serum            Every 2-4       CKD Stage 3/4 0.9 –     Adjustment of phosphate binder dosage
 Phosphorous      weeks until     1.5 mmol/l              and communication of changes
 concentration    stable levels                           between the Specialist, GP and Renal
                  are reached     Dialysis 1.1 – 1.8      Dietician                                        PRESCRIBING COSTS:- / DRUG
                  and then 1-3    mmol/l                                                                         INFORMATION
                  months as
                  directed by
                  the clinician
 Serum            1-2 monthly     CKD Stage 3/4 2.1 -     Adjustment of calcium/Vitamin D          Phosphate binders           Cost of 28 days
 calcium                          2.6 mmol/l              supplement dosage and communication                                  treatment (BNF 56)
 concentration                                            of changes between the Specialist, GP
                                  Dialysis 2.2 – 2.5      and Renal Dietitian                      Calcichew 2tds              £15.67
                                  mmol/l
 Ca x P                           CKD Stage 3/4 <4.2      Adjustment of Sevelamer / Vitamin D
                                  mmol/l                  dosage and communication of changes
                                                          between the Specialist, GP and Renal     Phosex 2tds                 £18.47
                                  Dialysis <4.8mmols/l    Dietitian
 Parathyroid      Every 12        CKD Stage 1-3, ULN*     Adjustment of Vitamin D dosage
 Hormone          months for                              *NR = normal range                       Sevelamer 3tds              £171.86
 (PTH)            CKD Stage 3     CKD Stage 4, 2 x        *ULN= upper limit of normal
                                  ULN
                  Every 3
                  months for      CKD Stage 5,
                                                                                                   Lanthanum 1tds 750mg        £142.03
                  CKD Stages      dialysis & transplant
                  4 and 5         2-4 x ULN*




                                                                                                                                                    63
SUPPORTING INFORMATION:

Introduction:

Phosphate retention occurs in chronic kidney disease due to the reduction in the glomerular filtration rate. Hyperphosphataemia leads to a series of changes
resulting in secondary hyperparathyroidism. This is a major concern because the high parathyroid hormone (PTH) levels play an important role in the
development of renal osteodystrophy and considered as a “uraemic toxin” as well.

From the viewpoint of calcium and phosphate balance, initially the hypersecretion of PTH may be appropriate. This would increase the calcium and phosphate
release from bone and enhances urinary phosphate excretion as well. It can thus correct the hypocalcaemia and to some extent hyperphosphataemia. However,
when the glomerular filtration rate (GFR) falls below 30 mls/min, this physiological change is no more maintained. At this stage, dietary phosphate restriction
may still reduce the plasma phosphate and PTH levels to an extent but may not normalise the values. As a result, oral phosphate binders are more often
required. This problem gets worse once the renal failure is advanced, especially in dialysis patients. In end stage renal disease (CHD 5), there is essentially no
phosphate excretion by the kidneys and oral phosphate binders are a must to limit the dietary phosphate absorption.

The combination of hyperphosphataemia and calcium product (determined by multiplying plasma, calcium and phosphate in mmol/L) when in excess of 4.4,
there is a tendency for calcium to precipitate in soft tissues such as arteries, joints and viscera. This phenomena can lead to various vascular complications
including coronary artery disease and peripheral vascular disease. Thus both morbidity and mortality rate increases with these advanced complications.


Phosphate restriction: Restricting phosphate intake can be attempted with about 800 to 1000mgs per day (1)which some patients find acceptable. However,
care must be exercised as limiting phosphate intake significantly can reduce protein intake resulting in malnutrition which can also increase the morbidity and
mortality. A Specialist Renal Dietitian’s advice will be very useful in balancing such a diet. Most often in dialysis patients, we encourage them to avoid
unnecessary dietary phosphate products such as colas, certain vegetables and excessive dairy products. At the same time, high biological value protein
sources must also be increased to avoid malnutrition. Lengthening the dialysis or using larger and high efficiency dialysers may influence very marginally the
phosphate removal. Many patients with chronic Kidney disease and all dialysis patients require the administration of oral phosphate binders to limit the
absorption of dietary phosphate. Agents used to regulate phosphate balance include calcium salts and more recently Sevelamer and Lanthanum carbonate.
Magnesium and Aluminium containing binders are now avoided because of safety concerns.


Phosphate binders – bind phosphate in the gut and prevent its absorption. They must be taken with phosphate containing foods to be effective, they should
not be taken at the same time as iron preparations and some antibiotics because together they form insoluble compounds in the gut – which reduces the
efficacy of both drugs.

There is some evidence that calcium containing phosphate binders are related to arterial/vascular calcification when compared to non-calcium containing
binders. Hypocalcaemia can also cause soft tissue calcification.

Produced by:
Jane Elvidge, Senior Renal Pharmacist, RHH
Clair Huckerby, Pharmaceutical Adviser, Dudley PCT
Dr K A Shiva Kumar, Consultant Renal Physician, RHH
Christine Morgan, Senior Specialist Renal Dietitian, RHH
Alison Whitlock, Clinical Pharmacist
Lucy White, Administration, Public Health Dept. Dudley PCT

In consultation with:
AMMC
Renal LIT


References:

     1.   Renal Association Guidelines for the treatment of adult patients with renal failure; 4th Edition.

     2.   National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. AM J Kidney Dis 2003;
          42(Suppl 3): S1-S202.

     3.   Summary of product characteristics for Sevelamer (Renagel).

     4.   Block GA, Hulbert-Shearon TE, Levin NW, Port FK. Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic
          haemodialysis patients: a national study. AM J Kidney Dis 1998; 31: 607-617.

     5.   Goodman WG, Goldin J, Kuizon BD et al. Coronary-artery calcification in young adults with end stage renal disease who are undergoing dialysis. N
          Engl J Med 2000; 342: 1478-1483.

     6.   Guerin AP, London GM, Marchais SJ, Metivier F. Arterial stiffening and vascular calcifications in end stage renal disease. Nephrol Dial Transplant
          2000; 15: 1014-1021.

     7.   Hutchison A, Webster I. Lanthanum carbonate, a novel, non-aluminium, non-calcium phosphate binder, is effective and well tolerated in
          hyperphosphataemia. Poster presented at the 9th Asian Pacific Congress of Nephrology, 16-20 February 2003, Pattaya, Thailand.

     8.   Wilson J. ARIF request on the risk of cardiovascular problems in patients using calcium versus metal- free (non- calcium) phosphate binders to treat
          hyperphosphataemia. ARIF. University of Birmingham.




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