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Section 6: Management in primary care

Section 6: Management in primary care. Particular emphasis on nurse practitioner’s role. Effects of age on eGFR. The “normal” eGFR is age-related In normal “healthy” individuals, the eGFR will fall by one percent for every year after 40 years of age

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Section 6: Management in primary care

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  1. Section 6: Management in primary care Particular emphasis on nurse practitioner’s role

  2. Effects of age on eGFR • The “normal” eGFR is age-related • In normal “healthy” individuals, the eGFR will fall by one percent for every year after 40 years of age • An 80 year old man will have an expected eGFR of 50-60 ml/min • Not all patients with reduced eGFR need active management

  3. % subjects with CKD stage 3 by age and gender East Kent Data 70 50 % 30 10 <45 45-54 55-64 65-74 75-84 >85 Age bands de Lusignan et al 2005

  4. CKD Stage 1 CKD 2 CKD 3 CKD 4 CKD 5 “Normal” inulin GFR declines with age EDTA F 150 100 50 0 70 80 20 30 40 50 60 90

  5. Which individuals with abnormal eGFR should we to worry about? • Those with very poor function for age • Those with deteriorating function • Those who may have reversible/treatable cause (unexplained proteinuria/haematuria) • Those with functional consequences of CKD (anaemia, renal bone disease, persistent hyperkalaemia)

  6. 2008 NICE guidance for CKD – focus on vascular risk • Lifestyle modification • Attention to known CV risk factors • smoking • statins for secondary prevention regardless of lipid level • Anti-platelet drugs for secondary prevention • Medicines management • BP targets

  7. NICE 2008: recommendations for BP control in CKD

  8. NICE 2008: Diagnosis of CKD • Proteinuria=ACR>30 or PCR>50 (NOT dipstick) • 3 eGFR estimations <60 over a period not less than 90 days • Progressive decline defined as eGFR falling by >5mls/min/year • Focus on those whose observed rate of decline would necessitate RRT ‘within their lifetime’

  9. NICE: 2008 Classification of CKDwaking up to the impact of proteinuria • Stage 1: GFR>90 + abnormal urinalysis • Stage 2: GFR 60-89 + abnormal urinalysis • Stage 3A: GFR 45-59 • Stage 3B: GFR 30-44 • Stage 4: GFR 15-29 • Stage 5: GFR <15 or dialysis dependent Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)

  10. QOF indicators for CKD 2009

  11. Monitoring of CKD • Each assessment should include • Review of symptoms and fluid status • Blood pressure • Medication review (metformin, NSAIDs) • Urine ACR or PCR • Blood test for renal and bone status • FBC in advanced CKD

  12. Frequency of monitoring

  13. What data is required for effective referral? • Current creatinine and eGFR • Previous creatinines (tracing back to last normal) • Blood pressures (recent and historical) • Urine dip for blood, ACR/PCR • FBC, Ca, Pi • Renal US only if :- • stage 4 • resistant HT • lower tract symptoms

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