Transcript NICE CKD Guideline update 27/11/15

NICE CKD Guideline Update
Karen Jenkins
Consultant Nurse
Chair Kent & Medway Renal Collaborative
Kent Kidney Care Centre
EKHUFT
Background
• NICE (2008) guidance on the early
identification and management of chronic
kidney disease (CKD) in adults in primary and
secondary care has been updated using new
available evidence (NICE,2014)
• Published July 2014
http://www.nice.org.uk/guidance/cg182
What’s new?
• New information focussing on:
– Identification and investigation of people who
have or are at risk of developing CKD
– Classification of CKD and identification of people
at risk of CKD complications and progression
– Definition of CKD progression
– Relationship between acute kidney injury (AKI)
and CKD
– Self-management of CKD
– Pharmacotherapy
Investigations
• Equation used to calculate eGFR is due to change
from MDRD (Modification of Diet in Renal
Disease) to the Chronic Kidney Disease
Epidemiology Collaboration (CKD-EPI) creatinine
equation
• CKD-EPI is expected to diagnose fewer people
with CKD than MDRD
• If there is a need to confirm diagnosis in someone
with eGFR creatinine 45–59 ml/min/1.73 m² for
at least 90 days who has no proteinuria, consider
using a one-off eGFRCystatin-C test
Consider factors affecting eGFR results
• Muscle mass & medications influence creatinine levels;
– extremes of muscle mass (e.g. bodybuilders or people with muscle
wasting disorders or amputations).
– Reduced muscle mass leads to overestimation and increased muscle
mass to underestimation of the GFR.
• People advised not to eat any meat in the 12 hours before blood
test for eGFR. Exogenous creatinine from the diet enters the blood
affecting the assay.
• Dehydration can lower eGFR
• Blood samples should be received and processed by the laboratory
within 12 hours of venepuncture
• Trimethoprim interferes with creatinine secretion by the kidneys
and can lower eGFR
• Therefore creatinine-based eGFR may not always be reliable as a
basis for the diagnosis of CKD
eGFR Cystatin C
• Why another test?
– Creatinine based formulas can under estimate eGFR especially with
near normal/normal creatinine levels; leading to over estimation of
people with stage 3CKD
• Test Cystatin C not influenced by muscle mass or medication better marker of kidney function and prognosis.
• At present assay is not available in all laboratories.
• Although more costly than eGFR creatinine it is estimated that
reduced medical costs of over diagnosis will make it cost effective.
KEY MESSAGE
• Those with an eGFRcreatinine 45–59 ml/min/1.73 m², an
eGFRcystatinC >60 ml/ min/1.73 m² and no other marker of kidney
disease should not be diagnosed with CKD
• Cystatin C estimation can be used as a “one off” to confirm or
refute a diagnosis of CKD
Who should be screened for Kidney
Disease?
• People should be offered testing for eGFR and urinalysis if they have the
following risk factors:
– Cardiovascular disease (ischaemic heart disease, cerebral vascular disease,
peripheral vascular disease, chronic heart failure)
– Hypertension
– Diabetes
– Structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
– Family history of stage 5 CKD or hereditary kidney disease.
– Nephrotoxic medications e.g. mesalazine NSAIDs (>12 mths), lithium,
calcineurin inhibitors
– Multisystem diseases with potential kidney involvement e.g. Lupus
– Opportunistic detection of haematuria
• Note that although the incidence of CKD is increased in Asian and black
race and age, these in isolation are not reasons for screening tests
Proteinuria
• Terms proteinuria and albuminuria are often used
interchangeably
• 2014 NICE guideline has chosen to use the term
proteinuria recommending albumin: creatinine ratio
(ACR) as the best means of measuring this
• Urine dipsticks can’t reliably detect an ACR less <
30mg/mmols
• Term microalbuminuria used to describe range 370mg/mmol now obsolete
• Upper limit of the normal range for ACR was different
in males and females now the same >3mg/mmol.
Proteinuria
• Fresh morning sample recommended (misleading ↑ACR
exercise/active)
• If ACR>3mg/mmol on non morning sample repeat using am
sample to confirm, if >70mg/mmol don’t repeat
• A confirmed ACR of >3 mg/mmol should be regarded as
clinically significant proteinuria and trigger regular monitoring
• Categories of ACR:
CKD classification
• Slight change from the 2008 NICE classification
• Stages 1-5 of CKD are now described as categories
G1-5(G, defined by eGFR) which are each subdivided
into A1-3 (A, defined by ACR)
• Using categories of increasing proteinuria is intended
to reflect the increase in risk associated with
increasing proteinuria
CKD classification
eGFR & Albuminuria
GFR
ml/min/1.73m²
Albuminuria
Categories
mg/mmol
A1
A2
A3
G1 ≥ 90
No CKD
G1 A2
G1 A3
G2 60-89
No CKD
G2 A2
G2 A3
G3a 45-59
G3a A1
G3b A2
G3b 30-44
G3b A1
G2b A2
G3a A3
G3b A2
G4 15-29
G4 A1
G4 A2
G4 A3
G5 <15
G5 A1
G5 A2
G5 A3
Lower eGFR higher ACR = increased CV risk
Risk & Progression
• Progression defined as: sustained decrease in
eGFR of ≥25% in a year or a decrease in eGFR 15
ml/min/1.73m²
• Minimum of 3 eGFR estimations over a period of
<90 days unchanged
• Finding a new ↓ eGFR repeat within 2 weeks to
exclude causes of acute deterioration in kidney
function (e.g. AKI) or staring a renin-angiotensin
system antagonist therapy (RAAS antihypertensive).
Risk & Progression
• Risk factors
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–
–
–
–
–
–
–
–
Cardiovascular disease
Proteinuria
Hypertension
AKI
Diabetes
Smoking
African Caribbean, Asian origin
Long term use of NSAIDs
Untreated urinary outflow obstruction
Monitoring
• Agreed with person & dependent on:
– Underlying cause
– Past patterns of eGFR and ACR
– Comorbidities
– Changes in treatment (RAAS, NSAIDs, diuretics)
– Intercurrent illness
– Whether they chose to have renal replacement
therapy or be treated conservatively
Table Frequency of monitoring
GFR
Category
GFR
mL/min
Frequency of monitoring
eGFR (times per year)
GFR
Description
A1
A2
A3
Normal or high
≤1
1
≥1
≤1
1
≥1
1
1
2
≤2
2
≥2
G1
≥90
G2
60-89
Mildly decreased
G3a
45-59
Mildly to Moderately decreased
G3b
30-44
Moderately to severely decreased
G4
15-29
Severely decreased
2
2
3
G5
<15
Kidney failure
4
≥4
≥4
ACR Categories: A1 (normal to mildly increased) < 3 mg/mmol, A2 (moderately increased) 3-30 mg/mmol, A3 (severely increased) > 30 mg/mmol
Pharmacotherapy
• It is recommended drugs acting on Renin-AngiotensinAldosterone Sytstem (RAAS) be offered to people with:
– CKD, diabetes and ACR ≥3 mg/mmol (A2/A3)
– CKD, hypertension and ACR ≥30 mg/mmol (A3
– CKD and ACR ≥70 mg/mmol (irrespective of hypertension
or cardiovascular disease)
– Not used if renal artery stenosis
• A combination of RAAS antagonists (ACEI, ARBs)
should not be offered to CKD patients
• Those with CKD, hypertension and ACR <3 mg/mmol
without Diabetes follow BHS guidelines
Pharmacotherapy
• Sodium Bicarbonate
– Consider oral supplementation to manage metabolic acidosis if eGFR
is 30 ml/min/1.73 m² and serum bicarbonate concentrate is <20
mmol/L.
• Vitamin D
– Do not routinely offer to treat CKD mineral bone disorder.
• Anti-platelet therapy
– Offer to prevent secondary cardiovascular disease. Apixaban can be
considered in preference to warfarin in people with a confirmed eGFR
of 30–50 ml/min/1.73 m² with non-valvular atrial fibrillation and one
or more of these risk factors:
•
•
•
•
•
Prior stroke or transient ischaemic attack
≥75 years
Hypertension
Diabetes
Symptomatic heart failure
Dietary Advice
• Advice should be offered appropriate to the
severity of CKD about
– potassium
– phosphate
– calorie and salt intake,
Low-protein diets with a protein intake of <0.6–0.8
g/kg/day should not be offered to people with CKD
Managing people with CKD
•
•
•
•
Receive up to date information
Reduce cardiovascular risk: lifestyle changes
Take active role in management
Diabetes: good blood sugar & BP management
reduces progression
• Access to blood results: Renal patient view
Referral to Kidney Doctors
• eGFR < 30ml/min with or without Diabetes
• ACR 70 mg/mmol or more, unless known to be caused by
diabetes and already appropriately treated
• Sustained ↓ GFR of 25% or more and a change in GFR
category or sustained ↓ GFR of 15 ml/min/1.73 m² or more
• ↓ eGFR of >25% after starting ACEi or ARB
• hypertension that remains poorly controlled despite the
use of at least 4 antihypertensive drugs at therapeutic
doses
• Known or suspected rare or genetic causes of CKD
• Suspected renal artery stenosis.
Summary
• The equation used to calculate eGFR due to change from the MDRD
equation to the CKD-EPI creatinine equation
• There is a need to confirm CKD in someone with an eGFR creatinine 45–59
ml/min/1.73 m² for at least 90 days and no proteinuria
• One-off eGFRCystatin-C test can be used to confirm the diagnosis
• CKD will now be classified using a combination of eGFR and ACR
categories
• The health of people with risk factors for CKD progression, such as
cardiovascular disease, hypertension and smoking, should be optimised
• ACR and eGFR testing should be offered to at-risk patients, such as those
with diabetes and a family history of CKD stage 5
• Emphasis on relationship between proteinuria, risk of progression of CKD
and cardiovascular events
• Informing patients about their diagnosis, involving them in decisionmaking and promote self management