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Chronic Kidney Disease

GP Dr Kathryn Griffith shares her expertise on managing CKD in primary care

GP Dr Kathryn Griffith shares her expertise on managing CKD in primary care

1 Before putting patients with an eGFR of 60-69 on the practice CKD register, make sure you have more than one abnormal result

The definition of CKD is that there must be at least two abnormal results three months apart. Many elderly patients have eGFRs hovering around 60 and are already being managed in chronic disease management clinics in the practice. The objective of CKD management is the early detection of patients with declining renal function and to target them for treatment – it is not to cause anxiety for those with minor abnormalities of renal function which is stable.

2 In newly diagnosed patients it is important to check that they do not have a palpable bladder

This is a potentially reversible cause of CKD. Many men will have symptoms of bladder outlet obstruction. A palpable bladder and deteriorating eGFR suggests urgent referral to a urologist.

3 Test urine for protein when managing patients with CKD

There is no need to perform a 24-hour collection, a positive (1+ or greater stick test) is all that is required. This simple test is the best way to detect patients who need referral to a renal physician and more active intervention. It is important to ensure the findings are persistent, with two or more samples, and that there is no associated infection. Early morning samples are best. This test can then be confirmed by sending a sample to the laboratory for a protein: creatinine ratio. There is a suggestion that urine testing is likely to be included as an indicator in an updated QOF and it makes sense to include it now in your follow-up of CKD patients.

4 Measuring an albumin:creatinine ratio is still recommended in patients with diabetes

The detection of small quantities of albumin in urine (microalbuminuria) requires a more specific stick test or sending a sample to the laboratory to determine albumin:creatinine ratio. This is a more sensitive measure of renal damage in patients with diabetes and allows GPs to target evidence-based treatments to reduce progression of CKD. Patients with persistent proteinuria do not need testing for microalbuminuria.

5 Check the patient's medication

While attempting to reduce renal damage, it makes little sense to continue drugs that make renal function worse. This particularly applies to non-steroidal anti-inflammatory drugs. If at all possible these should be stopped. However, it is important to consider the patient's quality of life, particularly when they have a significant connective tissue disorder, such as lupus or rheumatoid arthritis, which is causing their CKD. Trimethoprim should be used with care when eGFR falls below 30 as it can raise creatinine and potassium levels.

6 ACE inhibitors and ARB are not necessarily required for all CKD patients

Despite being included in the QOF there is currently little evidence that these drugs benefit all patients with stable CKD stage 3, a well-controlled blood pressure and no proteinuria or diabetes. Indeed changing to a drug from these classes is almost guaranteed to be associated with a further rise in the serum creatinine level. The priority for these patients should be to improve blood pressure control. These patients can be exempted from the need for an ACE inhibitor or ARB in the QOF if their blood pressure is controlled. There is extremely good evidence, however, that the use of these drugs in patients with proteinuria or diabetic patients with microalbuminuria is associated with a delay in the progression of renal damage1.

7 Target blood pressure is lower for patients with CKD, especially with proteinuria, than for any other conditions

The QOF audit standard for patients with CKD is 140/85mmHg, which is lower than for any other disease area. The actual targets for blood pressure control are lower than this, particularly where there is proteinuria. But the evidence is lacking for the optimal treatment level.

8 Patients with CKD are at greater risk of a cardiovascular event than they are of requiring renal replacement therapy

A patient with CKD 3 will have a five-year risk of 1.1% of requiring renal replacement therapy but a 24.3% risk of death largely through cardiovascular disease2. Cardiovascular disease prevention should be fundamental to management.

9 Lifestyle advice continues to be a vital part of management

Even with established CKD it is important to encourage smoking cessation because of high cardiovascular risk. Dietary advice is targeted at salt intake reduction and weight management. This is especially important when an obese patient may be considered unsuitable for a transplant due to weight restrictions for transplant recipients. Exercise has all the benefits of cardiovascular fitness, blood pressure and weight management.

10 Metabolic complications may occur in patients with diabetes

These are unusual in non-diabetic patients with CKD 3. It is useful to check for anaemia and calcium levels during an annual review. It is not necessary to check parathyroid hormone levels when calcium levels are normal. Patients with diabetes may, however, develop metabolic complications when eGFR falls below 45.

Dr Kathryn Griffith is a GP in York and cardiovascular and renal lead for North Yorkshire PCT

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