The video version of this podcast can be found here:

·      https://youtu.be/b9WhusF36qQ

The previous episode on diagnosis, and classification of CKD can be found here:

·      https://youtu.be/iJKpE3H_Lbk

The previous episode on investigations, monitoring, referral recommendation and BP management in CKD can be found here:

·      https://youtu.be/6WtRlgjCt34

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the guideline on CKD, NG203, by the National Institute for Health and Care Excellence (NICE), last updated in November 2021, focusing on what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

If you haven’t already, I recommend checking out the two previous episodes on diagnosis, classification, monitoring, referral recommendation and BP management in CKD

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE guideline chronic kidney disease: assessment and management [NG203] can be found here:

·      https://www.nice.org.uk/guidance/ng203

The links to other relevant guidance covered in this episode can be found here:

The 4-variable Kidney Failure Risk Equation can be found here:

·      https://www.nice.org.uk/guidance/ng203/chapter/recommendations#variable-kidney-failure-risk-equation

A Kidney Failure Risk Equation calculator can be found here:

·     https://ukidney.com/calculators/kidney-failure-risk-equation-kfre

The NICE technology appraisal guidance on SGLT2 inhibitors for adults with CKD, can be found here:

• Empagliflozin (TA942, 2023): https://www.nice.org.uk/guidance/ta942/chapter/1-Recommendations
• Dapagliflozin (TA775, 2022): https://www.nice.org.uk/guidance/ta775/chapter/1-Recommendations

The recommendations on hyperkalaemia treatment in adults with categories G3b to G5 chronic kidney disease can be found here:

·      Zirconium: https://www.nice.org.uk/guidance/ta599

·      Patiromer: https://www.nice.org.uk/guidance/ta623

The link to the hypertension video can be found here:

·      https://youtu.be/wjIbwy9SdAQ?si=dsPA_Wc6uvxhNANd

The links to the videos on cardiovascular disease risk reduction and lipid modification can be found here:

·      Part 1: https://youtu.be/jIhlkmOcsiI?si=4BGzj8Bwz9KqPMKJ

·      Part 2: https://youtu.be/QyN3toBGCNU?si=9kTWk5HVTHrHVeCv

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are doing a review of the NICE guideline on CKD, or NG203, focusing what is relevant to Primary Care only.

Given how extensive the guidance is, in this episode I will just focus on other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

If you haven’t already, I recommend checking out the two previous episodes on diagnosis, classification, monitoring, referral recommendation and BP management in CKD

Right, let’s jump into it.

And let’s remember that, for this review, I have excluded recommendations related to children and young people with CKD. While their management is often similar to that of adults, most children with CKD are managed by secondary care, which is why I am focusing on adults only.

SGLT2 inhibitors have been proven to help CKD in both people with and without diabetes. There is NICE guidance on dapagliflozin and empagliflozin but their use is outside the scope of this episode. Links to this guidance are in the episode description.

The advice on statins in CKD is also covered in a different NICE guideline. The link is also in the episode description. But in summary, in CKD we will give Atorvastatin 20 mg for both primary and secondary prevention. Then, if the lipid target is not met and the eGFR is 30 or more, we will increase the dose. However, if eGFR < 30, we will discuss and agree the use of higher doses with a renal specialist

We will offer antiplatelet medicines only for the secondary prevention of cardiovascular disease, being aware of the increased risk of bleeding in CKD. 

And why is this? The real cause for the association between CKD and bleeding is not well known but research studies have shown that CKD has been associated with a 1.5-fold increased risk of bleeding, which has been attributed to platelet dysfunction and activation of the fibrinolytic system.

However, although some patients are prone to bleeding, other patients also develop excessive clot formation. Little is known about the reasons why some patients develop bleeding problems, while others have excessive clotting.

So, in summary, for the secondary prevention of CVD, we definitely need to give aspirin, but being aware of the risks. 

We know that renal anaemia can be common. Do we need to fully investigate everyone with CKD for this? 

NICE says that we should investigate and treat anaemia in CKD if:

·      their Hb is 110 g/litre or less or

·      they develop symptoms like tiredness, shortness of breath, etc 

Then:

·      If eGFR is above 60, we will fully investigate other causes because it is unlikely to be due to CKD.

·      If eGFR is between 30 and 60 ml/min/1.73 m2, we will investigate other causes but we will use clinical judgement to decide how extensive this investigation should be, because the anaemia may be caused by CKD.

·      And, if eGFR is below 30 ml/min/1.73 m2, we will think about other causes but we will note that anaemia is often caused by CKD in these circumstances. 

Why is this? Let’s have a look at the causes. Anaemia of CKD is generally a normocytic normochromic, hypoproliferative anaemia. Although the widely accepted aetiology is a decreased renal production of erythropoietin, the hormone responsible for stimulating red cell production, anaemia of CKD is of multifactorial origin. Other mechanisms include uraemia, folate and vitamin B12 deficiency, iron deficiency, a shortened lifespan of red blood cells and bleeding due to dysfunctional platelets. And very significantly, CKD patients are at higher risk of iron deficiency, so we must always consider iron supplementation as part of their treatment.

Consequently, as we have just said, the management of anaemia in CKD involves iron therapy, erythropoietin stimulating agents and blood transfusions. Let’s begin with iron therapy.

In primary care, we should check for iron deficiency at least every 3 months and we will diagnose iron deficiency if:

·      The Percentage of hypochromic red blood cells (%HRC) is more than 6%, or

·      The reticulocyte haemoglobin content is less than 29 pg, or

·      Transferrin saturation (TSAT) is less than 20% and ferritin is less than 100 µg/L.

However, these last two tests alone are not ideal for assessing iron status in CKD. They should only be used when other diagnostic tests are unavailable or when the patient has conditions like thalassaemia or thalassaemia trait.

When treating with iron, NICE says that ferritin levels should not exceed 800 µg/L and to prevent this, we will review the iron dose when ferritin reaches 500 µg/L.

So, what this means is that we are going to keep giving iron to our patients even when their ferritin is well above the normal range. Why? This is because, in addition to true iron deficiency, CKD patients also have a functional iron deficiency, which is a type of cell iron blockade. This results in reduced iron release from body stores which is then unable to meet the requirement for erythropoiesis. By having a higher-than-normal ferritin level we would expect iron to be released for erythropoiesis more easily.

Erythropoietin -Stimulating Agents and Blood Transfusions will be guided by secondary care and I will not cover it here except to say that we should avoid transfusions in patients who are candidates for a kidney transplant. This is multiple transfusions increase the risk of developing HLA antibodies, which can reduce long-term graft survival.

Other aspects of CKD management include:

·      Hyperphosphataemia and

·      Renal acidosis

Which will normally be managed in secondary care, so the use of phosphate binders or bicarbonate will not be covered here.

However, NICE does talk about the effect of CKD on bone metabolism and osteoporosis. What is CKD mineral bone disease? It is the disturbed mineral metabolism caused by uraemic toxins and secondary hyperparathyroidism which disturbs bone mineralisation and makes it difficult for calcium and phosphate to enter the bones. This can result higher serum calcium and phosphate as well as in bone loss. The prevalence of osteoporosis in the population with CKD certainly exceeds the prevalence in the general population.

As already mentioned, when bone resorption exceeds bone formation, calcium and phosphate are released and contribute to hyperphosphatemia and hypercalcemia. This is an important stimulus to what is called heterotopic calcifications, especially in blood vessels, which can lead to cardiovascular events and mortality.

Consequently, vascular calcification and osteoporosis are the most common complications related to CKD mineral bone disease.

And because vitamin D deficiency plays an important role in this, vitamin D supplements are important in treating both osteoporosis and vascular calcifications at the same time. Although NICE says that vitamin D should not be prescribed routinely, proven vitamin D deficiency should be treated with colecalciferol or ergocalciferol.

Then, if vitamin D deficiency is corrected but symptoms of CKD–mineral and bone disorders persist, this may indicate a need for treatment with alfacalcidol or calcitriol.

And let’s take a moment here too to understand why. For this, let’s give a quick overview of vit D metabolism in the human body. The proximal tubular cells in the kidney converts Vit D, into the active form calcitriol also known as 1,25-dihydroxycholecalciferol. As kidney disease worsens, there is a reduction in the renal 1α-hydroxylase activity for converting Vit D into the active form calcitriol.

So why do we bother with colecalciferol or ergocalciferol? Well, whilst you would think that giving calcitriol straightaway would be the solution, we also know that treatment with colecalciferol or ergocalciferol has been shown to increase calcitriol levels in both stage 3 and 4 CKD. So, this is the reason why cholecalciferol and ergocalciferol are the first line approach and treatment with alfacalcidol or calcitriol remain second line.

So that is it, a review of other CKD management in Primary Care, including the management of renal anaemia and CKD mineral bone disease.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.