The video version of this podcast can be found here:
· https://youtu.be/6WtRlgjCt34
The previous episode on diagnosis, and classification of CKD can be found here:
· https://youtu.be/iJKpE3H_Lbk
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 investigations, monitoring, referral recommendation and BP management in CKD
I recommend checking out the previous episode on diagnosis, and classification of CKD. In the next episode, I will cover referral the rest CKD management in Primary care, including renal anaemia and mineral bone disease 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.
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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 table showing the minimum number of monitoring checks per year is:
· https://www.nice.org.uk/guidance/ng203/chapter/Recommendations#frequency-of-monitoring
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 investigations, monitoring, referral recommendation and BP management in CKD
If you haven’t already, I recommend checking out the previous episode on diagnosis, and classification of CKD.
In the next episode, I will cover referral the rest CKD management in Primary care, including renal anaemia and mineral bone disease in CKD, so stay tuned for that.
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.
We will offer a renal ultrasound scan in CKD if there is:
· visible or persistent invisible haematuria
· suspicion of urinary tract obstruction
· a family history of polycystic kidney disease and are older than 20
· a GFR of less than 30
· if there is a need for a renal biopsy and
· accelerated progression of CKD.
We will define accelerated progression of CKD as:
· a sustained decrease in eGFR of 25% or more and a change in GFR category within 12 months or
· a sustained decrease in eGFR of 15 per year.
· These people are at high risk of progression to end stage renal disease
If we are worried and we want to identify the rate of progression of CKD:
· We will obtain a minimum of 3 eGFRs over no fewer than 90 days.
· And, if we see a low GFR for the first time, we will repeat the GFR within 2 weeks to exclude acute deterioration e.g. acute kidney injury or secondary to starting treatment with an ACE inhibitor or ARB.
Although CKD is not progressive in many people, we should monitor CKD regularly and the frequency will depend on the stage. It will be once a year when the risk is low, for example categories G1, G2 and up to 4 times a year or more when the risk is very high, for example category G5. For G3a, G3b and G4 the frequency of monitoring will depend on the ACR level. There is a table showing the frequency of monitoring depending of the CKD classification, which you can find in the episode description.
Monitoring should be tailored according to:
· the underlying cause
· the rate of decline in eGFR or increase in ACR
· other risk factors, including heart failure, diabetes and hypertension
· changes to their treatment (such as ACE inhibitors, ARBs, NSAIDs and diuretics) and
· intercurrent illness (for example acute kidney injury)
Risk factors for CKD progression are:
· cardiovascular disease
· proteinuria
· previous episode of acute kidney injury
· hypertension
· diabetes
· smoking
· African, African-Caribbean or Asian family origin
· untreated urinary outflow tract obstruction and
· chronic use of NSAIDs
And let’s remember that in CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR, so we should exercise caution when prescribing them.
When it comes to patient education, we will give lifestyle and dietary advice including guidance on potassium, phosphate, calorie, and salt intake. However, we will not offer low-protein diets.
We should give patients information about their 5-year risk of needing renal replacement therapy. For this, there is a 4-variable Kidney Failure Risk Equation. You’ll find a link to the calculator in the episode description.
We will refer for specialist assessment if they have:
· a 5-year risk of needing renal replacement therapy greater than 5%
· an ACR of 70 or more, unless caused by diabetes and already treated
· an ACR of more than 30 with haematuria
· poorly controlled hypertension despite 4 antihypertensive medicines
· known or suspected rare or genetic causes of CKD
· suspected renal artery stenosis and
· accelerated progression of CKD. Accelerated progression of CKD is defined as a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months or a sustained decrease in eGFR of 15 or more per year
Additionally, we will refer people with CKD and renal outflow obstruction to urological services
Let’s look at the management of various aspects in CKD.
In respect of blood pressure control in CKD, if ACR is under 70, we will aim for a clinic BP below 140/90 mmHg
However, if ACR is 70 or more, we will go for a lower clinic BP below 130/80.
If someone has hypertension and CKD with an ACR of 30 or less, we will simply follow the NICE guideline on hypertension. The link to the corresponding episode on this channel is in the episode description.
However, for those with hypertension and CKD with an ACR over 30, we will offer an ACE inhibitor or an ARB in the first instance, and we will titrate it to the highest licensed tolerated dose. If they also have diabetes, we will lower this threshold to an ACR of 3 mg/mmol or more.
And, as we know, the combination of ACEIs and ARBs are not recommended.
We will measure potassium and eGFR before starting an ACEI or ARB and between 1 and 2 weeks after starting treatment and after each dose increase. More frequent monitoring may be needed if they are already taking medicines known to promote hyperkalaemia.
We will not routinely offer an ACEI or ARB if their pre-treatment potassium is greater than 5.0 mmol/litre. In these cases, we will:
· assess and treat any factors that promote hyperkalaemia and we will
· check the potassium again
We will stop ARBs and ACEIs if the potassium level increases to 6.0 mmol/litre or more and other medicines known to promote hyperkalaemia have been discontinued.
There is a separate guidance on the management of hyperkalaemia – and a link to it is in the episode description.
Because their mode of action, ARBs and ACEIs can reduce the eGFR and increase the creatinine levels. However, after starting or increasing the dose, we will not modify the dose if either:
· the eGFR drop is less than 25% or
· the serum creatinine increase is less than 30%.
· In these cases, we will repeat the test 1 to 2 weeks later and we will not change anything if the decrease in eGFR remains less than 25% or the increase in creatinine remains less than 30%.
Why this advice? Let’s remember a little bit of anatomy. The glomerulus receives its blood supply from an afferent arteriole and, unlike most capillary beds, the glomerular capillaries exit into efferent arterioles rather than venules. Let’s also remind ourselves that ACEI prevent the conversion of angiotensin I to angiotensin II, and ARBs block the effect of angiotensin II. This results in relative vasodilation, which preferentially reduces postglomerular resistance. Consequently, this will lower intraglomerular pressure which will reduce the glomerular filtration rate and cause a subsequent rise in creatinine.
So, as stated before, an increase in creatinine of up to 30% and a decrease of eGFR of up to 25% are acceptable and, in the absence of renovascular disease, creatinine levels will frequently return to baseline or below if blood pressure is lowered, despite the continued use of an ACEI or ARB.
However, if the eGFR decrease is 25% or more, or the increase in creatinine is 30% or more:
· We will investigate other causes, such as volume depletion or concurrent medication (for example, NSAIDs)
· And if no other cause is found, we will stop the ACEI or ARB or reduce the dose to a previously tolerated lower dose, adding an alternative antihypertensive medication if needed.
So that is it, a review of monitoring, referral recommendation and BP management in CKD.
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.
