How To Treat Chronic Kidney Disease

Transcription

1 Fast-track Summary Guidelines November 2006 Chronic Kidney Disease (CKD) Primary objectives for CKD A practice register of CKD stages 3-5, classified according to estimated glomerular filtration rate (egfr). Regular review including BP, urinalysis, egfr and medication. Optimise hypertension management. Angiotension converting enzyme inhibitors (ACE I) as first choice of antihypertensive agents. ISBN x Annual BP and egfr in at risk groups. Improved information for patients and carers. Audit performance towards these objectives. Contents Prevalence and natural history 2 Risk factors 2 How is egfr calculated? 2 Creating a QOF compliant practice CKD register 2 Staging and investigation of CKD 3 Proteinuria and haematuria 4 Further baseline investigations for CKD in primary care 5 Treating modifiable risk factors Hypertension 2. Hyperlipidemia and CVD prevention 3. Optimising diabetic control Aim of Guideline This summary guideline is designed to be used by primary and outpatient services to improve the identification and management of patients with CKD. It includes the clinical information and data collection framework required by practices for the quality framework elements of the 2006 ngms contract. The guideline is based on the NSF for renal disease (DOH 2005) and the UK CKD guidelines Other management interventions which reduce risk of progression 8 4. Vaccines 5. Medication review Monitoring CKD in primary care: identifying progressive disease 8 Referral to nephrologist 9 Local renal services and contact information 10 Patient information sheet Patient resources, acknowledgements 13

2 2 Summary guidelines Prevalence and natural history Surveys suggest that up to 5% of adults have stage 3-5 chronic kidney disease, and another 5% have stage 1-2. These are likely to be over-estimates of prevalence. For those with stage 3-5, two thirds are over 70 years, 75% have hypertension, 25% have diabetes. Locally people with diabetes make up more than 30% of the dialysis programme. Risk Factors The people most at risk of CKD are those with diabetes, hypertension and cardiovascular disease. These risk factors interact to cause high rates of CKD Creating a QOF Compliant Practice CKD Register CKD can be divided into five stages according to the Kidney Disease Outcome Quality Initiative (K/DOQI) staging. For the CKD domain of the 2006 quality and outcomes framework a register of patients over 18 years with CKD stages 3-5 is required. There is NO automatic linkage between the egfr values which come down the GP links, and CKD staging. This has to be done by the practice. The EMIS 'potential CKD finder' tool can also be used to generate a list of patients with possible CKD based on the previous two creatinine values. Step 1. Ensure that egfr (451E) is set as a value. (See CEG bulletin June 2006, or get advice from your locality facilitator) Diabetes Chronic kidney disease Hypertension Step 2. Search the current data base for a list of patients with egfr <60. If reduced egfr is present for >3 months, consider assigning patient to a CKD stage. Add the Read coded diagnosis to the current problem list. Diagnosing CKD remains a clinical decision which requires judgement in each individual case. Cardiovascular disease 1Z12 CKD stage 3 (egfr 30-59) 1Z13 CKD stage 4 (egfr 15-29) 1Z14 CKD stage 5 (egfr <15 or renal replacement therapy) Step 3. Maintain the diagnostic register. As new egfr results arrive, assign them to a CKD stage. How is egfr calculated? Estimating the GFR is essential for the diagnosis of CKD. Serum creatinine measurements on their own may be insufficiently sensitive to detect moderate CKD as many patients who have reduced GFR have serum creatinine concentrations that fall within laboratory "normal" ranges. In adults ( 18 years old) egfr is calculated using the 4- variable Modification of Diet in Renal Disease (MDRD) equation. The four variables are: - Serum Creatinine concentration Age Sex Ethnic Origin (for African-Caribbean people only, egfr multiplied by 1.212) Laboratory reports should indicate whether a correction has been applied. The egfr is reported as ml/min/1.73 m2. The normal range is >90 (but see table, page 3, for classification of CKD). It should be noted that egfr is an estimate with confidence intervals. 90% of egfr will be within 30% of the true GFR. Variability in egfr measurement is greatest at higher values. Values below 45 are more stable, and falling levels are more likely to represent a true decline in renal function. egfr varies according to an individual's hydration level, is overestimated with a low muscle mass (e.g. amputee) and is only valid if renal function is stable. It is not valid in pregnant women. In acute renal failure egfr values may lag behind the rise in creatinine, and should not be relied on for diagnosis.

3 Chronic Kidney Disease 3 The 5 Stages of CKD (K/DOQI Staging) Stage egfr (ml/min/1.73m 2 ) Description & frequent complications Suggested monitoring frequency frequency 1* 90 With a renal abnormality* Hypertension more frequent than among patients without CKD Annually 2* With a renal abnormality* Hypertension frequent Annually Moderately decreased GFR Hypertension common, increased risk of CVD, chronic anaemia of renal failure with decreased erythropoietin, renal bone disease and altered lipoprotein metabolism Six monthly if evidence of progression Severely reduced GFR As above but more severe. Metabolic acidosis, hyperkalaemia, fluid retention and decreased libido Three monthly 5 <15 Kidney failure (established renal failure) As above with greater severity. Anorexia, vomiting, pruritus, salt and water retention causing apparent heart failure Three monthly * Must have documented renal damage eg proteinuria, haematuria, microalbuminuria (in diabetes), polycystic disease or reflux nephropathy. egfr >60 with no other abnormality = normal. The stages are a pragmatic tool for determining management. There is not a perfect relationship between the CKD stage and symptoms. Staging and Investigation of CKD A diagnosis of CKD should be considered in all patients with diabetes, hypertension, CVD and heart failure. These groups should have yearly egfr measurement as part of an annual review. Other at risk groups include those with:- Bladder outflow obstruction. Recurrent kidney stones, those with staghorn calculus. Recurrent UTI with persistent abnormal urinalysis after treatment. Patients on long term NSAIDs especially if in combination with an ACE I / ARB. Suspected multisystem disease with possible renal involvement, eg. SLE. Staging of CKD is confirmed by measurement of the egfr. Further investigations will be required to identify the cause of renal disorder; some of this can be done within primary care, with referral onwards for those requiring invasive investigation or those with advanced CKD (stages 4 and 5).

4 4 Summary guidelines Proteinuria and Haematuria Many patients will present in primary care with a finding of proteinuria or haematuria. These patients will require investigation to establish the cause of urinary abnormality. Only a minority will have CKD. Summary of investigation of proteinuria in primary care Proteinuria is a common finding in primary care. Only a small proportion (about 2%) will represent primary renal disease. But persistent proteinuria ( 1+ proteinuria on two occasions, after exclusion of UTI) will need quantification and investigation to rule out serious treatable glomerular disorders. Summary of investigation of haematuria in primary care If haematuria is associated with proteinuria and/or a low egfr, referral to a nephrologist should be considered. Macroscopic haematuria: This always needs investigation - either to rule out a urinary tract infection where it is usually associated with symptoms - or to rule out malignancy or other causes when it may be painless. 20% of cases are due to malignancy. 2 week urology suspected cancer referral recommended. Causes of Proteinuria include: Benign: fever, dehydration, intense exercise, general inflammation, orthostatic Primary Glomerular causes: glomerulonephritis (various) Secondary Glomerular causes: diabetes, amyloidosis, infection, malignancy, drugs If urinalysis shows persistent proteinuria, check a protein:creatinine ratio (PCR) to quantify the amount of proteinuria (see table below). This is done on a spot urine sample (preferably an early morning urine specimen). 24 hour urine collections are not required. If the PCR is >100 mg/mmol (equivalent to 1gm of protein a day) further investigations and referral are indicated. If proteinuria is associated with haematuria, glomerular disease is more likely. Refer to nephrologist if PCR >45mg/mmol with microscopic haematuria. Microscopic haematuria In people under 40 years without symptoms or clinical abnormality but who have microscopic haematuria on more than one occasion, ( 3 red blood cells per high powered field OR 1+ blood on dipstick) a renal ultrasound (and plain KUB film for stone) in conjunction with other tests (U&E, PSA, MSU, urine cytology) is sufficient to rule out serious pathology. If all the investigations are normal, no further assessment is required. In this group the diagnosis of bladder cancer is unusual and in the absence of macroscopic blood, risk factors or clinical signs and symptoms, flexible cystoscopy is not usually justified. In people over 40 years the lower urinary tract is a more common cause of haematuria. As bladder cancer is a significant cause of haematuria in this age group, flexible cystoscopy, renal USS and IVU (OR cystoscopy and upper renal tract CT) can be requested at the same time to prevent unnecessary delay. 2 week urology suspected cancer referral recommended. Proteinuria Conversion Table Dipstick PCR ACR* 24 hour protein mg/mmol mg/mmol (g/24 hr) Negative < <0.15 Trace or *Albumin:creatinine ratio (ACR) is only recommended for diabetes, and only if dipstick is negative for proteinuria.

5 Chronic Kidney Disease 5 Further baseline investigations for CKD in primary care The diagnosis is confirmed by measurement of egfr. If this is a first finding, repeat test (timing will depend on clinical context) to assess whether the egfr is stable or declining. Always check urinalysis. If dipstick protein 1+ check a baseline PCR. Further tests to consider, depending on the clinical context, include:- FBC: If Hb<11, then check haematinics (ferritin, B12, folate). Consider chronic anaemia of renal failure if Hb <11gm, normal haematinics and egfr<60 ml/min; then consider referring for treatment with erythropoietin. Lipid profile, LFTs & TFTs: Untreated hypothyroidism increases lipid levels and the risk of statin induced myositis. ESR, CRP, ANA: If a multisystem disorder is suspected. Renal USS: indicated if the history is suggestive of obstruction or if there is a positive FH for polycystic kidney disease. Ca & PO4: In stage 3 CKD, serum corrected calcium and phosphate should be measured every 12 months. Patients with confirmed abnormalities of serum corrected calcium or phosphate should be referred to a nephrologist. Renal bone disease Vitamin D insufficiency is common in the east London population. In CKD decreased activation of vitamin D, decreased calcium gut absorption and increased phosphate reabsorption occurs. As egfr declines these processes may trigger secondary hyperparathyroidism with bone reabsorption, pathological fractures and metastatic calcification, increasing cardiovascular risk. PTH Up to 30% of patients with stage 3 CKD will have some disturbance of calcium metabolism. 1) Check PTH (NR 1-6pmol/L) when the diagnosis of CKD stage 3 is first made, prioritising patients with egfr <45. 2) If the PTH is <7.7pmol/L, annual review is advised, particularly for those with a progressive decline in egfr. 3) If the PTH concentration is raised (>7.7pmol/L), check serum 25-hydroxyvitamin D. If this is low (<75 nmol/l or <30mg/ml), suggesting vitamin D deficiency treat with: Vitamins A and D capsules, 2 capsules od (net price 100 = 3.20) Colecalciferol with calcium supplement (not calcium phosphate), either: adcal-d3, 2 tabs od (net price 100 = 7.13) calcichew-d3 forte, 2 tabs od (net price 100 = 7.50) Each of the three alternative preparations are equivalent to vitamin D 800units /day. 4) Repeat PTH and serum 25-hydroxyvitamin D after 3 months. 5) If the PTH remains high (>10pmol/L) and vitamin D replete (>75nmol/L) suggesting secondary hyperparathyroidism, refer or discuss with nephrologists.

6 6 Summary guidelines Management in Primary Care The main aims of primary care management include:- Treating modifiable risk factors. Identifying progressive CKD, with referral if indicated. Provision of information for patients and carers. Treating modifiable risk factors 1. Hypertension If egfr falls by 5-15% recheck in 2-3 weeks to ensure decline is not progressive. If egfr falls by >15% stop the ACE I or ARB and consider specialist advice on whether to stop treatment, or to investigate further, e.g. for renal artery stenosis. If potassium >6 stop ACE I or ARB, and review other medication. Consider giving simple diet advice (reduce bananas, soft fruit, fruit juices and chocolate). Note that high blood sugar in diabetics is a common cause. Cautiously re-institute ACE I or ARB once potassium is in the normal range. If the potassium level is >6.5, (on an unhaemolysed sample) it should be rechecked and managed on the same day. If potassium >7, the patient may need assessment in A&E on the same day. Lowering blood pressure reduces the rate of decline in GFR whatever the cause of CKD. This will delay the need for renal dialysis or replacement. There is evidence that ACE I and ARB are more effective than other agents in reducing deterioration in renal function, especially with significant proteinuria. Both drugs appear to reduce proteinuria independent of their antihypertensive effect. The UK CKD guidelines state:- Treatment threshold 140/90 - Target 130/80 If urine PCR >100mg/mol, treatment threshold 130/80 - Target 125/75 The ngms 2006 Quality and Outcomes Framework aims for BP measurements of <140/80. The guidance describes this as a pragmatic starting point for a new indicator, recognising that more rigorous targets are hard to achieve particularly among the frail elderly. Angiotensin converting enzyme inhibitors are the first line agent to treat hypertension. Angiotensin receptor blockers are an alternative drug to use if ACE I are not tolerated. Both ACE I and ARB are associated with a fall in egfr. A fall of <15% is acceptable. Both drugs are also associated with a rise in serum potassium. This is of greatest concern in those patients with low egfrs and on other medication which also affects potassium levels (e.g. potassium sparing diuretics; and erythropoetin which also increases blood pressure). There is no egfr below which an ACE I / ARB would be contraindicated but the lower the initial egfr the greater the monitoring requirement. For both of these drugs, check egfr and potassium within 2 weeks of starting, or after dose increases. Other Antihypertensives Most patients will require 2 or 3 agents to control their hypertension. The choice of other antihypertensives used will depend on existing co-morbidities. Following an ACE I / ARB, a diuretic maybe used (often a thiazide, but in CKD stages 4 and 5, a loop diuretic may be needed, such as frusemide, possibly at high doses if there is fluid overload). Next choice would be a calcium channel blocker (e.g. amlodipine), then a beta-blocker (reduce dose depending on the level of egfr) and then an alpha blocker. Occasional patients may require both an ACE I and an ARB to control hypertension and proteinuria. This combination should only be started by a nephrologist. ACE I Contraindications Hypersensitvity, including angioedema which is rare, but ACE I / ARBs are common drug triggers Known or suspected renal artery stenosis (caution with peripheral vascular disease or generalised atherosclerosis) ACE I Cautions Aortic stenosis (if severe or symptomatic) Collagen vascular disease (agranulocytosis risk, FBC recommended) ACE I Potential Side effects Cough (persistent, dry) Profound hypotension & renal impairment

7 Chronic Kidney Disease 7 2. Hyperlipidaemia and CVD prevention CKD is a powerful risk factor for CVD, hence the importance of implementing standard CVD secondary and primary prevention. Statins should be used to treat hyperlipidaemia according to local guidelines. For secondary prevention treat all those with established vascular disease including MI, angina, stroke, PVD, heart failure secondary to CHD, and diabetics >40 years of age. For primary prevention treat those with a coronary heart disease risk 15% (= CVD risk 20%). Simvastatin 40mg, should be the drug of first choice. Consider a lower dose if not tolerated. If creatinine clearance <30ml/min, doses above 10mg daily should be used with caution. CKD increases the risk of statin induced myositis. Aspirin if indicated according to local guidelines. For secondary prevention treat all those with established vascular disease (see above). For primary prevention treat those with a coronary heart disease risk 15% (= CVD risk 20%) where blood pressure is well controlled. Smoking Cessation is the single most important change that can be achieved to reduce coronary heart disease. Physical activity advise as for those with CVD. Diet 3. Optimising diabetic control People of south Asian origin are particularly at risk of CKD and CVD linked to the early onset of type 2 diabetes. Diabetic nephropathy is a major cause of renal failure. It is characterised by progressive increase in proteinuria and associated retinopathy. Good glycaemic and blood pressure control slows the development of microalbuminuria, an early marker for renal damage. Microalbuminuria is not an indicator of progressive renal disease in other patient groups, so do not request ACR measurement in non diabetics. An annual check for microalbuminuria should be done, unless persistent known proteinuria. Request albumin:creatinine ratio (ACR) on a spot urine sample (preferably EMU). Microalbuminuria is defined as ACR 2.5 mg/mmol (male) or 3.5 mg/mmol (female) ideally on 2 out of 3 tests; but not during acute illness, intercurrent infection or menstruation. If microalbuminuria is present an ACE I / ARB should be started regardless of initial blood pressure. If proteinuria or microalbuminuria is present the target blood pressure should be 125/75. Advice or referral to nephrology should be targeted at those with: Progressive proteinuria and / or decline in egfr. Difficult to control hypertension. Non diabetic renal disease - consider in patients with haematuria, absence of retinopathy and normal blood pressure. Weight loss is beneficial among patients with CKD, largely through an effect on blood pressure reduction. Salt restriction contributes to lowering blood pressure. There is some evidence it amplifies the protective effect of ACE I in those with proteinuria. Dietetic advice is an essential component of management for those with CKD 4 and 5, and for all diabetics. Advice or referral to diabetologist can be considered if diabetic CKD 3 with: poor glycaemic control (HbA1c >7.5%) poor BP control Metformin should be stopped if the egfr <30 due to the risk of lactic acidosis.

8 8 Summary guidelines Other Management Interventions which reduce risk of progression 4. Vaccines Influenza and pneumococcal immunisation. Hepatitis B immunisation for patients in a renal replacement programme. 5. Medication review Annual medication review. Avoid long term NSAIDs where possible. Particular caution and regular monitoring is required with drugs such as Lithium, digoxin and DMARDs used in inflammatory arthritis. In patients with impaired renal function drug prescribing should be kept to a minimum. If egfr is low, particularly for the elderly, review need for dose adjustment. The BNF (appendix 3) gives further information on prescribing including dose adjustments. Monitoring CKD in Primary Care: Identifying progressive disease The purpose of monitoring CKD in primary care is to optimise preventive care, and to detect progressive renal disease which may require specialist referral and investigation. Of the 5% of the population with CKD stage 3, only about 5% will have progressive disease. A sustained fall in egfr and / or the development of significant proteinuria ( 1+ proteinuria on dipstick) are the most important markers of progressive disease. Monitoring intervals suggested by the Renal Association UK guidelines are based on best practice rather than trial evidence. The highest priority for clinicians in primary care is to concentrate regular monitoring on those with CKD 3. Monitoring intervals may be adjusted depending on the stability of the condition. For CKD 3: annual egfr, BP and urinalysis. PCR if dipstick proteinuria is increasing. Six monthly if evidence of progression (decline in egfr or increase in proteinuria). For CKD 1 or 2: annual egfr, BP and urinalysis. PCR only if indicated (e.g. If on urinalysis proteinuria has increased from 1+ to 2+). Other sources of prescribing information: Medicines Information Service at BLT: Summary of Product Characteristics ( PCT prescribing advisors. NSAIDs and the kidney Damage from NSAIDs can occur in a number of ways: Increased cardiovascular risk by fluid retention and hypertension. An idiosyncratic interstitial nephritis or nephritic syndrome. A decrease in renal blood flow - causing a reduction in egfr, this effect is synergistic with that of ACE I / ARBs and diuretics. The elderly and those with low egfrs are most vulnerable. Long term use increases the risk of analgesic nephropathy.

9 Chronic Kidney Disease 9 Referral to Nephrologist CKD Indications (based on egfr <15 CKD stage 5 Urgent referral, unless clinically inappropriate egfr CKD stage 4 egfr CKD stage 3 Routine referral (if stable) Routine referral only if other problems such as: Microscopic haematuria + PCR > 45 mg/mmol Urinary PCR >100mg/mmol (unless established diabetic nephropathy) Uncontrolled hypertension Systemic disease (eg SLE) Sustained fall in egfr > 5ml over 12 months egfr >60 CKD stage 1 or 2 Routine referral If fall in egfr > 15 ml in 12 months or 5ml/year over 3 years. Renal problems irrespective of GFR Immediate referral for: Malignant hypertension Hyperkalaemia (potassium >7.0 mmol/l) Acute renal failure Urgent referral for Proteinuria with oedema and low serum albumin (nephrotic syndrome) Routine referral for: Dipstick proteinuria present and urine PCR >100mg/mmol unless known diabetic Dipstick proteinuria and microscopic haematuria present Macroscopic haematuria but urological tests negative Information suggested for referral letters 1. General medical history. 2. Urinary symptoms. 3. Medication history. 4. Examination, e.g. BP, oedema, palpable bladder or other positive findings. 5. Urine dipstick for blood and protein. 6. Urine protein:creatinine ratio, if proteinuria present - early morning urine (EMU) preferable (in diabetes, result of urine albumin:creatinine ratio if dipstick proteinuria negative). 7. Blood count. 8. Serum creatinine, sodium, potassium, albumin, calcium, phosphate, cholesterol. 9. HbA1C (in diabetes). 10. Previous serum creatinine / egfr results. 11. Result of renal ultrasound scan if available.

10 10 Summary guidelines Renal services in Newham, Hackney and Tower Hamlets All renal services are located at Barts and the London Routine referrals can be booked using Choose and Book. Urgent referrals can be booked using Choose and Book, faxed to or discussed with the on call renal specialist registrar. Immediate referrals should be discussed with the on call renal specialist registrar on the same day. Advice by phone or A dedicated phone line for consultant advice on investigation, management and the need for referral will run daily 12-1pm, Monday to Friday (ext 3369). Non urgent queries can be sent to: btl-tr.bltrenalopinions@nhs.net Consultants Dr Neil Ashman General nephrology and haemodialysis Dr Alistair Chesser General nephrology and haemodialysis Dr Stan Fan General nephrology and peritoneal dialysis Dr Martin Raftery Clinical Director. Glomerulonephritis and transplantation Dr Raj Thuraisingham Cardiovascular disease in renal patients and general nephrology This website includes the list of named consultants with individual contact numbers: The Royal London Hospital Paulin Ward (surgical) Devonshire Ward Transplant Clinic ext 3204 (RLH) Other Staff Nurse led erythropoeitin service (ext 2439) Renal dietician Renal pharmacist Medical Information Services The local Barts and the London Chronic Kidney Disease guidelines are available at:

11 Barts and The London NHS Trust Patient Information Chronic Kidney Disease Stage 3 The kidney Most people have two kidneys, though you can live a normal life with one. They are found at the back of your body just below your rib cage. They remove the waste products and excess fluid from your body and regulate certain chemicals that your body needs, such as potassium and calcium. They also help to manage your blood pressure, make red blood cells and keep your bones healthy and strong. What is chronic kidney disease (CKD)? How common is CKD? This is a term used by doctors to include any abnormality of the kidneys, even if there is only very slight damage. Chronic means a condition that does not get completely better. Some people think that chronic means severe, this is not the case, and often CKD can be only a very slight abnormality in the kidneys. Around 1 in 10 people in the population have CKD, but it is less common in young adults. In those aged over 75 years, CKD is present in 1 out of 2 people. However, many elderly people with CKD may not have diseased kidneys, but have normal ageing of their kidneys. Although severe kidney failure will not occur with normal ageing of the kidneys, there is an increased chance of high blood pressure and heart disease or stroke, so annual medical checks will be helpful. What causes CKD? There are many causes of CKD, and the commonest are high blood pressure, the natural ageing of the kidneys and diabetes. Very few of the causes of CKD are completely curable, so it is often not necessary to do extensive tests to find a cause, so long as blood tests show the kidney function is stable. If someone has markedly reduced kidney function, declining kidney function, or associated problems such as kidney pain, a scan of the kidneys will be performed. Some people will also have tests such as a cytoscopy (a flexible tube to look inside the bladder), or a kidney biopsy (a small piece of kidney is removed with a needle and looked at under the microscope). How do you measure kidney function? A test called the egfr (estimated glomerular filtration rate) is used to measure kidney function. The egfr is calculated by the laboratory from the level of a chemical called creatinine in the blood. A normal egfr is about 100 ml/min in young adults. Some young adults with normal kidneys will have an egfr as low as 75 ml/min, and this falls by about 1 ml/min per year as people get older (i.e. over the age of 40 years), so many healthy people aged 75 will have an egfr of ml/min. What does it mean to have CKD Stage 1, 2 or 3? It means that there is some minor damage to the kidney. In Stage 3 CKD there is moderate reduction in kidney function. CKD Stage 1 is where the egfr is greater than 90 ml/min, with some sign of kidney damage on other tests. How do you know if you have CKD? In most cases CKD does not cause any symptoms, and is detected because tests are abnormal. These may be urine tests for blood or protein; an X-ray or scan of the kidneys; or a blood test to measure kidney function. Most cases are picked up by your GP as part of your normal care. CKD Stage 2 is where the egfr is between ml/min with some sign of kidney damage on other tests. CKD Stage 3 is where there is moderate reduction in kidney function. If your kidney damage progresses to stages 4 or 5 you would normally be reviewed in a renal clinic.

12 Barts and The London NHS Trust Patient Information What is the treatment for CKD? Your blood pressure should be treated carefully. If it is above 140/85 on three consecutive occasions, tablets are usually needed. The aim is to get the blood pressure down to 130/80 or lower. Your cholesterol should be checked, and some people will be advised to take a daily aspirin tablet. Good control of blood sugar levels in people with diabetes helps to prevent and delay further kidney damage. Annual check up Living with CKD You will need to have a blood and urine test every year and a check of your blood pressure, to monitor your kidney function. If the urine tests show a lot of protein in the urine, or the kidney function is declining over time, your GP will discuss your case with a kidney specialist, or refer you for advice. What can I do? Try to live a healthy lifestyle as you are more at risk of getting heart disease and developing further damage to your kidneys. Try to do the following: If you are overweight, you should lose weight. Take regular exercise. Stop smoking. Reduce the amount of salt in your diet in order to help control your blood pressure. Eat a balanced diet. Drink about 2 litres of fluid a day (2 litres is about 10 cups or 6 mugs). There is no benefit in drinking large amounts of fluid, except in people who get lots of urine infections, or in a few other special cases. Avoid NSAIDs (anti-inflammatory drugs), including some that you can buy over the counter without a prescription, unless your GP has approved them, e.g. ibuprofen. Consider buying an automatic blood pressure monitor to check your blood pressure at home. Have an annual flu jab (influenza vaccination), and have the pneumonia (pneumococcal) vaccination once - talk to your GP about this. Useful Websites The National Kidney Federation (NKF) The only UK charity run by kidney patients for other kidney patients. They provide information and support to those with kidney disease. This leaflet is adapted from the information available on their website. You can contact them by: The National Kidney Foundation Inc. This is a voluntary health organisation which seeks to prevent kidney and urinary tract disease, improve the health and well-being of individuals and families affected by these diseases, and increase the availability of all organs for transplantation. Website: Telephone: Website: Other sites:

13 Chronic Kidney Disease 13 Providing Information for Patients A CKD leaflet suitable for patients with CKD stage 3 is attached to this guide. Others are available at Patient support groups and Voluntary Organisations Useful websites for patients: Kidney Research UK (KRUK): National Kidney Federation (NKF): Kidney patient guide: Renal patient information: Acknowlegements and References This guideline was written by Dr Sally Hull and Dr Alex Sohal, with advice from Dr Alistair Chesser, Dr Tahseen Chowdhury, Dr John Robson, Georgina Glass (Renal pharmaceutical advisor) and Dr Jasper Mahon.

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16 Further copies can be obtained from: Clinical Effectiveness Group Centre for Health Sciences Institute of Health Sciences Education Barts and the London Abernathy Building 2 Newark Street London E1 2AT Tel: Contact details: Administrator Tel: ihse-ceg-admin@qmul.ac.uk Jo Tissier - Tower Hamlets Facilitator Tel: j.r.tissier@qmul.ac.uk Jo Law - Hackney Facilitator Tel: j.m.law@qmul.ac.uk Anne-Marie Maher - Primary Care Audit Facilitator Tel: a.e.maher@qmul.ac.uk Keith Prescott - Manager Tel: k.a.prescott@qmul.ac.uk John Robson - Clinical Lead Tel: j.robson@qmul.ac.uk Kambiz Boomla - IT Lead Tel: k.boomla@qmul.ac.uk Sally Hull - Mental Health Clinical Lead Tel: s.a.hull@qmul.ac.uk Gladys Fordjour - Information Officer Tel: g.fordjour@qmul.ac.uk Louise Cotton - Database Manager Tel: l.cotton@qmul.ac.uk Susan Hunter - Database Manager Tel: s.c.hunter@qmul.ac.uk Website: