Courtney, A.E.

Fogarty, Damian

Maxwell, Alexander

Queen's University Belfast Research Portal

Using estimated glomerular filtration rate (eGFR) to help managepatients with chronic kidney diseaseCourtney, A. E., Maxwell, A., & Fogarty, D. (2007). Using estimated glomerular filtration rate (eGFR) to helpmanage patients with chronic kidney disease. The Ulster Medical Journal, 76(3), 154-156.Published in:The Ulster Medical JournalDocument Version:Peer reviewed versionQueen's University Belfast - Research Portal:Link to publication record in Queen's University Belfast Research PortalGeneral rightsCopyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or othercopyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associatedwith these rights.Take down policyThe Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made toensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in theResearch Portal that you believe breaches copyright or violates any law, please contact openaccess@qub.ac.uk.Download date:15. Feb. 2017© The Ulster Medical Society, 2007. www.ums.ac.ukUlster Med J 2007; 76 (3) 154-1561 Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, 2 Nephrology Research Group, Queen’s University Belfast, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB Correspondence to Dr Courtney.E: aecourtney@doctors.org.ukClinical PracticeUsing estimated glomerular filtration rate (eGFR) to help manage patients with chronic kidney diseaseAisling E Courtney1, A Peter Maxwell1,2, Damian G Fogarty1,2Accepted 25 March 2007INTRODUCTIONChronic kidney disease (CKD) has been considered an uncommon condition requiring specialist management. The traditional view of CKD has been of patients with end-stage renal disease (ESRD) requiring dialysis or a kidney transplant as forms of renal replacement therapy (RRT). However the prevalence of CKD is much higher than previously appreciated and this has provided a stimulus to the integration of primary and secondary care to optimise the health of persons with CKD. In particular up to 40% of ESRD patients had been referred to specialists shortly before they needed dialysis. Such late referral often results in increased morbidity and mortality for patients and poor acceptance and planning for RRT1,2. In 2002, in response to growing evidence confirming the benefit of early versus late renal specialist input, the UK Renal Association proposed that all patients with a serum creatinine level >150 µmol/L should be referred to a nephrologist3. However, it soon became apparent that the community prevalence of CKD had been grossly underestimated and strict adherence to this guideline would simply have overwhelmed existing renal services4. Although the majority of persons with CKD will never progress to ESRD, they do have an increased rate of cardiovascular events and risk of premature death5.Subsequently, in January 2005, the second part of the National Service Framework for Renal Services set standards relating to the prevention, early detection and minimisation of CKD progression6. The widespread adoption of a formula based estimation of glomerular filtration rate (eGFR), to be reported by all biochemical laboratories, was recommended to help achieve these goals. The traditional means of assessing renal function using serum creatinine is limited by the variability of this parameter with muscle bulk and age. The degree of renal dysfunction, especially in women and older people, can be underestimated using serum creatinine levels alone and is a major factor in delayed recognition and referral of CKD patients. An eGFR provides a more accurate measurement of kidney impairment. An internationally agreed categorisation of CKD based on a four-variable eGFR equation incorporating age, gender, race and serum creatinine, is now widely utilised (Table I). UK Guidelines for the management of CKD, developed by the Royal College of Physicians, the Royal College of General Practitioners and the Renal Association were also published in 20057. Recommendations followed suggesting that the markers for quality of care of CKD be incorporated into the Quality and Outcomes Framework (QOF) to enable full implementation of the guidelines across the National Health Service.Consequently the updated General Practice QOF specified four indicators (accounting for 27 points) in relation to CKD. These depend on the generation of a register of patients with CKD (eGFR <60mls / min / 1.73m2), measurement of blood pressure, treatment of blood pressure to target, and greater use (if appropriate) of angiotensin converting enzyme inhibitor or angiotensin receptor blocker medication in patients with CKD (Table II)8. Table IInternational classification of chronic kidney diseaseStage eGFR mls/min/1.73m2 Description1 90+Normal kidney functionWith urinary or structural abnormalities2 60-89Mildly reduced kidney functionWith urinary or structural abnormalities3* 30-59Moderately reduced kidney functionWith or without urinary abnormalities4* 15-29Severely reduced kidney functionWith or without urinary abnormalities5* <15Established renal failure Very severe or dialysis- dependent kidney failure* Stages 3-5 are the stages of CKD currently recognized within the General Practice Quality and Outcomes Framework and thus identified with eGFR reporting. © The Ulster Medical Society, 2007.Using estimated glomerular filtration rate (eGFR) to help manage patients with chronic kidney disease 155www.ums.ac.ukIn Northern Ireland in 2006 the Clinical Resource Efficiency Support Team (CREST) published specific guidelines on CKD management9, the General Practice QOF targets for CKD were introduced, and all laboratories began to routinely report eGFR with any creatinine measurement. These developments were coupled to local educational initiatives to explain and disseminate best practice for the care of persons with CKD. What conclusions can be drawn from this first year of eGFR reporting in Northern Ireland?CKD IS COMMONPatients with an eGFR <60ml/min/1.73m2 have CKD stage 3, 4 or 5 and are the focus of guidelines and the new QOF indicators. The epidemiological evidence has confirmed that CKD is common in Northern Ireland with approximately 5% of the adult population having CKD stages 3, 4 or 54. The majority of these patients are elderly and although they have minor elevation of serum creatinine they are categorized as having stage 3 CKD based on eGFR. Some clinicians are concerned that use of eGFR generates a ‘disease’ that may merely be age related kidney function decline. However the data supporting a high risk of cardiovascular events in CKD stage 3 patients is robust and since the growth in ESRD incidence is largely confined to the elderly we consider the benefits of this staging system outweighs this putative drawback.  CKD IS INCREASINGLY RECOGNISEDThe identification of patients with CKD has increased following routine eGFR reporting coupled with implementation of CKD QOF criteria. Electronic registers of persons with an eGFR < 60 ml/min/1.73m2 now exist in general practice and will heighten awareness of opportunities for reduction of cardiovascular risk and reduce the likelihood of prescribing problems in persons with renal impairment.THE MAJORITY OF CKD IS MANAGED IN PRIMARY CAREFor CKD patients, the guidelines recommend targeting classical cardiovascular risk factors, including meticulous control of blood pressure and lipids, smoking cessation, lifestyle advice and, in diabetic patients, optimisation of blood sugar control. Since many of these patients’ main risk is cardiovascular in nature the most relevant and cost-effective place for this to happen is primary care, as suggested by the guidelines for CKD7. The local guidelines provide specific advice on those who would benefit from specialist input9, and a summary version has been distributed to GPs (fig 1). AN IMPORTANT MINORITY PROGRESS TO END-STAGE RENAL DISEASEUnfortunately some people with CKD stages 3 and 4 will progress to ESRD (stage 5 CKD) and require dialysis.10 Diabetes, hypertension and proteinuria are all predictors for progressive renal failure. The number of people with ESRD requiring RRT continues to rise worldwide placing an increasing strain Table II.Quality and Outcomes Framework indicators for Chronic Kidney DiseaseIndicator PointsRecordsCKD 1The practice can produce a register of patients aged 18 years and over with CKD stages 3-56Initial managementCKD 2The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months 6On-going managementCKD 3 The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less 11CKD 4 The percentage of patients on the CKD register with hypertension who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded) 4Figure 1.  The summary of chronic kidney disease management guidelines recommended by CREST© The Ulster Medical Society, 2007.156 The Ulster Medical Journalwww.ums.ac.ukon limited healthcare resources. In Northern Ireland, at the start of 2007, over 750 patients were receiving regular dialysis therapy with the absolute number of dialysis patients predicted to rise to over 1000 by the end of 2010. While the provision of RRT in Northern Ireland compares very favourably with the rest of the UK, (the dialysis take-on rate here is the higher than all other UK regions)11, the UK has the lowest dialysis provision per million population in the developed world. It is projected that prevalent dialysis patient numbers will not reach steady state for at least a further 20 to 25 years11. RRT is expensive with an estimation that in the near future it will account for 2% of the total NHS budget.7 Despite the commendable dialysis take-on rate in Northern Ireland there has been evidence of both under- and late-referral4,12. CKD must therefore remain a high profile public health issue. The identification and early referral of the subgroup of patients that would benefit from specialist renal input will reduce the costs incurred by late referral2. However before realizing this there will need to be an increase in nephrology outpatient services to support primary care colleagues in this endeavour.There are testing times ahead for primary and secondary care health professionals managing persons with CKD. The introduction of eGFR reporting has provided a useful tool to recognise the burden of CKD in the community and to track the progression of kidney disease in an individual over time. The authors have no conflict of interest. REFERENCES1 Obrador GT, Pereira BJG. Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis 1998;31(3):398–417.2 McLaughlin K, Manns B, Culleton B, Donaldson C, Taub K. An economic evaluation of early versus late referral of patients with progressive renal insufficiency. Am J Kidney Dis 2001;38(5):1122-8.3 Renal Association: Treatment of adults and children with renal failure: standards and audit measures. 3rd ed. London: Royal College of Physicians of London and the Renal Association, 2002. Available from: http://www.renal.org/Standards/standards.html [Accessed May 2007].4 Kee F, Reaney EA, Maxwell AP, Fogarty DG, Savage G, Patterson CC. Late referral for assessment of renal failure. J Epidemiol Community Health 2005;59(5):386-8.5 Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351(13):1296-305.6 Department of Health. The National Service Framework for Renal Services. London: 2004 [Updated 2005 Feb 11]. Available from: http://www.dh.gov.uk/Renal. [Accessed May 2007].7 The Renal Association [homepage on the Internet]. UK guidelines for the management of chronic kidney disease.  Royal College of Physicians of London and the Renal Association, 2006. Available from: http://www.renal.org/CKDguide/ckd.html [Accessed May2007].8 NHS Primary Care Contracting. [homepage on the Internet]. Quality and Outcomes Framework Guide. NHS Primary Care Contracting. 2006. Available from: http://www.primarycarecontracting.nhs.uk/16.php [Accessed May 2006].9 CREST Clinical Resource Efficiency Support Team. Guidelines for chronic kidney disease in Northern Ireland. CREST, 2006. Available from: www.crestni.org.uk./chronic-kidney-guidelines.pdf  [Accessed May 2007]10 Hallan SI, Dahl K, Oien CM, Grootendorst DC, Aasberg A, Holmen J, et al. Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey. BMJ 2006;333(7577):1047. Epub 2006 Oct 24.11 Roderick P, Davies R, Jones C, Feest T, Smith S, Farrington K. Simulation model of renal replacement therapy: predicting future demand in England. Nephrol Dial Transplant 2004;19(3):692-701.12 Kee F, Reaney EA, Savage G, O’Reilly D, Patterson CC, Maxwell AP, et al. Are gatekeepers to renal services referring patients equitably? J Health Serv Res Policy 2007 12(1):36-41.

Using estimated glomerular filtration rate (eGFR) to help manage patients with chronic kidney disease

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