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Audit Protocol – Chronic Kidney Disease For renally eliminated medication, dose adjustments are necessary to prevent the adverse effects associated with potentially elevated drug concentrations. In addition, some medications can worsen renal function and should therefore be avoided or carefully considered for use in patients with renal impairment. Studies that have evaluated medication-related hospital admissions showed that impaired renal function is a potential risk factor for these admissions1, 2. General Practices are required to keep a register of patients with impaired renal function as part of their Quality Outcomes Framework (QOF). The patient management requirements of QOF are summarised in the appendix. The stages for chronic kidney disease (CKD) are summarised below: Stage 3 eGFR* is 30 – 59mL/min Stage 4 eGFR* is 15 – 29mL/min Stage 5 eGFR* is below 15mL/min or on dialysis This audit focuses on reviewing the medicines of patients who are categorised as being in CKD stages 4 and 5. Patients with CKD stages 4 & 5 should be searched using search criteria as eGFR ≤ 30mL/min. NB: Do not conduct the search as clinical codes CKD stages 4 and 5 because this may not pick up all patients if they have not been correctly coded by the Practice. Do not include patients with eGFR <30 on only 1 occasion (ie. whose eGFR has subsequently recovered after an episode of acute kidney injury). Having identified patients with CKD 4 or 5: Review the medicines of all patients who are categorised as being in CKD stages 4 and 5 Compile a list of all patients who need their dose modifying using the Renal Drug Handbook as a reference source. Send a task message (Patient Note) to the patient’s usual GP with any recommended dose changes or attempt to contact them directly for any issues which are judged as requiring immediate attention Confirm that all patients with an eGFR* of less than 15mL/min are under specialist care. NICE recommends that all patients with CKD 4 and 5 should be referred for specialist assessment. Check correspondence from CKD specialists to see if the patient is currently prescribed an erythropoiesis-stimulating agent (ESA). If so, and if this is not listed on the patient’s repeat medication at the Practice, recommend that it is added to the list as a ‘do not issue’ (supplied by hospital) medication, for information. Arrange with individual Practices any Read-Coding to be undertaken pertaining to the CKD register Report any interventions on the HARMS template Notes Where eGFR* has persistently been recorded below 60 the CKD (stage 3) label continues to apply, even if future management may lead to an improvement in eGFR. The presence of proteinuria is a key risk multiplier at all stages of CKD. The gold standard test for measuring proteinuria is a 24-hour urine collection; though problems with timing and completeness make this an impractical test to use in * All GFR values are normalised to an average surface area (size) of 1.73m² _ _ general practice. The alternatives are to test the ACR (albumin:creatinine ratio) or PCR (protein:creatinine ratio) in the urine. ACR is the preferred measure of proteinuria as it has greater sensitivity than PCR for low levels of proteinuria. ACE-I and ARBs are generally more effective than other anti-hypertensives in minimising deterioration in kidney function and this effect is most marked where there is significant proteinuria. NICE recommends that if serum potassium rises to ≥ 6.0 mmol/l and other drugs that promote hyperkalaemia have been discontinued, ACE inhibitors/ARBs should be stopped. NICE also recommends that when vitamin D supplementation is indicated in people with CKD 4 or 5 offer 1-alpha-hydroxycholecalciferol (alfacalcidol) or 1,25dihydroxycholecalciferol (calcitriol) and monitor serum calcium and phosphate concentrations. People with stage 3B, 4 and 5 CKD should have their haemoglobin checked to identify anaemia (Hb < 110 g/L (11.0 g/dL)). NICE CG 114 recommends that treatment with erythropoiesis-stimulating agents (ESAs) should be offered to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function. The correction to normal levels of Hb with ESAs is not usually recommended: typically maintain the aspirational Hb range between 110 and 120 g/L for adults. People receiving ESA maintenance therapy should be given iron supplements to keep their: serum ferritin levels between 200 and 500 μg/L in both haemodialysis and non-haemodialysis patients, and either transferrin saturation level above 20% (unless ferritin is greater than 800 μg/L) or percentage hypochromic red cells (%HRC) less than 6% (unless ferritin is greater than 800 μg/L). (in practice it is likely this will require intravenous iron) Consult the NICE Pathway for recommendations concerning the use of phosphate binders in the management of hyperphosphataemia (see reference 4 for link) Useful References 1. Leendertse AJ, Egberts AC, Stoker LJ, et al.; HARM Study Group. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med 2008;168:1890-6. 2. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother 2002;36:1331-6. 3. The Renal Drug Handbook, third ed. Ed C Ashley & A Currie. Radcliffe Publishing 2009. ISBN-13:978 184619 2 4. NICE Clinical Guideline 73 - Chronic kidney disease. Quick reference guide, Sept 2008, accessed on 11 June 2013 via: http://www.nice.org.uk/nicemedia/live/12069/42119/42119.pdf 5. NICE Clinical Guideline 114 – Anaemia management in people with chronic kidney disease. Quick reference guide, Feb 2011, accessed on 11 June 2013 via: http://www.nice.org.uk/nicemedia/live/13329/52857/52857.pdf 6. NICE Pathway – Hyperphosphataemia in people with chronic kidney disease overview. Accessed on 11 June 2013 via: http://pathways.nice.org.uk/pathways/hyperphosphataemia-in-chronic-kidneydisease#content=view-node%3Anodes-second-line-phosphate-binder-treatment-for-adults * All GFR values are normalised to an average surface area (size) of 1.73m² Appendix Chronic kidney disease (CKD)Points Pt Quality and Outcomes framework guidance for GMS contract 2013/2014 Indicator Points Achievement thresholds Records CKD001. The practice can produce a register of patients 6 aged 18 years or over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD) Ongoing management CKD002. The percentage of patients on the CKD register 11 41–81% in whom the last blood pressure reading, measured in the preceding 12 months, is 140/85 or less CKD003. The percentage of patients on the CKD register 9 45–80% with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) CKD004. The percentage of patients on the CKD register 6 45–80% whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months * All GFR values are normalised to an average surface area (size) of 1.73m²