The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay

Renal Disease

Bradford VTS Clinical Resources

WEBLINKS

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AKI at a glance

Anyone with 

  • a rapidly declining eGFR

and/or 

  • signs of acute nephritis 
      • oliguria,
      • haematuria,
      • acute hypertension and
      • oedema

These patients should be regarded as a medical emergency and admitted to hospital.

  • What to do if ACE inhibitor or ARB reduces eGFR further…

    • ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that’s how they work!). 
    • As a result GFR can decline when treatment is initiated.
    • After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.
    • If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB 
    • If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB.  Refer to a nephrologist.

Drugs that can cause AKI

Watch out for the triple whammy that can cause an AKI

  1. BP drugs (ACE inhibitor or ARB) plus
  2. Diuretics plus
  3. Pain killers (NSAIDs or COX2 inhibitors (except low dose aspirin)

Admission

Admit to hospital if the person is at risk of a hyperglycaemic emergency (vomiting, abdominal pain reduced conscious level, heavy ketonuria, dehydration requiring IV fluids, hypotension, and serious intercurrent problem).

Same day referral

Refer to be seen on the same day if the patient is acutely ill, consider Type 1 Diabetes/pancreatic insufficiency if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, and polyuria).

Early Referral

Diabetes and pregnancy requires referral to the hospital diabetes team

Tell the patient…

When you are unwell with any of the following…

  • Vomiting or Diarrhoea (unless only minor and mild)
  • Fevers, sweats and shaking (unless only minor and mild) – this can often happen with common cold/flu, chest infections, water infections

Then

  1. STOP taking the medicines I have written down for you
  2. Restart these when you are well (after 24-48 hours of eating and drinking normally)
  3. If you are in any doubt, contact the pharmacist, doctor, nurse or call 111.

Medicines to STOP on sick days (mnemonic SADMAN)

  • SGLT-2 inhibitors: medicine names ending in “flozins” like canagliflozin, empagliflozin, dapagliflozin
  • ACE inhibitors: medicine names ending in “pril” like ramipril, lisonopril, enalapril, captopril, perindopril
  • Diuretics: e.g. medicine names ending in “ide” like furosemide, bendroflumethiazide, bumetanide
  • Metformin (which is a medicine for diabetes)
  • ARBs: medicine names ending in “sartan” like losartan, candesartan, valsartan, irbesartan
  • NSAIDs: anti-inflammatory pain killers like ibuprofen, diclofenac, naproxen, ketoprofen

Also tell the patient: Other Measures…

  • Take some rest
  • Drink plenty of sugar-free fluids. Aim to drink at least three litres (five pints) a day, UNLESS YOU HAVE HEART FAILURE – see box on right. 
  • Try to keep to your normal meal pattern, but if you are unable to, see box on right.
  • Avoid too much caffeine as this could make you dehydrated.
  • Take painkillers in the recommended doses as necessary.
  • Contact your GP to see if treatment with antibiotics is necessary.
  • If you are vomiting uncontrollably, contact your GP or call 111

SPECIAL CASES…

Oral fluids in patients with Heart Failure

  • Ask your Heart Failure nurse or GP or ring 111 about how much fluid you should drink.  
  • You may need to stick to around 1.5-2 litres.   
  • Weigh yourself every day.  
  • If you suddenly gain more than 2Kg in 3 days, contact the emergency doctor or call 111. 

If you cannot eat your normal meals…

  • You can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as
      • yoghurt,
      • milk and other milky drinks,
      • fruit juice or
      • sugary drinks such as Lucozade, ordinary cola or lemonade.
      • You may find it useful to let fizzy drinks go flat to help keep them down

If you are a diabetic on insulin or diabetes medication…

  • Keep taking your insulin or diabetes medications even if you are not eating.   HOWEVER, stop metformin and blood pressure medication if you are dehydrated.
  • Test your blood four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Test your urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Testing for ketones
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.

NICE recommended Hba1c targets are:

  • 48mmol/mol – people who are managed by lifestyle and diet
  • 48mmol/mol – people who are managed by lifestyle and diet combined with a single drug not associated with hypoglycaemia (such as metformin)
  • 53mmol/mol – people who are taking a drug associated with hypoglycaemia (such as sulphonylurea), combination treatment

See table below for suggested targets for frail/elderly patients.  Please exempt from QoF if you follow these targets putting an explanation in the notes.

Hba1c Target: aim for 48mmol/mol (if on diet or single drug not affected by hypoglycaemia ) or <53mmol/mol (if on SU, or more than one medication).  Caution: elderly

  • Start Oral treatment usually Metformin at diagnosis. Metformin 500mg ideally with evening meal, increasing to 1 gram a week later if they have no side effects.
  • Please remember Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction.
      • Metformin has to be stopped if eGFR fall below 30!
      • Metformin MR can be used if they run into problems with GI side effects.
  • Don’t forget that on starting hypoglycaemics to complete the prescription exemption form for those patients under 60 years of age.
  • If you are starting a sulphonylurea (ideally Glimepiride) – ensure they are counselled and documented about:
      • symptoms of hypos
      • hypo management
      • hypos and driving and remind them about informing their car and travel insurer AND document this in their records. If they hold HGV or PSV license then check with the 6 monthly updated DVLA guidance with respect to them having to inform the DVLA.
      • Ensure they have been given a glucometer and a sharps bin, test strips and lancets are added to their repeat prescription
    •  
  • DISCUSS AKI SICK DAY RULES ADVICE – see hypertension protocol for full advice.

FUNCTIONALLY DEPENDENT

  • Due to loss of function, having impairments of ADLs
  • Increased likelihood of requiring addition medical &/or social care
  • HBA1c target: 53 – 64mmol/mol

FRAIL

– Combination of significant fatigue, recent weight loss,       severe restriction in mobility & strength, increased propensity for falls & increased risk of institutionalisation

 – A recognised condition & accounts for 25% of older people with diabetes

 – Clinical Frailty scale or CHSA 9-point scale (assessment tool)

HBA1c target: 60-70mmol/mol

DEMENTIA

– Degree of cognitive impairment leading to sig. Memory problems, a degree of disorientation, or a change in personality & unable to self care

 – MiniCog tool (easy to use assessment tool)

HbA1c target: 60-70mmol/mol

END OF LIFE CARE

  • Significant illness or malignancy & have life expectancy reduced to <1 year
  • Glycaemic aim – hypo and symptomatic hyperglycaemia avoidance

Medication

Mode of action

Side effects

Cautions (check BNF for more detail)

Dose

METFORMIN

1st line treatment, unless BMI <25 (23 in South Asian population)

Low Hypo risk

Reduces CVD risk, weight neutral

Helps to stop the liver producing new glucose.

It helps to overcome insulin resistance by making insulin carry glucose into muscle cells more effectively.

 

Main side effect if GI affects, generally dose dependent-can be reduced with gradual increase in dose over several weeks or trying modified release Metformin

Also: metallic taste, reduced absorption of vitamin B12, build up of lactic acid in the blood, allergic reaction and liver problems.

STOP/DO NOT USE IF eGFR <30 ml/min

*Lactic acidosis- care if eGFR < 45ml/min.

Document that advice has been given to stop these tablets if they become dehydrated (restart when eating normally again)

*GI side effects. Titrate dose slowly to reduce side effects

NOTE IF ALT> 3 TIMES NORMAL

Start at 500mg ideally with evening meal, increasing to 1g with evening meal after a week if they have no side effects.

Max dose 2 gram  over 4 weeks.

Consider slow release for to reduce tablet load or if they are struggling with GI side effects.

 

SGLT-inhibitor

Empagliflozin

Low hypo risk

Can help with weight loss

Sodium-glucose co-transporter 2 (SGLT2) inhibitor that prevents glucose reuptake in the kidney, leading to the excretion of excess glucose in the urine.

Polyuria, polydipsia, thrush. UTI, fluid depletion

Increased risk of amputation- avoid if h/o leg ulcers

Only start if Cr Clearance > 60.

Care if > 75 years. Risk of postural hypotension.

Care needed if they have skin ulcers – risk of amputation.

Document advice about normoglycaemic ketoacidosis and give ketostix.

Empagliflozin 10mg. Can be increased to 25mg.

Expensive so only continue if there is a clear response after 6 months

SULPHONYLUREA (SU)

Glimepiride

Risk of hypos

Good if rapid response is needed.

They work by stimulating cells in the pancreas to make more insulin.

They also help insulin to work more effectively in the body.

 

Weight gain.

Hypoglycaemia, gastrointestinal side effects, low sodium, facial flushing and intolerance of alcohol, allergies etc.

 

Can cause hypoglycaemia, particularly if there is renal impairment or they are elderly.

Consider occupation – hypos if not eating regularly, fasting.

Make sure you give and document advice about hypos.

Make sure they are able to test their blood glucose – issue glucometer, test strips, lancets and sharps bin. (SGBM)

Document advice about driving/insurance.

Start at 1mg and titrate up to 4mg depending on glucose level.  Should have an effect on Hba1c over a 2 month period.

GLIPTIN

Do not cause weight gain and encourages patient satiety. Although they probably reduce Hba1c levels less than other drug treatments.

Low hypo risk

They work by blocking the action of the enzyme, DPP-4, which destroys the hormone Incretin.

 

Gastro-intestinal effects, oedema, headache,

 Avoid if h/o Pancreatitis or heart failure or liver problems.

*Expensive- only continue if they meet NICE guidance.

*Not v powerful max likely reduction ~ 11 mmol/mol

*Do not use if a h/o pancreatitis

*Monitor egfr at reviews

*Don’t use if heart failure risk

Linagliptin 5mg if eGFR < 50

GLITAZONE

Pioglitazone

Low hypo risk

Consider in people with very significant features of metabolic syndrome.

South Asian

Reducing insulin resistance.

Improving insulin sensitivity.

 

Oedema esp if heart failure or at risk.

Rare reports of liver dysfunction.

Weight gain,

gastro-intestinal side effects, headache, dizziness.

 

Discuss with member of Level 2 team before starting.

Avoid if they have heart failure or risk of fluid overload

Avoid if h/o bladder cancer, undiagnosed haematuria

Avoid if fracture risk

Monitor LFTs at each diabetic review.

Annual urine dip looking for haematuria

Pioglitazone:15mg-30mg.

A six month period may be needed to really see an effect from these tablets. NICE recommends that they are only continued if at least a 11 mmol/l reduction in Hba1c is seen within 6 months of starting the treatment.

 

GLP-1 mimetic/insulin

Discuss with Level 2 doctor

  

 

  • People with moderate or severe CKD is defined as
      • eGFR <45 mL/min/1.73 m2 or
      • persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol (females))
  • They are considered to be at the highest risk of a cardiovascular event (>15% probability in five years).
  • Failure to recognise the presence of moderate to severe CKD may lead to a serious under-estimation of cardiovascular disease (CVD) risk in that individual.

Advise patients the following: if you do go down with a cold, flu or any other illness…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or diabetes clinic.
  • Insulin or diabetes medications
      • Keep taking your insulin or diabetes medications even if you are not eating. Stop metformin and blood pressure medication if you are dehydrated.  CONSIDER AKI SICK DAY RULES – see hypertension protocol.
  • Testing
      • Test your blood or urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Ketoacidosis
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
  • Testing for ketones
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
  • Food and drink
      • It is important to keep taking your medication as normal and drink plenty of sugar-free drinks. Aim to drink at least three litres (five pints) a day. Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down

Advise patients the following: if you do go down with a cold, flu or any other illness…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or diabetes clinic.
  • Insulin or diabetes medications
      • Keep taking your insulin or diabetes medications even if you are not eating. Stop metformin and blood pressure medication if you are dehydrated.  CONSIDER AKI SICK DAY RULES – see hypertension protocol.
  • Testing
      • Test your blood or urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Ketoacidosis
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
  • Testing for ketones
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
  • Food and drink
      • It is important to keep taking your medication as normal and drink plenty of sugar-free drinks. Aim to drink at least three litres (five pints) a day. Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down
  • Renal function goes down as we age.  It is a naturally ageing process and does not necessarily equate with morbidity and mortality in the elderly.
  • Therefore the care of elderly people with CKD requires an individualised approach taking into account
      1. comorbidities,
      2. functional status
      3. life expectancy and 
      4. health priorities.

What if ACE inhibitor or ARB reduces eGFR further?

  • ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that’s how they work!). 
  • As a result GFR can decline when treatment is initiated.
  • After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.
  • If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB 
  • If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB.  Refer to a nephrologist.

Diabetes in pregnancy is associated with risks to the woman and the developing fetus.

Planning a pregnancy

Women planning a pregnancy should be referred to a diabetes pre-conception clinic.

Pre-pregnancy planning includes:

  • Diet and exercise, weight loss advised if body mass index > 27kg/m2
  • Retinal photography unless carried out in last 12months
  • Renal assessment (including microalbuminuria)
  • Folic acid 5mgs for 3 months preconception and continued for first trimester.
  • Establish rubella status, booster organised if required.
  • Blood pressure should be monitored
  • Smoking/alcohol cessation advice

Review of medications

  • Metformin may be used before and during pregnancy, as well as or instead of insulin.  The diabetes antenatal clinic will oversee their care whilst pregnant.
  • Isophane insulin is the first-choice long-acting insulin during pregnancy.
  • Discontinue oral hypoglycaemic agents (apart from metformin), ACE-inhibitors, Angiotensin Receptor Blockers and statins

Gestational diabetes

  • 6 weeks post-partum patients require a HbA1c to establish whether glucose tolerance has returned to normal.
  • All patients require advice on their elevated long term risk of diabetes.
  • All patients require advice on their risk of gestational diabetes in future pregnancies.
  • All patients require advice regarding diet, weight control and exercise

All patients require an ANNUAL HbA1c in view of their elevated risk of Type 2 diabetes. Please add an ‘AT RISK OF DIABETES’ recall to their notes.

CKD at a glance

DEFINITION

Chronic Kidney Disease (CKD)  is indicated when
eGFR < 60 ml/min/1.73m²
for >3m
with or without kidney damage
(so you need at least 2 GFRs)
————————————

It can also be in people with eGFR > 60 if…
they have markers of kidney damage that are persistent for >3m
 (= micro or macro albuminuria)
————————————–

CKD in itself is not a diagnosis.
Attempts should be made to identify the underlying cause of CKD.

Did you know…

CKD is a stronger risk factor for future coronary events and all-cause mortality than diabetes.

WHY IS IT IMPORTANT

If untreated a patient is more likely to have

  1. Hypertension that is difficult to control, which then leads to…
  2. IHD, HF, PVD, Stroke, which may then lead to…
  3. greater risk of cardiovascular MORTALITY
  4. hypoglycaemic events (kidneys excrete insulin usually) 
  5. ankle swelling and fluid retention
  6. hip fractures (changes in calcium metabolism/vit D deactivation)
  • Individuals with risk factors for CKD should undergo a Kidney Health Check every 1-2 years.

Source: https://kidney.org.au/uploads/resources/CKD-Management-in-Primary-Care_handbook_2020.1.pdf

ALSO DON’T FORGET…

  • Patients with structural renal disease – recurrent calculi or BPH
  • Multisystem disease which might involved the kidneys e.g. SLE
  • Gout 
  • Incidental haematuria or proteinura

BUT MOST IMPORTANTLY

  • Don’t forget those discharged from hospital who had an AKI – every AKI will lead to a further worsening of CKD

ALL OF THESE PATIENTS NEED AT LEAST ANNUAL TESTING

  1. eGFR 
  2. Creatinine (U&E)
  3. ACR (urine)

Source: https://kidney.org.au/uploads/resources/CKD-Management-in-Primary-Care_handbook_2020.1.pdf

Admission

Admit to hospital if the person is at risk of a hyperglycaemic emergency (vomiting, abdominal pain reduced conscious level, heavy ketonuria, dehydration requiring IV fluids, hypotension, and serious intercurrent problem).

Same day referral

Refer to be seen on the same day if the patient is acutely ill, consider Type 1 Diabetes/pancreatic insufficiency if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, and polyuria).

Early Referral

Diabetes and pregnancy requires referral to the hospital diabetes team

LIFESTYLE

BMI                        
Aim for healthy BMI <25 – consider dietition, Orlistat, other dietary measures & EXERCISE

ALCOHOL            
Not to exceed recommended limits. (14 units men and women)

SMOKING          
Stop!

BLOOD PRESSURE

Active management is essential!

Over half of all diabetics are hypertensive. Trials have shown that excellent BP control reduces retinopathy, nephropathy, strokes, heart failure and MI. BP control is as important as glycaemic control! TARGET < 130/80

Treatment

  • 1st line – ACEi, ARB if they cannot tolerate it.
    Ramipril starting regime derived from the  HOPE study regime and BNF guidelines
    If U&Es pre treatment reveal a creatinine < 150 micromol/l and a sodium >130 mmol/l then 2.5 mg Ramipril daily (1.25mg if on lower dose concomitant diuretics) for one week with check U&Es and an increase to 5.0 mg Ramipril for a further two weeks. Re-check U&Es and if indicated increase to 10mg Ramipril and repeat U&Es at least on an annual basis. If eGFR falls > 25% or creatinine rises by > 30% stop or back titrate treatment – see NICE guidelines. Don’t forget BNF cautions and contraindications.
  • 2nd line – CCB or, thiazide like diuretic or, Beta blocker (especially if there is a history of ischaemic heart disease),. Follow hypertension protocol

LIPIDS AND CVD RISK (see lipid modification protocol)

Offer generic Atorvastatin 40mg (Bradford Healthy Hearts) if their Q risk >10% (aged between 18-84 yrs), have been diabetic for > 10 years or, over 40 years old.  Target chol <4mmol/l

For diabetics with established CVD offer secondary prevention or Chol > 4mmol/l – Atorvastatin 80mg

Triglycerides:

If TG level remains high (above 4.5mmol/l) please ref to CKS guidance on lipid modification or in-house lipid modification protocol.

Do not routinely offer Nicotinic acid or Omega fish oils.

MICROALBUMINURIA  AND CKD

  • All diabetics need testing annually for microalbuminuria and eGFR – microalbuminuria is the first sign of diabetic kidney disease and occurs before eGFR falls.
  • SEE CKD PROTOCOL

ANTIPLATELETS

  • Do not offer anti-platelets unless there is evidence of CVD

NICE recommended Hba1c targets are:

  • 48mmol/mol – people who are managed by lifestyle and diet
  • 48mmol/mol – people who are managed by lifestyle and diet combined with a single drug not associated with hypoglycaemia (such as metformin)
  • 53mmol/mol – people who are taking a drug associated with hypoglycaemia (such as sulphonylurea), combination treatment

See table below for suggested targets for frail/elderly patients.  Please exempt from QoF if you follow these targets putting an explanation in the notes.

Hba1c Target: aim for 48mmol/mol (if on diet or single drug not affected by hypoglycaemia ) or <53mmol/mol (if on SU, or more than one medication).  Caution: elderly

  • Start Oral treatment usually Metformin at diagnosis. Metformin 500mg ideally with evening meal, increasing to 1 gram a week later if they have no side effects.
  • Please remember Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction.
      • Metformin has to be stopped if eGFR fall below 30!
      • Metformin MR can be used if they run into problems with GI side effects.
  • Don’t forget that on starting hypoglycaemics to complete the prescription exemption form for those patients under 60 years of age.
  • If you are starting a sulphonylurea (ideally Glimepiride) – ensure they are counselled and documented about:
      • symptoms of hypos
      • hypo management
      • hypos and driving and remind them about informing their car and travel insurer AND document this in their records. If they hold HGV or PSV license then check with the 6 monthly updated DVLA guidance with respect to them having to inform the DVLA.
      • Ensure they have been given a glucometer and a sharps bin, test strips and lancets are added to their repeat prescription
    •  
  • DISCUSS AKI SICK DAY RULES ADVICE – see hypertension protocol for full advice.

THE DOCTOR

  • Medication adjustments are often needed in people with CKD and without them kidney function can be further compromised.
  • If you prescribe anything acute, look up to see whether it can have an effect on the kidney function.  Could it cause an acute kidney injury? (see the “medicines that can cause acute kidney injury” tab.

EMPOWER THE PATIENT

  • Educate your patients to flag their kidney status with other providers and ensure your patient is aware that having CKD can affect prescribing of medications.

 THE PHARMACY TEAM

  • Consider referral to a pharmacist for a Medication Review and Medication Optimisation.

Drugs that can cause AKI

The Triple Whammy

Watch out for the triple whammy that can cause an AKI

  1. BP drugs (ACE inhibitor or ARB) plus
  2. Diuretics plus
  3. Pain killers (NSAIDs or COX2 inhibitors (except low dose aspirin)

Diabetic meds

  • If eGFR>45 – can use metformin up to max dose 1g bd
  • If eGFR lower than this, risk of lactic acidosis
  • If eGFR<45 – reduce metformin to 500mg bd
  • If eGFR<30 – stop metformin.

Medication

Mode of action

Side effects

Cautions (check BNF for more detail)

Dose

METFORMIN

1st line treatment, unless BMI <25 (23 in South Asian population)

Low Hypo risk

Reduces CVD risk, weight neutral

Helps to stop the liver producing new glucose.

It helps to overcome insulin resistance by making insulin carry glucose into muscle cells more effectively.

 

Main side effect if GI affects, generally dose dependent-can be reduced with gradual increase in dose over several weeks or trying modified release Metformin

Also: metallic taste, reduced absorption of vitamin B12, build up of lactic acid in the blood, allergic reaction and liver problems.

STOP/DO NOT USE IF eGFR <30 ml/min

*Lactic acidosis- care if eGFR < 45ml/min.

Document that advice has been given to stop these tablets if they become dehydrated (restart when eating normally again)

*GI side effects. Titrate dose slowly to reduce side effects

NOTE IF ALT> 3 TIMES NORMAL

Start at 500mg ideally with evening meal, increasing to 1g with evening meal after a week if they have no side effects.

Max dose 2 gram  over 4 weeks.

Consider slow release for to reduce tablet load or if they are struggling with GI side effects.

 

SGLT-inhibitor

Empagliflozin

Low hypo risk

Can help with weight loss

Sodium-glucose co-transporter 2 (SGLT2) inhibitor that prevents glucose reuptake in the kidney, leading to the excretion of excess glucose in the urine.

Polyuria, polydipsia, thrush. UTI, fluid depletion

Increased risk of amputation- avoid if h/o leg ulcers

Only start if Cr Clearance > 60.

Care if > 75 years. Risk of postural hypotension.

Care needed if they have skin ulcers – risk of amputation.

Document advice about normoglycaemic ketoacidosis and give ketostix.

Empagliflozin 10mg. Can be increased to 25mg.

Expensive so only continue if there is a clear response after 6 months

SULPHONYLUREA (SU)

Glimepiride

Risk of hypos

Good if rapid response is needed.

They work by stimulating cells in the pancreas to make more insulin.

They also help insulin to work more effectively in the body.

 

Weight gain.

Hypoglycaemia, gastrointestinal side effects, low sodium, facial flushing and intolerance of alcohol, allergies etc.

 

Can cause hypoglycaemia, particularly if there is renal impairment or they are elderly.

Consider occupation – hypos if not eating regularly, fasting.

Make sure you give and document advice about hypos.

Make sure they are able to test their blood glucose – issue glucometer, test strips, lancets and sharps bin. (SGBM)

Document advice about driving/insurance.

Start at 1mg and titrate up to 4mg depending on glucose level.  Should have an effect on Hba1c over a 2 month period.

GLIPTIN

Do not cause weight gain and encourages patient satiety. Although they probably reduce Hba1c levels less than other drug treatments.

Low hypo risk

They work by blocking the action of the enzyme, DPP-4, which destroys the hormone Incretin.

 

Gastro-intestinal effects, oedema, headache,

 Avoid if h/o Pancreatitis or heart failure or liver problems.

*Expensive- only continue if they meet NICE guidance.

*Not v powerful max likely reduction ~ 11 mmol/mol

*Do not use if a h/o pancreatitis

*Monitor egfr at reviews

*Don’t use if heart failure risk

Linagliptin 5mg if eGFR < 50

GLITAZONE

Pioglitazone

Low hypo risk

Consider in people with very significant features of metabolic syndrome.

South Asian

Reducing insulin resistance.

Improving insulin sensitivity.

 

Oedema esp if heart failure or at risk.

Rare reports of liver dysfunction.

Weight gain,

gastro-intestinal side effects, headache, dizziness.

 

Discuss with member of Level 2 team before starting.

Avoid if they have heart failure or risk of fluid overload

Avoid if h/o bladder cancer, undiagnosed haematuria

Avoid if fracture risk

Monitor LFTs at each diabetic review.

Annual urine dip looking for haematuria

Pioglitazone:15mg-30mg.

A six month period may be needed to really see an effect from these tablets. NICE recommends that they are only continued if at least a 11 mmol/l reduction in Hba1c is seen within 6 months of starting the treatment.

 

GLP-1 mimetic/insulin

Discuss with Level 2 doctor

  

 

  • People with moderate or severe CKD is defined as
      • eGFR <45 mL/min/1.73 m2 or
      • persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol (females))
  • They are considered to be at the highest risk of a cardiovascular event (>15% probability in five years).
  • Failure to recognise the presence of moderate to severe CKD may lead to a serious under-estimation of cardiovascular disease (CVD) risk in that individual.

Advise patients the following: if you do go down with a cold, flu or any other illness…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or diabetes clinic.
  • Insulin or diabetes medications
      • Keep taking your insulin or diabetes medications even if you are not eating. Stop metformin and blood pressure medication if you are dehydrated.  CONSIDER AKI SICK DAY RULES – see hypertension protocol.
  • Testing
      • Test your blood or urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Ketoacidosis
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
  • Testing for ketones
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
  • Food and drink
      • It is important to keep taking your medication as normal and drink plenty of sugar-free drinks. Aim to drink at least three litres (five pints) a day. Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down
  • Renal function goes down as we age.  It is a naturally ageing process and does not necessarily equate with morbidity and mortality in the elderly.
  • Therefore the care of elderly people with CKD requires an individualised approach taking into account
      1. comorbidities,
      2. functional status
      3. life expectancy and 
      4. health priorities.

What if ACE inhibitor or ARB reduces eGFR further?

  • ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that’s how they work!). 
  • As a result GFR can decline when treatment is initiated.
  • After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.
  • If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB 
  • If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB.  Refer to a nephrologist.

Diabetes in pregnancy is associated with risks to the woman and the developing fetus.

Planning a pregnancy

Women planning a pregnancy should be referred to a diabetes pre-conception clinic.

Pre-pregnancy planning includes:

  • Diet and exercise, weight loss advised if body mass index > 27kg/m2
  • Retinal photography unless carried out in last 12months
  • Renal assessment (including microalbuminuria)
  • Folic acid 5mgs for 3 months preconception and continued for first trimester.
  • Establish rubella status, booster organised if required.
  • Blood pressure should be monitored
  • Smoking/alcohol cessation advice

Review of medications

  • Metformin may be used before and during pregnancy, as well as or instead of insulin.  The diabetes antenatal clinic will oversee their care whilst pregnant.
  • Isophane insulin is the first-choice long-acting insulin during pregnancy.
  • Discontinue oral hypoglycaemic agents (apart from metformin), ACE-inhibitors, Angiotensin Receptor Blockers and statins

Gestational diabetes

  • 6 weeks post-partum patients require a HbA1c to establish whether glucose tolerance has returned to normal.
  • All patients require advice on their elevated long term risk of diabetes.
  • All patients require advice on their risk of gestational diabetes in future pregnancies.
  • All patients require advice regarding diet, weight control and exercise

All patients require an ANNUAL HbA1c in view of their elevated risk of Type 2 diabetes. Please add an ‘AT RISK OF DIABETES’ recall to their notes.

Lifestyle changes for CKD

  • Consume a varied diet rich in vegetables, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, and low-fat dairy products.
  • Limit salt to <6g /day (≤100mmol/day).
  • Limit intake of foods containing saturated and trans fats.
  • Limit intake of foods containing added sugars.
  • Drink water to satisfy thirst.
  • Avoid high calorie sweetened carbonated beverages at all costs.
  • Dietary protein no lower than 0.75 g/kg body weight / day.
  • Ideal BMI ≤25
  • Waist circumference (MEN): <94cm (<90cm in Asian men)
  • Waist circumference (WOMEN): <80cm (including Asian women).
  • Be active on most, preferably all, days every week.
  • Accumulate 2 ½ to 5 hours of moderate intensity physical activity or
  • 1 ¼ to 2½ hours of vigorous intensity physical activity, or
  • an equivalent combination of both moderate and vigorous activities, each week.
  • Do muscle strengthening activities on at least 2 days each week.
  • Stop smoking using counselling and, if required nicotine replacement therapy or other medication.
  • Limit intake to ≤2 standard drinks per day to reduce risk of alcohol–related disease or injury over a lifetime.
  • Do not drink >4 standard drinks on any single occasion.

Medical Targets for CKD

  • <130/80 mmHg
  • prescribe ACE inhibitor or ARBs to get it under control

What if ACE inhibitor or ARB reduces eGFR further?

  • ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that’s how they work!). 
  • As a result GFR can decline when treatment is initiated.
  • After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.
  • If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB 
  • If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB.  Refer to a nephrologist.
  • Blood glucose levels (BGL): 6-8mmol/L fasting; 8-10 mmol/L postprandial.
  • HbA1c: generally ≤53 mmol/mol (range 48-58); ≤7% (range 6.5-7.5).
  • Needs individualisation according to patient circumstances e.g.
      • disease duration
      • established vascular complications
      • important comorbidities
      • life expectancy
  • aim for 50% reduction in urine ACR.
  • prescribe ACE inhibitor or ARBs to get it BP under control and slow the progression of albuminuria

What if ACE inhibitor or ARB reduces eGFR further?

  • ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that’s how they work!). 
  • As a result GFR can decline when treatment is initiated.
  • After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.
  • If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB 
  • If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB.  Refer to a nephrologist.
  • Use statin or statin/ezetimibe combination in people ≥50 years with any stage of CKD, or
  • in people <50 years with any stage of CKD in the presence of one or more of
      • coronary disease
      • previous ischaemic stroke
      • diabetes or
      • estimated high cardiovascular risk (>15% over 5 years
  • No target serum cholesterol level recommended.
  • keep to Hb 100-115g/L
  • If low, consider a trial of iron supplementation maintaining: Ferritin >100 µg/L.
  • Specialist may need to initiate erythropoietin stimulating agent (ESA).
      • Once ESA commenced, maintain: Ferritin 200-500 µg/L; TSAT 20-30%.
  • K+ ≤6.0 mmol/L.
  • Influenza and invasive pneumococcal disease vaccination recommended for all people with diabetes and / or ESKD.

Ramadan & Fasting Advice for Renal Disease

Fasting is an obligation for competent, healthy adult Muslims although there are exemptions. Many of those who could seek exemption might still want to fast. It is important to respect this but it is advisable to start planning 6-8 weeks before Ramadan to avoid adverse outcomes e.g. patient self-adjustment of medication.

The fast of Ramadan lasts from dawn to sunset for a period of 29 or 30 days. It follows the lunar calendar so is brought forward by about 10 days each year.   Fasting people generally eat two meals a day: often a smaller meal before dawn (Suhoor) and a larger one after sunset (Iftar).  No fluids or food are taken during daylight hours. This includes water and most medication.

Who is exempt from fasting?

  • Acute or chronic illness
  • Travellers
  • Pregnant/breastfeeding*
  • Menstruating/postpartum bleeding
  • Children
  • Mentally unwell/lacks capacity

*Consensus by Islamic scholars that it is permissible not to fast if there is threat of harm to mother/child

Permissible interventions/medications

  • Blood tests
  • Vaccinations
  • Asthma inhalers*
  • Ear drops*
  • Eye drops
  • Transdermal patches

*Difference of opinions exist. Encourage patients to contact their local imam, or BIMA for advice.

Should I advise my patient NOT to fast?

BIMA have an interactive traffic light tool that help to classify patients into low/moderate risk, high risk, and very high risk at 

Patients in the two higher tiers should be advised that they ‘must not fast’ and ‘should not fast’ respectively. Consider advising these patients to fast in the shorter winter months. If they insist to fast, monitor regularly and ask that they should be prepared to break the fast in case of adverse events. Below is a shortened summary of the advice:

MUST NOT FAST
V. HIGH RISK

  • All those on dialysis
  • CKD stage 4-5
  • CKD 3-5 with cardiovascular disease

SHOULD NOT FAST
HIGH RISK

  • CKD 1-3 but unstable disease (rapidly declining GFR/fluid overload/frail)
  • CKD with electrolyte abnormality
  • Those on fluid restriction

INDIVIDUAL DECISION - WHAT IS THEIR ABILITY TO TOLERATE IT - LOW RISK

  • CKD 1-3 with stable renal function

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