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� Chronic Kidney Disease -‐ Arasu Gopinath, MD
October 31st 2014
Update in Medicine and Primary Care
• Objec;ves
1. Why focus on CKD (2013 data) 2. Define CKD (KDIGO) 3. Staging/ Classifica;on CKD (KDIGO) 4. Iden;fy risks for developing CKD and for its
progression 5. Who to refer and when 6. When not to refer 7. Case scenarios
• Effect of kidney func;on on homeosta;c processes
• CKD is a worldwide public health problem
Global Kidney Disease series, The Lancet Vol 382 July 2013
Prevalence data by country
• WHY FOCUS ON CKD?
• Many systemic diseases lead to CKD
CKD reduces life expectancy
• WHY FOCUS ON CKD? CKD increases mortality
CKD increases morbidity CKD increases costs
Case 1
57 Yr old W male without PMH
• Presents with several weeks of feeling poorly but no other localizing symptoms
• No medica;ons • PMH-‐ nega;ve • Exam reveals HTN 165/90 but is otherwise non-‐focal
• Labs-‐ Creat 1.5 WBC 9K Hgb-‐11 eGFR-‐50 ml/min
• U/A 2+ blood and 2+ protein
What would you do next?
A. Probable CKD. schedule FU in 3 month to repeat labs and confirm diagnosis
B. Probable CKD start lisinopril 20mg per day for HTN and proteinuria
C. Referral to Urology for evalua;on of hematuria D. Obtain old baseline labs and if not available
assume possible AKI given overall presenta;on E. Treat with ciprofloxacin for probable UTI
What would you do next?
A. Probable CKD. schedule FU in 3 month to repeat labs and confirm diagnosis
B. Probable CKD start lisinopril 20mg per day for HTN and proteinuria
C. Referral to Urology for evalua;on of hematuria D. Obtain old baseline labs and if not available
assume possible AKI given overall presenta;on E. Treat with ciprofloxacin for probable UTI
This is not CKD! • Baseline labs reveal Creat 0.9 in 2011 • Worrisome features include
– New onset HTN – Proteinuria – Hematuria (urine micro reveals RBC casts)
• Presenta;on most consistent with probable AKI and nephri;c syndrome
• Urgent referral to Nephrology is warranted • Renal Bx-‐ Pauci-‐immune GN • Treated appropriately baseline renal func;on now normal over 2 years out
• DEFINITION OF CKD
KDIGO (2012) -‐ Kidney Disease Improving Global Outcomes
KDOQI (2002) - Kidney Disease Outcomes Quality Initiative
• KDIGO 2012
KDIGO 2012
es;ma;ng GFR
Es;ma;ng GFR
Case 2
75 YO W F with PMH significant for HTN
• Presents for annual follow-‐up; asymptoma;c • PMH-‐ HTN well controlled for 5 yrs; Hypothyroidism
• Medica;ons-‐ synthroid; amlodipine • Exam BP 138/90 normal exam, no edema • Labs-‐ K 5.0 Creat 1.1 eGFR-‐49mL/min • U/A-‐ normal; no proteinuria • Review baseline labs demonstrates Creat 1.1 2012 • Normal UA 2012
1. What would you do next?
A. Diagnose CKD category G3a and obtain urinary albumin/creat to fully categorize
B. Obtain renal ultrasound to rule out obstruc;on
C. Obtain ANA, ANCA, C3/C4 and an; GBM ab D. Non-‐urgent referral to Nephrology E. All of the above
1. What would you do next?
A. Diagnose CKD category G3a and obtain urinary albumin/creat to fully categorize
B. Obtain renal ultrasound to rule out obstruc;on
C. Obtain ANA, ANCA, C3/C4 and an; GBM ab D. Non-‐urgent referral to Nephrology E. All of the above
• Why divide CKD into 3a and 3b
Addi;onal Labs…
� UACR-‐ 70 mg/g � Calcium 8.5 � Phos-‐3.8 � Bicarb-‐24 � Albumin-‐ 4.0
2. Would you improve her hypertension management? A. Add HCTZ 25mg daily to improve BP control
goal BP <130/80 B. Stop Amlodipine and start Losartan 50mg
daily to protect kidneys C. Stop Amlodipine and start Diovan/Tekturna D. Add Lisinopril 20 mg per day to current
regimen E. No change, con;nue Amlodipine, Goal BP
<150/90
2. Would you improve her hypertension management? A. Add HCTZ 25mg daily to improve BP control
goal BP <130/80 B. Stop Amlodipine and start Losartan 50mg
daily to protect kidneys C. Stop Amlodipine and start Diovan/Tekturna D. Add Lisinopril 20 mg per day to current
regimen E. No change, con;nue Amlodipine, Goal BP
<150/90
3. What diet should she be on?
A. Renal diet B. Low potassium diet C. Low phosphorus diet D. Low protein diet E. 2 gm sodium without other restric;ons
3. What diet should she be on?
A. Renal diet B. Low potassium diet C. Low phosphorus diet D. Low protein diet E. 2 gm sodium without other restric;ons
5. Will this pa;ent benefit from Nephrology referral? • No • reduc;on in eGFR is age and possibly hypertension related
• Mainstay of therapy is BP control (goal <150/90)
• Recommend a low salt diet • Annual FU with PCP most appropriate • Her risk for progressive kidney failure is extremely low ( < 1 % in 5 yr)
WHEN TO REFER TO NEPHROLOGY
� eGFR < 30ml/min � albuminuria >300mg/g or proteinuria >500mg/24hrs
� progression of CKD
WHEN ELSE TO REFER
• AKI or abrupt fall in GFR • Red cell casts • CKD and refractory hypertension • Persistent abnormali;es of Potassium • Recurrent or extensive nephrolithiasis • Hereditary kidney disease • Risk of CKD to ESRD is 10-‐20% in the next year
4. What is her risk for progression to ESRD ?
A. 2 year-‐ 15%; 5 year-‐80% B. 2 year-‐ 10%; 5 year-‐60% C. 2 year-‐ 5%; 5 year-‐ 20% D. 2 year-‐ <1%; 5 year -‐ <1% E. Unknown risk
4. What is her risk for progression to ESRD ?
A. 2 year-‐ 15%; 5 year-‐80% B. 2 year-‐ 10%; 5 year-‐60% C. 2 year-‐ 5%; 5 year-‐ 20% D. 2 year-‐ <1%; 5 year -‐ <1% E. Unknown risk
• KIDNEY FAILURE RISK EQUATION
A Predictive Model for Progression of Chronic Kidney Disease to Kidney Failure - (Levey et al) JAMA. 2011;305(15):1553-1559.
2 & 5 yr risk calculation @ QxMD.com
What is her risk for progression to ESRD ?
Iden;fying risk for CKD progression
Case 3
52 Yr Hispanic female • PMH-‐ DM2 with re;nopathy; HTN; obesity • Family History – posi;ve for kidney failure requiring dialysis in mother and brother
• Medica;ons-‐ lisinopril 40 mg; merormin 1gm bid; ibuprofen for arthri;s; fenofibrate 145 mg
• Exam-‐ BP 168/90; BMI-‐38 • 2-‐3+ edema • Creat-‐1.4; eGFR-‐43ml/min; K-‐5.2; Bicarb 17 • U/A-‐ trace blood; 2+ protein • Creat 1.5 2013
Next Steps?
A. Obtain addi;onal labs to fully categorize CKD and determine risk
B. Diagnose CKD presumed secondary to diabe;c nephropathy G3A3 and schedule FU in 1 year
C. Stop Merormin given reduced eGFR and add Actos
D. Stop Fenofibrate and NSAID, adjust BP meds and reevaluate in 3 months
E. Obtain renal ultrasound to rule out obstruc;on
Next Steps?
A. Obtain addi;onal labs to fully categorize CKD and determine risk
B. Diagnose CKD presumed secondary to diabe;c nephropathy G3A3 and schedule FU in 1 year
C. Stop Merormin given reduced eGFR and add Actos
D. Stop Fenofibrate and NSAID, adjust BP meds and reevaluate in 3 months
E. Obtain renal ultrasound to rule out obstruc;on
Addi;onal Labs…
• UACR-‐ 2800mg/gm • Calcium 8.2 • Phos-‐5.0 • Bicarb-‐17 • Albumin-‐ 3.2 • Hgb-‐ 9.8 • PTHi 248
What is her risk for progressing to ESRD?
A. Cannot calculate has to be G4 or higher B. 2yr-‐5 %; 5 yr-‐ 20% C. 2yr-‐ 8%; 5yr-‐ 30% D. 2yr-‐ 15%; 5yr-‐ 40% E. 2yr-‐ 40%; 5 yr-‐ 90%
What is her risk for progressing to ESRD?
A. Cannot calculate has to be G4 or higher B. 2yr-‐5 %; 5 yr-‐ 20% C. 2yr-‐ 8%; 5yr-‐ 30% D. 2yr-‐ 15%; 5yr-‐ 40% E. 2yr-‐ 40%; 5 yr-‐ 90%
What is her risk of progressing to ESRD?
RISK FACTORS FOR CKD
Poten;al risk factors for developing CKD
Family History of ESRD
• Diabe;c pa;ents with a posi;ve family history for Diabetes and ESRD
– Albuminuria was present in 46% – Only 1/3 had adequate BP control (<130/80) – Only 58% were receiving ACEI or ARB’s – Poor glycemic control and smoking were also common
• Especially true for Ethnic minori;es
How would you manage her BP?
A. Stop Lisinopril given hyperkalemia (5.2) B. Add Chlorthalidone 25 mg per day Goal <
130/80 and see frequently un;l at goal C. Add Amlodipine 10 mg daily D. Add Losartan 100 mg daily (ONTARGET, ALTITUDE, VA
NEPHRON-‐D) E. Add Spirinolactone 25 mg daily
How would you manage her BP?
A. Stop Lisinopril given hyperkalemia (5.2) B. Add Chlorthalidone 25 mg per day Goal <
130/80 and see frequently un;l at goal C. Add Amlodipine 10 mg daily D. Add Losartan 100 mg daily E. Add Spirinolactone 25 mg daily
CKD complica;ons
• Hypertension • Anemia • Mineral Bone disorder • Acidosis • Hyperkalemia • Volume overload • Cardiovascular disease • Malnutri;on • Drug toxicity
CKD complica;ons
How would you treat her acidosis?
A. Add sodium bicarbonate 1300 mg bid for target bicarb 24
B. Low protein diet 0.8 gm/kg per day with mostly plant based proteins
C. Add fludrocor;sone 0.1 mg bid for RTA D. Add lasix 20 mg bid E. Both A&B
How would you treat her acidosis?
A. Add sodium bicarbonate 1300 mg bid for target bicarb 24
B. Low protein diet 0.8 gm/kg per day with mostly plant based proteins
C. Add fludrocor;sone 0.1 mg bid for RTA D. Add lasix 20 mg bid E. Both A&B
Acidosis
• Normal acid produc;on: 1 mEq/kg/day. • In CKD, kidneys are unable to excrete this amount due to :
– Reduced ammoniagenesis – Reduced filtra;on of ;tratable acids (sulfates, phosphates etc)
– Reduced proximal tubule bicarb reabsopr;on – Buffer therefore is oven phosphates and carbonates from the bone
– Chronic acidosis leads to bone demineraliza;on • Treat if serum bicarbonate < 22 mmol/ l • Oral bicarbonate supplements including Baking Soda (1 tsp =
60 mEq of bicarb)
Copyright ©2009 American Society of Nephrology de Brito-Ashurst, I. et al. J Am Soc Nephrol 2009;20:2075-2084
Figure 3. Kaplan-Meier analysis to assess the probability of reaching ESRD for the two groups
How do you manage her anemia?
A. Check iron stores and if sugges;ve of rela;ve iron deficiency-‐ add oral iron and follow
B. Transfuse 1 unit PRBC C. Start ESA and ;trate dose to target Hgb 13-‐14 D. Start ESA and ;trate dose to target Hgb 10-‐11 E. Recommend liver smothered in onions for
breakfast at least 3 ;mes per week
How do you manage her anemia?
A. Check iron stores and if sugges;ve of rela;ve iron deficiency-‐ add oral iron and follow
B. Transfuse 1 unit PRBC C. Start ESA and ;trate dose to target Hgb 13-‐14 D. Start ESA and ;trate dose to target Hgb 10-‐11 E. Recommend liver smothered in onions for
breakfast at least 3 ;mes per week
Anemia in CKD • Hgb < 13 g/dl in men, < 12 g/dl in women • Check annually if eGFR <30-‐59 ml/min/1.73 sq.m. • Check at least twice a year in eGFR < 30 ml/min/1.73 sq.m. • EPO level not necessary if CKD stage III or higher. • Rule out iron deficiency
– Ferri;n > 100 and/or Trans Sat > 20% – If either low give iron unless ferri;n >800. – Low threshold for IV iron – Oven anemia will correct with iron supplementa;on and will not require ESA.
How to slow progression of kidney failure?
A. Correct metabolic acidosis B. More plant protein, less red meat C. Correct Anemia D. Diabetes control goal A1C <7.0% E. BP control goal <140/90 (?<130/80) F. A & B G. D & E H. All of the above. I. All of the above except C.
How to slow progression of kidney failure?
A. Correct metabolic acidosis B. More plant protein, less red meat C. Correct Anemia D. Diabetes control goal A1C <7.0% E. BP control goal <140/90 (?<130/80) F. A & B G. D & E H. All of the above. I. All of the above except C.
Delaying CKD progression • BP control and RAAS blockade • Limi;ng protein intake • Glycemic control • Avoiding AKI • Salt intake • Hyperuricemia (insufficient evidence) • Lifestyle changes
Would she benefit from Nephrology referral ?
• Yes • She is high risk for progressive kidney failure • Her risk may be higher than calculated given her ethnicity and posi;ve family history
• she has mul;ple complica;ons of CKD
What can Nephrology do for you/her?
• Co-‐manage HTN • Help manage CKD complica;ons • Educate, Educate, Educate about CKD and her risk for progressive kidney failure
• Planning for “right start dialysis” • More u;liza;on of Peritoneal Dialysis
– Less cost to the system – Probable bezer outcomes in the first 2 years
• Timely referral for transplant
Planning for a Vascular Access • eGFR 30-‐59 ml/min (Cr ~ 1.5 -‐ 3 mg/dL)
– Preserve Access Sites ü Inform pa;ent not to allow venipuncture in non-‐dominant arm ü Avoid central lines ü No PICC lines
• Establish communica;on between nephrologist and PCP • Refer to surgeon for fistula when eGFR <25, or dialysis
an;cipated within 1 year • Fistula may take 3 to 4 months to mature • May not be needed for those who choose PD and are
transplant candidates
Cardiovascular disease
� CKD pa;ents = highest CVD risk category
� CVD risk factors accelerate CKD
� CKD uniquely exacerbates CVD
� Most CKD pa;ents die of CVD before ESRD
� Majority of new ESRD pa;ents have CVD
� CKD pts need treatment for CVD risk reduc;on
Probability of death aver AMI by CKD status
2010
Jan. 1 pt. prev. Medicare pts. age 66 & older; first CVD diag. in 2007–2008.
Probability of death aver CVA/TIA
Jan. 1 pt. prev. Medicare pts. age 66 & older; first CVD diag. in 2007–2008.
CKD-‐Mineral Bone Disorder
CKD-‐Mineral Bone Disorder
CKD-‐Mineral Bone Disorder
Mineral Bone disorder
• Check serum Ca, Phos, PTHi and Alkaline Phosphatase at least once when eGFR < 45 ml/min/1.73 sq.m.
• Avoid rou;ne bone mineral density tes;ng in eGFR < 45 ml/min/1.73 sq.m.
• Avoid bisphosphonates in eGFR < 30 ml/min/1.73 sq.m. • When PTHi is high, screen for hyperphosphatemia,
hypocalcemia or Vitamin D deficiency.
Timing of Dialysis
• Mostly symptom driven – Not simply based on eGFR
• Usual indica;ons such as hyperkalemia or fluid overload unresponsive to medical management
• No survival benefit to “early ini;a;on” • Increased risk for death if proper vascular access not in place
• Most pa;ents know when it is ;me based on symptoms – Flu that does not go away – ? Improved compliance
Uremia
83
0
3
6
9
12
15
18
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Months pre- & post-initiation
PPPM
exp
endi
ture
s ($
, in
1,00
0s)
Medicare FFS
The Basis for the Integrated Care Strategy
Opportuni;es for Improving Outcomes and Cost
Slow CKD Progression
Prepare for Dialysis (50% crash into dialysis)
Smoother Transition into Dialysis (>30% mortality)
Manage Hospitalizations
(55% potentially avoidable)
Late Stage CKD Incident ESRD
Prevalent ESRD
84
Clear Early Risk Prepara;on is Paramount
Implementa;on of a CKD Checklist for Primary Care Providers
Clin J Am Soc Nephrol 9: 1526–1535, 2014 (Mendu et al)
Implementa;on of a CKD Checklist for Primary Care Providers
Clin J Am Soc Nephrol 9: 1526–1535, 2014 (Mendu et al)
Implementa;on of a CKD Checklist for Primary Care Providers
Dos and don’ts in CKD • Use RAAS blockade when indicated • Preserve veins in non dominant arm • Avoid PICC and Mid lines where possible, esp in stages G4-‐5 • Avoid NSAIDs • Minimize contrast use and take appropriate precau;ons
when contrast is to be administered in stages G3-‐5 • Avoid Gadolinum for MRI in stage G4-‐5 • Minimize blood draws (coordinate with others where
possible) • Do not limit protein intake if malnourished
Summary
-‐ Screen when risk factors are present -‐ Stage appropriately -‐ Resolve AKI and minimize risk for AKI -‐ Treat factors associated with progression -‐ Manage Cardiovascular risk -‐ Follow dos and don’ts -‐ Refer on ;me
PCP – Nephrology partnership
• One quarter of pa;ents > age 60 have been iden;fied as having CKD G3 or worse – 8-‐9 million pa;ents – Not enough nephrologists to staff all pa;ents – Most will die before reaching ESRD – CKD G3b or worse will need management of comorbidi;es and their increased CKD induced CVD risk
– The PCP is essen;al in the care of CKD pa;ents
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