chronic kidney disease for the general internist

CHRONIC KIDNEY DISEASE FOR THE GENERAL INTERNIST

Selma Durakovic & Parker Gregg

Learning Objectives

How do you diagnose CKD?

What is the basic workup of CKD in the primary care setting?

What do you monitor in your patients who have CKD?

When do you refer your patient to nephrology?

63 M, IMMIGRANT FROM ETHIOPIA (IN 2008)

8/2013 – Cr 1.3, eGFR 56, HbA1c 7.8% – LOST TO FOLLOW UP

PMH: DM 2 WITH RETINOPATHY, HTN, AND HLD

2/2014 – BP 148/95, Cr 1.4, eGFR 51

NEW PATIENT IN PCC

DOES HE HAVE CHRONIC KIDNEY DISEASE?

Chronic Kidney Disease≥ 3 months

Renal Abnormalities– Functional

- eGFR < 60 mL/min/1.73m2

OR

– Structural - Kidney damage (albuminuria, cystic

changes, etc)- “Catch all category” for any renal

abnormality

It is not all about GFR!

Staging: CKD and GFR

60

30

Staging: CKD and Albuminuria

30 300

Why is Albuminuria so Important?

Diagnosis Does the patient have albuminuria?

– YES: Think Diabetes OR Glomerular Disease– NO: HTN, cystic diseases, drug toxicites, TI disease, etc

Prognosis– Inversely related to prognosis

Management– Decrease the albuminuria and slow the progression of CKD

Can you diagnose CKD in a patient with a GFR of 95?

CKD Staging : Putting It All Together

*60

30

30 300

CKD – Primary Diagnoses

Prevalence?

73 Mil 31 Mil26 Mil

HTN DMCKDMore US Adults have CKD than DM!

CKD

Prevalence

HTN

DM

31 Mil U.S. Adults

44% due to DM28% due to HTN


PMH – DM2 WITH RETINOPATHY, HTN, AND HLD, TODAY WITH NEWLY DIAGNOSED CKD.

HE WANTS TO KNOW WHY HE HAS KIDNEY DISEASE AND WHAT CAN BE DONE ABOUT IT.

BACK TO OUR PATIENT

WHAT WORKUP SHOULD BE DONE FOR NEWLY DIAGNOSED CKD?

Learning Objectives





Workup for every patient with newly diagnosed CKD

baseline creatinine UA and ACR renal

ultrasound

What can you learn from the ultrasound?

“Medical Renal Disease”

Normal Ultrasound Renal Parenchymal Disease

Increased echogenicity

“Normal” length 11-14 cm

< 9 cm indicative of CKD

Thin cortex

Dilated Calyces

Cysts and Masses

Workup for every patient with newly diagnosed CKD

baseline creatinine UA and ACR renal

ultrasound

What other workup do you do for newly diagnosed CKD?

Category Differential Diagnosis Workup

Pre-renal physiology

Intrinsic renal vascular disease

Glomerular diseases

Intrinsic tubular and interstitial diseases

Obstructive nephropathy

Differential and Comprehensive Workup for CKD


Pre-renal physiology Heart failure, cirrhosis TTE, liver enzymes, liver US


Glomerular diseases







Hypertensive nephrosclerosis, RAS, renal artery dissection HTN, imaging as appropriate

Glomerular diseases








Glomerular diseases

Nephrotic or nephritic pattern and the associated Ddx for each

HIV, HBV, HCV, A1c, anti-GBM antibodies, ANA, ANCA, complements








Glomerular diseases




Myeloma cast nephropathy, PKD, nephrocalcinosis, sarcoid, Sjögren’s, NSAIDs

SPEP/UPEP with immunofixation, serum free light chains



Multiple myeloma/paraproteinemias can cause CKD in several ways:- Glomerular: amyloid, IG deposition- Tubular: cast nephropathy, Fanconi’s

syndrome- Interstitial: plasma cell infiltration,

interstitial nephritis

The following patients are at increased risk for multiple myeloma:- Over 40 w/o other cause of CKD- Other manifestations of MM

- Hypercalcemia- Bone Pain- Radiographic lesions- Anemia >> CKD





Glomerular diseases




Myeloma cast nephropathy, PKD, nephrocalcinosis, sarcoid, Sjögren’s, NSAIDs

SPEP/UPEP with immunofixation, serum free light chains


Prostatic disease, metastatic cancer, retroperitoneal fibrosis

Imaging and physical exam as appropriate



Pre-renal physiology

Intrinsic renal vascular disease HTN

Glomerular diseases


HIV, HBV, HCV, A1c


Myeloma cast nephropathy SPEP/UPEP with immunofixation, serum free light chains




LABS – Cr 1.8, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE SPEP/UPEP NORMAL

RENAL US – BILAT 8 CM KIDNEYS, 1.2 CM ECHOGENIC CORTEX

BACK TO OUR PATIENT

HOW DO YOU INTERPRET THIS ULTRASOUND?WHAT SEQUELAE OF CKD DO YOU WANT TO MONITOR?

Learning Objectives





CKD Sequelae – It’s as easy as ABC

• A – albuminuria, anemia

• B – blood pressure, bone health

• C – cholesterol

• D – diet/drug avoidance

• E – electrolytes

Albuminuria, Anemia

Albuminuria– Monitor ACR based on patient’s stage• Yearly if ACR < 300• Q6 months if ACR > 300

Anemia– EPO deficiency -> normochromic, normocytic– First step: exclude non-renal causes– Fe supplementation– Refer to start EPO at Hb < 10 g/dL

Blood pressure, Bone health

Blood pressure– <130/80 for diabetics– <140/90 for non-diabetics– Treat as you would: ACE, thiazide

Bone health– Vit D, calcium, PO4, PTH

– Follow calcium and PO4 with each visit

CholesterolSo … who doesn’t get a statin?

Age > 50eGFR > 60 with CKD eGFR < 60 & not on HD

Age 18-49 with CKD + ANY OF:

CADDMprior CVA10 year risk for CAD > 10%

Dialysis or Renal transplant?

Treatmentstatinstatin ± ezetimibe

statinstatinstatinstatin

Don’t start it! Don’t stop it!

Diet/Drug Avoidance

Diet– Low protein, Low salt

Drugs– NSAIDs– Aminoglycosides– Cocaine/illicits– Tobacco

Electrolytes

Hyperkalemia– Often severe when eGFR < 10 mL/min/1,73 m2

-or- – Impaired K+ metabolism (ACEi/ARB/NSAIDs)

Hyperphosphatemia– Excretion of PO4 drops as kidney function decreases– PTH is compensatory until ~ eGFR 30 mL/min/1,73 m2

Chronic Kidney Disease (.ckd)Diagnosis:Stage:Nephrology:Anemia:Bones:Cholesterol:Diet:Electrolytes:Dialysis:

Date, type, biopsy?ACR, eGFRConsult requiredHct, Fe panel, on EPO?Ca, PO4, Vit D, PTH Don’t start/stop if on HD or transplantLow protein, low salt, nutrition consultK+, on kayexelate?Access, schedule, plan for transplant


PMH – DM2 WITH RETINOPATHY, HTN, AND HLD

LABS – Cr 1.8, eGFR 45, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE Hct 39, K 4.8, Phos 5.1

BACK TO OUR PATIENT

WOULD YOU REFER TO NEPHROLOGY?

Learning Objectives





Refer sooner rather than later!

Delayed nephrology referral (<3-6 months prior to initiation of

dialysis)

Increased mortality

Preferably patients will should be referred 1 year prior to needing dialysis to allow them time to

choose their option, have a fistula placed and allow that fistula to mature, and get dialysis teaching.

When to Refer

Other Reasons to Refer

Refer to nephrology

Unclear etiology

Hematuria (> 3 RBC/hpf)

Rapid decline in

eGFR

Complications of CKD

A: anemiaB: bone/mineral disorders, resistant HTNE: electrolyte abnormalities

Take Home PointsKnow how to stage CKD based on GFR (30-60)

and albuminuria (30-300)

Tailor your workup to your patient

Monitor the ABCs

Early referral saves lives

Questions?

Sources• Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 38:

The Genitourinary Tract; Techniques and Anatomy. 2008. Accessed electronically 5 Feb 2014.• Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 39:

Renal Parenchymal Disease, Including Renal Failure, Renovascular Disease and Transplantation. Accessed electronically 5 Feb 2014.

• Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. 2012. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf

• KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease. Nov 2013. http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf

• National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, section on Approach to Chronic Kidney Disease Using These Guidelines. 2002. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p9_approach.htm

• National Kidney Foundation KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002. http://www.kidney.org/professionals/kdoqi/pdf/ckd_evaluation_classification_stratification.pdf

• Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2013. http://annals.org/article.aspx?articleid=1757302&resultClick=3

http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf

http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf

http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p9_approach.htm

http://www.kidney.org/professionals/kdoqi/pdf/ckd_evaluation_classification_stratification.pdf

http://annals.org/article.aspx?articleid=1757302&resultClick=3

http://annals.org/article.aspx?articleid=1757302&resultClick=3

chronic kidney disease for the general internist

Documents

progression of ckd

severe ckd

moderate ckd

gfr categories

normal gfr

basic workup of ckd

kidney abnormality

ti disease