‘clinical pearls’: updates in - island health...
TRANSCRIPT
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‘CLINICAL PEARLS’: UPDATES IN CHRONIC KIDNEY DISEASE
MANAGEMENT
Chronic Disease Management Forum
Feb. 3, 2010Gaylene Hargrove BSc MD FRCPC
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THE QUIZ
The recommended target hemoglobin for patients with CKD treated with Aranesp or EPO is:
A. 100 – 110 g/L
B. 110 – 120 g/L
C. 120 – 130 g/L
D. 130 – 140 g/L
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THE QUIZ
Special caution should be exercised when using Aranesp or EPO in the following patient groups:
A. Diagnosis of malignancy
B. Documented CVD
C. Uncontrolled HTN
D. All of the above
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THE QUIZ
Your patient has a serum potassium of 5.8; the following measures are indicated:
A. Referral to a renal dietitianB. Stop ACEI or ARB indefinitelyC. Initiate KayexalateD. Initiate a loop diuretic (if not already
taking)E. A,C, and D are correct
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THE QUIZ
Contraindications to peritoneal dialysis include the following:
A. Obesity
B. Cognitive dysfunction/dementia; spouse
competent/highly functional
C. Age > 80 y/o
D. Previous abdominal surgery
E. History of IBD, multiple surgeries,
adhesions, previous SBO
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OBJECTIVES
Discuss recent clinical trials and review current guidelines for anemia management in CKD pts.
Discuss approach to management of hyperkalemia in CKD patients.
Review aspects of peritoneal dialysis: new program initiatives in VIHA.
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ANEMIA MANAGEMENT IN CKD
Guiding principles: Significant anemia develops in patients with GFR < 40
mL/min, due to reduced erythropoietin production
Before recombinant EPO, patients required multiple PRBC transfusions to maintain Hgb
rEPO revolutionized patient care: improved QOL, reduced need for PRBC txn
Uncontrolled trials demonstrated improved CV outcomes, improved survival, and better QOL scores with Hgb >110 g/L
Therefore, we hypothesized that treating to normalize Hgb would improve outcomes even more……..
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ANEMIA MANAGEMENT IN CKD
Trial to Reduce CV Events with Aranesp Therapy (TREAT); Pfeffer, M et al. NEJM 2009
Objective: To determine whether treatment of low hemoglobin with darbepoetin(Aranesp) would reduce the risk of death and CV events and renal events in pts with Type 2 DM, CKD, and anemia
4038 pts; median eGFR 33-34 mL/min, baseline Hgb 104-105 g/L; Aranesp vs placebo (‘rescue’ Tx for placebo pt if Hgb < 90)
Target Hgb in treatment grp was 130 g/L; median F/U 29 mos
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ANEMIA MANAGEMENT IN CKD
TREAT trial, cont’d Results:
Treatment grp Hgb: 125 vs. 106 in placebo grp
No difference in death or nonfatal CV events between grps
No difference in death or ESRD
*Fatal/nonfatal stroke more likely in treatment grp (5.0% vs 2.6%, HR 1.92 P<0.0001)
Increased stroke risk not explained by higherSBP
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ANEMIA MANAGEMENT IN CKD
CHOIR Trial (Correction of anemia with EPO alpha in CKD); Singh et al. NEJM 2006
Trial halted after 16 months due to higher than expected CV event rate in higher target Hgb grp; both grps received EPO (not placebo-controlled)
Targets were 135 g/L vs 113 g/L
HR of CV events for higher Hgb grp 1.34, P=0.03
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ANEMIA MANAGEMENT IN CKD
Conclusions/Current Guidelines: Higher hemoglobin targets (greater than 130 g/L) in
pts with CKD treated with Aranesp or EPO are associated with a higher risk of CV events/stroke
Current recommended target hemoglobin:
110 – 120 g/L
NOT to exceed 130 g/L
Requires close monitoring (bloodwork q 1-3 mos)
Initiate ESA therapy when Hgb < 100 g/L
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HYPERKALEMIA IN CKD PTS
ETIOLOGY (usually multi-factorial): Low eGFR (over 90% extracellular K+ excreted via
renal mechanisms)
Dietary indiscretion
Drugs (impair renal K+ excretion): NSAIDs/COX-2 inhibitors
Septra/Bactrim
ACEI/ARB
Spironolactone, Triamterene
Cyclosporine, Tacrolimus (Transplant pts)
Extracellular shift (acidosis, insulin deficiency, cell lysis)
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HYPERKALEMIA IN CKD PTS
Management/approach depends on severity:
Severe (6.5 or greater)
Advise pt to go to ER; needs monitored bed
ACUTE Tx: IV Calcium, IV insulin/glucose, Salbutamol neb,
IV NaHCO3, PO Kayexalate, IV Furosemide
Moderate (5.6 – 6.4)
Obtain ECG, rpt labs
Hold culprit drugs, provide dietary counselling
Give Kayexalate (30 gm daily for 3 days, then PRN)
Start loop diuretic, or increase dose
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HYPERKALEMIA IN CKD PTS
Management, cont’d
Mild (5.1 – 5.5)
Dietary counselling
Diuretic
Usually no need to hold ACEI/ARB
*Ask about NSAID use, potassium-containing herbal Tx, OTC meds/supplements (in all cases)
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HYPERKALEMIA IN CKD PTS
When to ‘bail’ on ACEI/ARB therapy? ‘Life-threatening’ episode of hyperkalemia
Pt unable to comply with dietary restrictions
Associated acute drop in eGFR (>30%)
Documented bilateral renal artery stenosis (>70%)
Despite best efforts (dietary restriction, diuretic, Kayexalate), serum K+ > 5.6 (consistently)
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WHY DO PERITONEAL DIALYSIS?
PD is a ‘lifestyle’ choice:
Advantages:
Travel – limitless opportunities
Pts maintain independence, autonomy
Pts can maintain employment
No need for vascular access surgery
Disadvantages:
Pts should avoid swimming (esp. hot tubs)
Some pts (usually younger) may have body image issues
*NOTE: risk of peritonitis similar to risk of CVC-related bacteremia in hemodialysis pts
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WHO SHOULD NOT DO PD?
Absolute Contraindications:
Severe dementia, no committed caregiver
Morbid obesity, poor residual renal function
Unstable mental health disorder/psychiatric issues
‘No fixed address’ (need space to store supplies)
Severe liver disease with ascites, previous peritonitis
Hx of IBD, multiple surgeries, adhesions
Severe lung disease/oxygen-dependent; COPD or pulmonary fibrosis
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WHO SHOULD NOT DO PD?
Relative Contraindications:
Colostomy/Ileostomy/Urostomy (ileal conduit)
Severe visual impairment, no supports
Morbid obesity
Multiple previous abdominal surgeries, previous SBO due to adhesions
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NEW PROGRAM INITIATIVES
NAVIGATOR PROJECT (2008) Background
Only 17% if all VIHA dialysis pts are on PD
Findings of local study indicated 50% of pts on dialysis ‘parachute’ in (precipitous start, no prior education re: dialysis modalities)
Once on HD, many pts never received any educationregarding peritoneal dialysis as an option
Therefore, we proposed to pursue a project aimed to provide adequate education related to all RRT modalities, to enable pts to make independent choices to achieve the optimal modality
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NEW PROGRAM INITIATIVES
BEDSIDE PD CATHETER INSERTION Background
For past 10-15 yrs, only means of insertion for VIHA pts was surgical, under GA
Increasingly longer wait times for OR (up to 6 mos) identified as a barrier to pts ending up on PD as modality of choice
Three programs in BC have performed Bedside PD Catheter Insertion for 20-30 yrs; provincial study found these centers have much shorter wait times (1-4 weeks), equivalent (or less) complication rates, and more pts on PD (25-40%)
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NEW PROGRAM INITIATIVES
BEDSIDE PD CATHETER INSERTION Spring-Summer 2009: Project nurse worked toward
establishing standards of practice, set up protocols/order sets, established procedure room, ordered equipment/supplies
Sept-Oct 2009: Nurses trained, Dr. Hargrove trained
First four patients undergo procedure Oct 1-2
Nine pts to date; ‘successful’ in 8
Complications (all considered minor): Pericatheter leak in 2
Bleeding in one – procedure aborted, pt admitted O/N
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NEW PROGRAM INITIATIVES
BEDSIDE PD CATHETER INSERTION Advantages:
No GA – done under local anesthesia No need for admission – d/c home 2-4 hrs post Faster recovery time; diminished pain
*Contraindications: Pt requires hernia repair Colostomy/ileosomy Severe liver disease Morbid obesity Unstable mental health disorder Multiple previous abdominal surgeries
*These pts require referral to surgeon
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SUMMARY
ANEMIA MGMT IN CKD Current recommended target Hgb 110-120 g/L
Higher Hgb (>130 g/L) associated with adverse CV outcomes
HYPERKALEMIA In most cases, ACEI/ARB may be continued
Pts require dietary education, often a loop diuretic
PERITONEAL DIALYSIS An effective modality that may achieve better QOL
New initiatives: goal is to enable pts to pursue modality of choice, based on having received adequate education