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Blood Pressure Control and
Treatment in the CKD Patient
Horacio E. Adrogue, MDJames M. Atkins, MD
Chester H. Fox, MD, FAAFPJacqueline Nolen, PharmD
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TMF Health Quality Institute
TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For nearly 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.
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Disclaimer
• Neither Horacio E. Adrogue, MD, James Atkins, MD, Chet Fox, MD, Jacqueline Nolen, PharmD nor TMF Health Quality Institute have any relevant financial relationships to disclose.
• TMF Health Quality Institute does not accept commercial support from other organizations or companies for the development of Continuing Medical/Nursing Education activities.
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Continuing Medical Education• TMF Health Quality Institute is accredited by
the Texas Medical Association to provide continuing medical education for physicians.
• TMF Health Quality Institute designates this education activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
• This course has been designated by TMF Health Quality Institute for 1.0 credits of education in medical ethics and/or professional responsibility.
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Continuing Nursing Education• TMF Health Quality Institute is an
approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
• This educational activity has been awarded 1.5 contact hour(s).
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Objectives1. Discuss the key points in the treatment of
Chronic Kidney disease2. Explain the evidence-based treatment for
blood pressure control and reduction of proteinuria among patients with diabetes, hypertension, and/or kidney disease
3. Define medication therapies for blood pressure control
4. Interpret therapy and titration guidelines for angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blocking (ARB) agents
5. Acknowledge potential side-effects and impacts on lab values for patients with diabetes, hypertension, and/or kidney disease
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CKD is a Coronary Disease Equivalent
• Two New England Journal publications indicate that Cardiovascular survival is directly related to a patient’s kidney function!!
NS Anavekar, et al. N Engl J Med 2004;351:1285-95AS Go, et al. N Engl J Med 2004;351:1295-305
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THE KIDNEY COMPASS“Get Your Bearings on
Kidney Disease”
SAVE YOUR KIDNEYS AND SAVE YOUR HEART
Diabetes
HYPERTENSION/ PROTEINURIA
AnemiaBone Disease CKD
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KEY POINTS IN: Diagnosis Recognition of
Complications Medication Safety Treatment Preparation for
Vascular Access When to Refer
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Case Vignette GD is a 63 year old African American
female with poorly controlled HTN, DM, increased lipids, obesity, GERD , gout, and sleep apnea. She has not had an MI (yet) She smokes ½ PPD
Meds include Amlodipine 10 qd, HCTZ 25 qd, Clonidine 0.3 bid, Atorvastatin 10, Metoprolol 100 bid, Insulin glargine 30 at HS, Metformin 1000 po bid, Allopurinol 300 qd, L, Omeparazole 20 qd, and CPAP at 12 cm
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Case continued BP is 150/86; Labs: HbA1C is 10.4; Hb is 9.5,
HDL is 35, LDL is 115, triglycerides are 295; Ca is 9.8; Microalbumin/creatinine ratio is 54.5; Creatinine is 1.7: GFR = 39
GD has stage 3 CKD and most of it’s complications.
What should we do for this patient?
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Diagnosis
Urinalysis is normal Microalbumin/Creatinine >30 GFR < 60 GD has Stage 3 CKD
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She also has all the complications
HYPERTENSION/ PROTEINURIA
Bone Disease Anemia
Diabetes
KIDNEY DZ
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MEDICATION REVIEW There are meds that are
dangerous to her: We stop them or modify dose• Metformin can cause
lactic acidosis GD is taking OTC NSAIDS
for her back pain• We stop this and all
NSAIDS We avoid
Bisphosphonates
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What should we do for the Hypertension?
ACE is added to reduce proteinuria• GFR decreases to 32 but
stays there. Creat is 2.1• K+ is good at 4.0• We leave her on the ACE
Her BP goes down to 130/70
We stop her clonidine as it is no longer need
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For Her Diabetes• She starts a diet and
exercise program– We encourage patient
centered goal setting (Motivational Interviewing)
• We intensify her insulin regimen
• We add Sitagliptin or glypizide to her insulin
• Her HbA1C drops to 6.8 over 6 months
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We Protect her Heart We increase her statin to
Simvastatin 80 mg qd We start ASA 81 mg qd We give her the ACS quit
smoking line number We add Niaspan 500 qd
or Omega 3’s 500 tid to raise HDL and decrease Triglycerides
She quits smoking, Her HDL is now 43, LDL 68 and Triglycerides 130
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For Her Anemia Colonoscopy is normal MCV is nl at 85 Fe is 50; TIBC is 200 for a saturation of
25% We start darbepoeitin 40 ug or
Erythropoieitin 10,000 units q 2 weeks We start oral iron √CBC ,Fe/TIBC monthly. We hold EPO if
Hb > 12.0 Hb rises to 11.5 and she feels much
better Transferrin saturations stay normal at
above 20%
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We preserve her Blood Vessels We remember
“Fistulas first and Catheters Kill”
We tell her to “save an arm” for blood draws
We refuse to allow any PICC lines to be put in when GFR < 45.
We refer her to nephrology when GFR < 30
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Our Patient Does Well She does not have a heart
attack Her kidney disease
stabilizes She feels better and has
more energy We delay the need for
dialysis She does not get a hip
fracture If she does progress, she
will be referred early
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Most Important PointsEvidence Based
Use GFR, Urine Microalbumin to diagnose CKD If GFR < 60 or Microalbumin/creat > 30 start
ACE (If cough on ACE, start ARB) Avoid NSAIDS Refer to Nephrology for GFR < 30 Promote smoking cessation Keep BP < 130/80 Keep HbA1C < 7.0 Keep LDL < 100 Avoid PICC lines for GFR < 45
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Other Important Points Strong Consensus based
Check Calcium, Phosphorous, PTH, and Vit D
Check Hemoglobin If iron is normal, start erythropoietin if
Hb< 10 or refer to Nephrology Refer to Nephrology for Phosphorous >4.5
or PTH > 100
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Referral Guidelines GFR< 30 Rapidly deteriorating kidney
function Difficult-to-control hypertension PTH > 100 or Phosphate > 4.5 GFR < 20; Refer for Transplant
evaluation
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Chet Fox, MD, FAAFP
• Contact Info
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Evaluation/CE requirements
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Thank you for your attention!
TMF Health Quality Institutehttp://KidneyHealth.tmf.org 1-866-439-8863
The National Kidney Foundation Kidney Kidney Disease Outcomes Quality Initiative (NKF KDOQI) http://www.kidney.org/professionals/KDOQI/
The Chronic Kidney Disease Task Force512-458-7200