Namita Singh MD FASN Year 2021 DISCLOSURES I have no financial relationships with commercial interests to disclose This presentation does not include discussion of offlabel or investigational use ID: 915417
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Slide1
Management of Chronic Kidney Disease (CKD)
Namita Singh, MD, FASN
Year 2021
Slide2DISCLOSURES
I have no financial relationships with commercial interests to disclose.
This presentation does not include discussion of off-label or investigational use.
Slide3Case Question 1
A 50-year-old Hispanic female was diagnosed with type 2 diabetes at age 30. She has taken medications as prescribed since diagnosis. The fact that she has confirmed diabetes puts this patient at:
A. Higher risk for kidney failure and CVD
B. Higher risk for kidney failure only
C. Higher risk for CVD only
D. None of the above
Slide4Case Question 2
A 50-year-old African American female was diagnosed with CKD. Her blood pressure is 150/85, her 24
hr
protein excretion in 1.5 g/day (normal less than 150 mg). What should be prescribed next?
A. Atenolol
B. Nifedipine
C. A diuretic e.g.
hydrochrolothiaze
25 mg/d
D. Lisinopril
Slide5What is CKD?
Slide6Kidney Disease in clinical terms
Test of renal function:
“estimated” glomerular filtration rate: “normal” varies according to age, sex, body size, and declines with age
Test of renal damage:
“protein” in the urine
Dipstick- semi-quantitative, screening only; affected by urine concentration
Urine protein/ creatinine ratio- All proteins (myeloma)
Urine albumin/ creatinine ratio- Standard for public health, clinical care, research
Slide7CKD Definition/ Criteria
Abnormalities of kidney structure or function, present for >3 months, with implications for health
Either of the following must be present for >3 months:
ACR >30 mg/g
Markers of kidney damage (one or more*)
GFR <60 mL/min/1.73 m
2
*Markers of kidney damage can include
nephrotic
syndrome, nephritic syndrome, tubular syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic radiologic abnormalities, hypertension due to kidney disease.
m²
National Kidney Foundation Kidney Disease Outcome Quality Initiative (KDOQI). Clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
Amer J Kid Dis
2002; 39(2 suppl 1):S18–S266.
Slide8Old Classification of CKD as Defined by Kidney Disease Outcomes Quality Initiative (KDOQI) Modified and Endorsed by KDIGO
Note: GFR is given in mL/min/1.73
2
m²
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(
suppl
1):S1-S266
Stage
Description
Classification by Severity
Classification by Treatment
1
Kidney damage with
normal or increased GFR
GFR ≥ 90
2
Kidney damage with
mild decrease in GFR
GFR of 60-89 T if kidney transplant3Moderate decrease in GFRGFR of 30-59 recipient4Severe decrease in GFRGFR of 15-29 D if dialysis5Kidney failureGFR < 15 D if dialysis
KDIGO, Kidney Disease: Increasing Global Outcomes
Slide9Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.
Kidney
Int
Suppls
. 2013;3:1-150.
Classification of CKD Based on GFR and Albuminuria Categories: “Heat Map”
Slide106.7%
6.6%
Slide courtesy Dr
Argyropoulos
Slide11ESRD, end stage renal disease.
USRDS ADR, 2007
Diabetes and Hypertension are Leading Causes of Kidney Failure
Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.
CKD Risk Factors*
Modifiable
Diabetes
Hypertension
History of AKI
Frequent NSAID use
Non-Modifiable
Family history of kidney disease, diabetes, or hypertension
Age 60 or older (GFR declines normally with age)
Race/U.S. ethnic minority status
*Partial list
AKI, acute kidney injury
Slide13Why do we care about CKD?
Slide14CKD as a Public Health Issue
26 million American affected
Prevalence is 11-13% of adult population in the US
28% of Medicare budget in 2013, up from 6.9% in 1993
$42 billion in 2013
Increases risk for all-cause mortality, CV mortality, kidney failure (ESRD), and other adverse outcomes.
6 fold increase in mortality rate with DM + CKD
Disproportionately affects African Americans and Hispanics
NKF Fact Sheets.
http://www.kidney.org/news/newsroom/factsheets/FastFacts
. Accessed Nov 5, 2014.
USRDS.
www.usrds.org
. Accessed Nov 5, 2014.
Coresh et al. JAMA. 2007. 298:2038-2047.
Slide15Functions of Kidneys
Maintain stability of “internal environment”
Filtration
Reabsorption
Secretion
Hormone function
Renin
Erythropoietin
Calcitriol
Metabolic function
Gluconeogenesis
Metabolize drugs and endogenous substances
Slide16Symptoms and Signs of Uremia
Signs
Nausea, vomiting, diarrhea
Platelet dysfunction (easy bruising)
Dyspnea, edema, chest pain
Uremic fetor
Restless legs, twitching, confusion
Hypertension
Pruritis, bruising. Uremic frost
Pericardial rub
Bone pain, arthritis
Neuropathy
Alteration of consciousness
Sodium imbalance in CKD
Slide courtesy Dr
Argyropoulos
Slide17Management of CKD (from a PCP perspective)
CKD is Part of Primary Care
Slide18Case Question 3
A 50-year-old African American female was diagnosed with type 2 diabetes. Her blood pressure is 150/85 and her urine albumin to creatinine ratio is 85 mg Alb/g Cr (normal <20). Her hemoglobin A1c is 6.9%. What should be prescribed next?
A. Insulin
B. Metformin
C. A diuretic e.g.
hydrochrolothiaze
25 mg/d
D. Losartan
E. A “
flozin
”
Slide19Hypertension Treatment in CKD
Threshold for starting therapy 140/90 mmHg
Goals of therapy < 130/80 mmHg
ACE-I or ARB first line for
CKD stage 3
CKD stage 1 and 2 with albuminuria > 300 mg/d
Slide20Slowing CKD Progression: ACEi
or
ARB
Risk/benefit should be carefully assessed in the elderly and medically fragile
Check labs after initiation
If less than 25%
SCr
increase, continue and monitor
If more than 25%
SCr
increase, stop
ACEi
and evaluate for RAS
Continue until contraindication arises, no absolute eGFR cutoffBetter proteinuria suppression with low Na diet and diureticsAvoid volume depletionAvoid ACEi and ARB in combination1,2Risk of adverse events (impaired kidney function, hyperkalemia)
Kunz R, et al.
Ann
Intern Med. 2008;148:30-48.Mann J, et al. ONTARGET study. Lancet. 2008;372:547-553.
Slide21Diabetes Management in CKD
Target HbA1c ~7.0%
Can be extended above 7.0% with comorbidities or limited life expectancy, and risk of hypoglycemia
Risk of hypoglycemia increases as kidney function becomes impaired
Guidelines for the treatment of patients with diabetes recommend
Target A1c of ~7%
Treat blood pressure in patients with proteinuria
Use an Angiotensin Receptor Blocker or an Angiotensin Converting Enzyme inhibitor to treat patients with proteinuria (albuminuria) and diabetes
Sodium Glucose Transporter 2 Inhibitors on top of Standard of Care
ACEi
/ARB
NKF KDOQI
. Diabetes and CKD: 2012 Update.
Am J Kidney Dis
. 2012 60:850-856.Kidney Int. 2012 Apr;81(7):674-83.
Slide22Modification of Other CVD Risk Factors in CKD
Smoking cessation
Exercise
Weight reduction to optimal targets
Lipid lowering therapy
In adults >50
yrs
, statin when eGFR ≥ 60 ml/min/1.73m
2
; statin or statin/ezetimibe combination when eGFR < 60 ml/min/1.73m
2
In adults < 50
yrs
, statin if history of known CAD, MI, DM, stroke
Aspirin is indicated for secondary but not primary prevention
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.
Kidney
Int
Suppls. 2013;3:1-150.
Slide23Interventions to Reduce Urine Albumin
Slide courtesy Dr
Argyropoulos
Slide24Medications and Hyperkalemia
Commonly prescribed
ACE-I
ARB
Used cautiously in CKD
Aldosterone antagonists
Renin inhibitors
Potassium-sparing diuretics
NSAIDS
Check Potassium:
ACEi
/ ARB/ Aldo antagonists/ Renin inhibitors within 7 days
K-sparing diuretics in CKD or diabetes within 3-7 days
Chobanian
et al. J AM Med Assoc 2003; 289(19): 2560-2571.
Slide25Management of Hyperkalemia
Reduce dietary potassium
Stop medications causing hyperkalemia
Stop or reduce beta-blockers,
ACEi
/ ARBs
Avoid salt substitutes that contain potassium
Use diuretics to increase renal potassium excretion
Use potassium binding resins (
patiromer
, sodium zirconium)
Slide26Management of Metabolic Acidosis
Usually occurs later in CKD
Serum bicarb >22mEq/L
Correction of metabolic acidosis may slow CKD progression and improve patients functional status
1,2
Mahajan, et al.
Kidney Int
. 2010;78:303-309.
de Brito-
Ashurst
I, et al.
J Am
Soc
Nephrol
. 2009;20:2075-2084.
Slide27Management of Anemia
Target Hb in CKD : 10 g/dL- 11.5 g/dL on treatment
Initiate iron therapy if TSAT ≤ 30% and ferritin ≤ 500 ng/mL (IV iron for dialysis, Oral for non-dialysis CKD)
Individualize erythropoiesis stimulating agent (ESA) therapy: Start ESA if Hb <10 g/dl, and maintain
Hb <11.5 g/dl. E
nsure adequate Fe stores.
Appropriate iron supplementation is needed for ESA to be effective
Slide28Management of CKD- Mineral and Bone Disorder (CKD- MBD)
Target levels:
Phosphorus < 5.5 mg/dL
Calcium > 7.5 mg/dL
PTH < 150
pg
/mL (varies with reference range)
Treat with D3 as indicated to achieve normal serum levels
2000 IU po
qd
is cheaper and better absorbed than 50,000 IU monthly dose.
Limit phosphorus in diet (CKD stage 4/5), with emphasis on decreasing packaged products - Refer to renal RD
May need phosphate binders
Slide29A Balanced Approach to Nutrition in CKD:
Macronutrient Composition and Mineral Content
Adapted from DASH (dietary approaches to stop hypertension) diet.
*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water fish, and poultry.
NKF KDOQI.
Am J Kidney Dis.
2007;49(suppl 2):S1-S179.
Slide30Case Question 4
A 75-year-old Caucasian female has a long standing history of CKD and HTN. She was last seen in the renal clinic six months ago and that time her BUN was 35 mg/dl and creatinine was 1.65 mg/dL. Four months ago she fell and broke her hip and she is currently using both opioids and over the counter analgesics for pain management. Her PCP saw her last week for a regular follow up. At that time she had a blood pressure of 185/95, 2+ pitting edema and was given furosemide 40 mg po bid. She is visiting with you today in the nephrologist clinic. Her blood pressure is 160/85, has trace lower extremity edema and her chem7 reveals a BUN of 90 mg/dL and creatinine of 2.5 mg/dL. What is the cause of the patient’s deterioration in renal function?
A. Over the counter acetaminophen
B. Opioids
C. Furosemide
D. Over the counter naproxen
E. C and D
Slide31Identification of Reversible Decreases in Renal Function in CKD
Decreased renal perfusion
(prerenal picture with BUN/Cr > 20)
Hypotension (myocardial dysfunction, pericarditis, CHF)
Volume depletion (vomiting, diarrhea, diuretic use)
Infection (sepsis)
Use of drugs that lower GFR (NSAIDs and ACEIs)
Administration of nephrotoxic drugs
Aminoglycoside antibiotics
Radiographic contrast material
Urinary tract obstruction
Slide courtesy Dr
Argyropoulos
Slide32CKD Patient Safety Issues
Medication errors
Toxicity (
nephrologic
or other)
Improper dosing
Inadequate monitoring
Electrolytes
Hyperkalemia
Hypoglycemia
Hypermagnesemia
Hyperphosphatemia
Miscellaneous
Multidrug-resistant infections
Vessel preservation/dialysis access
Fink JC, Brown J, Hsu, VD, et al.
Am J Kidney Dis
2009;53:681-668.
Slide33CKD Patient Safety Issues
Diagnostic tests
Iodinated contrast media: AKI
Gadolinium-based contrast: NSF
Sodium Phosphate bowel preparations: AKI, CKD
CVD
Missed diagnosis
Improper management
Fluid management
Hypotension
AKI
CHF exacerbation
AKI = acute kidney injury; CHF = congestive heart failure; NSF =
nephrogenic
systemic fibrosis.
Fink JC, Brown J, Hsu, VD, et al.
Am J Kidney Dis
2009;53:681-668..
Slide34Common Medications Requiring Dose Reduction in CKD
Allopurinol
Gabapentin
CKD 4- Max dose 300mg
qd
CKD 5- Max dose 300mg
qod
Reglan
Reduce 50% for
eGFR
< 40
Can cause irreversible EPS with chronic use
Narcotics
Methadone and fentanyl best for ESRD patients
Lowest risk of toxic metabolites
Renally cleared beta blockers
Atenolol,
bisoprolol, nadololDigoxinSome StatinsLovastatin, pravastatin, simvastatin. Fluvastatin, rosuvastatin
AntimicrobialsAntifungals, aminoglycosides, Bactrim, MacrobidEnoxaparinMethotrexateColchicine
Slide35Key Points on Medications in CKD
CKD patients at high risk for drug-related adverse events
Several classes of drugs
renally
eliminated
Consider kidney function and current
eGFR
(not just
SCr
) when prescribing meds
Minimize pill burden as much as possible
Remind CKD patients to avoid NSAIDs
No Dual RAAS blockade
Any med with >30% renal clearance probably needs dose adjustment for CKD
No bisphosphonates for eGFR <30Avoid GAD for eGFR <30
Slide36When to Refer?
Slide37Indications for Referral to Nephrology
Acute kidney injury or abrupt sustained fall in GFR
GFR <30 ml/min/1.73m
2
(GFR categories G4-G5)
Persistent albuminuria (ACR > 300 mg/g)
Atypical Progression
Hematuria (RBC casts, >20/
hpf
)
Refractory Hypertension (>4 or more antihypertensive agents)
Persistent abnormalities of serum potassium
Recurrent or extensive nephrolithiasis
Hereditary kidney disease
Slide38Kidney
damage and normal or
GFR
Kidney
damage and
mild
GFR
Severe
GFR
Kidney
failure
Moderate
GFR
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
NephrologistPrimary Care PractitionerThe Patient (always) and other subspecialists (as needed)GFR 90 60 30 15Who Should be Involved in the Patient Safety Approach to CKD?Patient safety Consult?
Slide39When to Discuss Dialysis And When Not in your >75 year old patient
Rosansky
et al. BMC
Nephrology
(2017) 18:200
Δ
eGFR
ml/min/1.73m2
Low Comorbidity
High Comorbidity
< 3
Conservative
Conservative
3-5
DialysisConservative
> 5
Dialysis
SDMAKIDialysisConservativeSlide courtesy Dr Argyropoulos
Slide40Case Question
5
A 42-year-old African American man with diabetic nephropathy and hypertension has a stable eGFR of 25 mL/min/1.73m
2
. Observational Studies of Early as compared to Late Nephrology Referral have demonstrated which of the following?
A. Reduced 1-year Mortality
B. Increase in Mean Hospital Days
C. No change in serum albumin at the initiation of dialysis or kidney transplantation
D. Decrease in hematocrit at the initiation of dialysis or kidney transplantation
E. Delayed referral for kidney transplantation
Slide41Observational Studies of Early vs. Late Nephrology Consultation
Chan M, et al.
Am J Med
. 2007;120:1063-1070.
http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS000293430700664X.pdf
KDIGO CKD Work Group.
Kidney
Int
Suppls
. 2013;3:1-150.
Slide42Take Home Points
PCPs play an important role
Identify risk factors
Know patient’s kidney function/ damage using appropriate screening tools
Help your patient adjust medication, avoid NSAIDs
Modify diet
Partner and refer to specialist
Slide43https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/managing
Slide44Thank you
Slide45Additional Online Resources for CKD Learning
National Kidney Foundation:
www.kidney.org
United States Renal Data Service:
www.usrds.org
CDC’s CKD Surveillance Project:
http://nccd.cdc.gov/ckd
National Kidney Disease Education Program (NKDEP):
http://nkdep.nih.gov