Management of Chronic Kidney Disease; Before the Nephrologist - PowerPoint Presentation

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Management of Chronic Kidney Disease; Before the Nephrologist

Stuart M

c

Adam, MD, FRCPC

General Internal Medicine

The Moncton Hospital

April 2022

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Conflicts of Interest

Nothing to disclose

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Objectives

Describe an approach to the work-up of chronic kidney disease (CKD)

Outline an approach to the management of CKD

Describe the indications for dialysis

Understand when you should refer to a Nephrologist

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Case

72 yo M referred for management of CKD

PMH: HTN, Diabetes, CKD, Smoker

Meds: Perindopril 4mg daily, Metformin 500mg BID, Semaglutide 0.5mg subcut weekly

Feels like he’s getting old, some mild edema

O/E : BP 148/70, HR 82, sats 96% RR 16, weight 70kg

Regular pulse, JVP 5cm, Normal S1/S2 no EHS or murmurs, lungs clear, abdo soft, non-tender, mild edema bilaterally

Labs: Na 133, K 4.8, HCO

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-18, Cl 100, Cr 150 (was 148 six months ago), Urea 6.8, GFR ~40ml/min/1.73cm2 WBC 9, HgB 98, Plts 230, Albumin 38, Calcium 2.20, Phos 1.10, PTH 7, Alk P 70, U ACR 300mg/g, A1c 7.0, ECHO Jan 2022 Diastolic dysfunction.

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Chronic Kidney Disease

CKD: Defined as abnormalities of kidney structure or function for >3 months

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Estimated 700 million people have CKD

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5

1.

KDIGO

Kidney Int 2013

2. Webster et al.

Lancet

2017

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CKD Work-Up

History

Exclude nephrotoxins

Risk factors (Diabetes, HTN, Smoking, Obesity, Family History, Age)

General review of systems

Physical

BP, Volume Status

Investigations

CBC, Lytes, Ext Lytes, HCO3, Cr, Urea, PTH, Alk P, Urinalysis, U ACR, Kidney U/S , Iron Studies, Lipid Profile, A1c

Further Investigations guided by situation may include: SPEP, Free light chains, ANCAs, Anti-GBM, ANA, Anti-dsDNA, C3, C4, HIV, Hep B, Hep C, Cryoglobulins, Kidney biopsy

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Management of CKD

Treat underlying cause

Treat risk factors: Ensure HTN, DM well controlled

Restrict sodium intake to <2g sodium/day

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*Key point*

Sodium increases BP and proteinuria, and blunts response to RAAS blockade

Lifestyle

150 minutes of moderate intensity exercise per week.

Healthy weight, No smokingRenally adjust medications, and avoid nephrotoxinsMultidisciplinary care teamManage complications

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1.

KDIGO

Kidney Int 2013

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Blood Pressure in CKD

ACE-I or ARB first line if proteinuric CKD

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Re-check lytes and Cr in about 2 weeks

Continue unless Cr increases >30% within 4 weeks

Sprint CKD Criteria GFR 20-59, <1g proteinuria/day or ACR<600mg/g

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If diabetic <130/80

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3. Rabi J .et al.

Canadian Journal of Cardiology

2020

4. The SPRINT Research Group.

N

Engl

J Med

2015

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Dyslipidemia in CKD5

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5. Pearson et al.

Canadian Journal of Cardiology

2021

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Management of Complications of CKD

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6.

Quaife

(n.d.)

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Hyperkalemia in CKD

Potassium restricted diet

Optimize acid-base status

Review medications that could contribute

Continue ACE-I/ARB if you can, but may need to reduce dose or stop

Add diuretic if indication

Potassium binders

Sodium Polystyrene Sulfonate (Kayexalate)

Patiromer Sorbitex Calcium (Veltassa) and Sodium Zirconium Cyclosilicate (Lokelma)

DialysisManagement acutely is separate

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Volume Overload

Target euvolemia

Sodium restriction

Diurese as needed to target euvolemia *Key Point*

Regardless of creatinine

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Anemia in CKD

Do usual work-up for anemia

Supplement iron if ferritin ≤ 500 and TSAT ≤ 30%

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*Key Point*

Suggest not using erythropoietin stimulating agent (ESA) if HgB ≥ 100

If HgB ≤ 100 despite optimizing iron stores, consider ESA after weighing risks and benefits

Suggest not targeting a HgB above 115 with ESA

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7.

KDIGO Anemia CKD.

Kidney Int 2012

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Acid Base in CKD

Target bicarbonate ≥ 22 with oral bicarbonate supplementation

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15.4 to 23.1

mEq

/day sodium bicarb in divided doses

Typically start around 500-650mg BID then titrate

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1.

KDIGO

Kidney Int 2013

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CKD Mineral and Bone Disorder

Target phosphate in normal range

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Phosphate binders

If hypercalcemic avoid ones containing calcium

Secondary hyperparathyroidism

Optimal PTH level not known

If persistently high look to optimize risk factors; hypocalcemia, hyperphosphatemia, vitamin D deficiency

Consider calcitriol in CKD stage 4-5 with severe and progressive hyperparathyroidism

Increased risk of osteoporosis

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1.

KDIGO

Kidney Int 2013

8. KDIGO CKD-BMD Kidney Int 2017

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Proteinuria

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9. McFarlane et al.

Can J Diabetes

2018

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Proteinuria

Non-diabetic CKD: ACE-I or ARB if albumin excretion >300mg/day

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Diabetic CKD: ACE-I or ARB if >30mg/day or ACR≥2mg/mmol

ACE-I and ARB are nephroprotective, reduce progression of CKD and proteinuria

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Monitor electrolytes and renal function, careful the lower the GFR

Sodium restricted diet <2g sodium/day

SGLT-2 inhibitors

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1.

KDIGO

Kidney Int 2013

10. Hou et al. NEJM 2006

11. Heerspink et al. NEJM 2020

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4303 participants with GFR 25 to 75 and urine ACR 200 to 5000 mg/g

Randomized to Dapagliflozin 10mg daily or placebo

All patients were on stable dose of ACE-I or ARB, unless unable

Primary Outcome sustained decline in GFR of at least 50%, ESRD, or death from renal or cardiovascular causes

Primary outcome in 9.2% Dapagliflozin vs 14.5% placebo, HR 0.61 p<0.001

Dapagliflozin discontinued in 12.7% vs 14.4% placebo, amputation rate 1.6% vs 1.8% placebo, major hypoglycemia 0.7% vs 1.3% placebo, no DKA with

Dapa

, volume depletion 5.9% vs 4.2% placebo (p=0.01)

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Heerspink

et al.

NEJM

2020

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11.

Heerspink

et al.

NEJM

2020

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4401 patients with GFR 30 to 89 and urine ACR 300 to 5000mg/g Canagliflozin 100mg daily or placebo

Were also treated with renin-angiotensin system blockade

Primary outcome ESRD, doubling of creatinine, or death from renal or cardiovascular causes

Primary outcome improved in canagliflozin, HR 0.70 p=0.00001No difference in amputations, there were higher rates of DKA with canagliflozin 0.5% vs 0.05%

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12.

Perkovic

V et al.

NEJM

2019

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12.

Perkovic

V et al.

NEJM

2019

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12.

Perkovic

V et al.

NEJM

2019

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Indications for Dialysis

AEIOU

– Refractory to medical management

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cidosis

E

lectrolyte abnormalities – hyperkalemiaIntoxication – certain toxicities

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verload – volume overload

Uremia – cognitive impairment, pruritis, loss of appetite, pericarditis

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1.

KDIGO

Kidney Int 2013

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When to refer to Nephrology in CKD

AKI or abrupt sustained fall in GFR

GFR < 30 cc/min/1.73 m

2

Consistent significant albuminuria (ACR ≥300mg/g or AER 300mg/day, approx. equal to PCR ≥500mg/g or PER ≥500mg/day

Progression of CKD

Urinary red cell casts, >20 RBCs per hpf sustained and not explained

CKD and HTN refractory to treatment with 4 or more antihypertensive agents

Persistent abnormalities of serum potassium

Recurrent or extensive nephrolithiasisHereditary Kidney DiseaseIndication for dialysis

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1.

KDIGO

Kidney Int 2013

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Back to the Case

72 yo M referred for management of CKD

PMH: HTN, Diabetes, CKD, Smoker

Meds: Perindopril 4mg daily, Metformin 500mg BID, Semaglutide 0.5mg subcut weekly

Feels like he’s getting old, some mild edema

O/E : BP 148/70, HR 82, sats 96% RR 16, weight 70kg

Regular pulse, JVP 5cm, Normal S1/S2 no EHS or murmurs, lungs clear, abdo soft, non-tender, mild edema bilaterally

Labs: Na 133, K 4.8, HCO

3

-18, Cl 100, Cr 150 (was 148 six months ago), Urea 6.8, GFR ~40ml/min/1.73cm2 WBC 9, HgB 98, Plts 230, Albumin 38, Calcium 2.20, Phos 1.10, PTH 7, Alk P 70, U ACR 300mg/g, A1c 7.0,. ECHO Jan 2022 Diastolic dysfunction.

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Case

Stage 3 CKD, likely from diabetes, hypertension

Order urinalysis, kidney U/S, SPEP

Treat risk factors: Target BP <130/80, DM control, quit smoking

Diet: Salt restrict <2g sodium /day. Education on low potassium diet

Edema: Diurese, start furosemide

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Case

Hypertension: Target <130/80, optimize fluid status, and perindopril, monitor lytes, renal function

Proteinuria: Optimize perindopril, SGLT2- Inhibitor in time

Acidosis: Start sodium bicarbonate

Anemia: Order usual work-up, optimize iron stores

Dyslipidemia: Order lipid profile, start statin

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Take Home Points

Sodium restrict patients with CKD

Optimize volume status, diurese as needed

ACE-I/ARB and SGLT2-I to reduce proteinuria, progression of CKD

Optimize iron stores in anemic patients

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References

1. Kidney Disease: Improving Global Outcomes (KDIGO) KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of Kidney Disease.

Kidney Int

. 2013; 3: 1-163

2. Webster AC,

Nagler

EV, Morton RL,

Masson P. Chronic kidney disease.

Lancet

2017; 389: 1238-52.3. Rabi D, McBrien K, Sapir-Pichhadze

R,

Nakhla

M, Ahmed S. Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Canadian Journal of Cardiology 2020; 36: 596-624 4. The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control.

N Engl J Med 2015; 373:2103-165. Pearson G, Thanassoulis G, Anderson T, Barry A, Couture P. 2021 CCS guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Canadian Journal of Cardiology 2021; 37: 1129-11506. Quaife, P. (n.d.). Retrieved March 16, 2022, from https://www.pinterest.co.uk/pin/564849978237603369/?mt=login 7. Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney Int. 2012; 2: 279-3358. Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD.

Kidney Int. 2017; 7:1-599. McFarlane P, Cherney D, Gilbert R, Senior P. Chronic Kidney Disease in Diabetes. 2018 Clinical Practice Guidelines. Can J Diabetes. 2018;42:S201-S20910. Hou F, Zhang X, Zhang G,

Xie D, Chen P. Efficacy and Safety of Benazepril for Advanced Chronic Renal Insufficiency. N Engl J Med 2006; 354:131-14011. Heerspink H, Stefansson B, Rotter R, Chertow G, Greene T et al. Dapagliflozin in Patients with Chronic Kidney Disease.

N Engl J Med 2020; 383:1436-144612. Perkovic V, Neal K, Bompoint S, Heerspink H,

Charytan

D et al. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy.

N

Engl

J Med

2019; 380:2295-2306

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Questions?

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