Management of Chronic Kidney Disease (CKD) - PowerPoint Presentation

ella . @ella

345 views
Uploaded On 2022-06-08

Management of Chronic Kidney Disease (CKD) - PPT Presentation

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

ckd kidney disease gfr kidney ckd gfr disease risk diabetes renal management stage function egfr hypertension dialysis year damage

Link:

Copy

Embed:

<iframe width="560" height="315" src="https://www.docslides.com/embed/915417" frameborder="0" allowfullscreen></iframe>

Download Presentation from below link

Download Presentation The PPT/PDF document "Management of Chronic Kidney Disease (CK..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.

Presentation Transcript

Slide1

Management of Chronic Kidney Disease (CKD)

Namita Singh, MD, FASN

Year 2021

Slide2

DISCLOSURES

I have no financial relationships with commercial interests to disclose.

This presentation does not include discussion of off-label or investigational use.

Slide3

Case 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

Slide4

Case Question 2

A 50-year-old African American female was diagnosed with CKD. Her blood pressure is 150/85, her 24

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

Slide5

What is CKD?

Slide6

Kidney 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

Slide7

CKD 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

*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.

Slide8

Old 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

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

Kidney damage with

normal or increased GFR

GFR ≥ 90

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

Slide9

Kidney 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”

Slide10

6.7%

6.6%

Slide courtesy Dr

Argyropoulos

Slide11

ESRD, 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.

Slide12

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

Slide13

Why do we care about CKD?

Slide14

CKD 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.

Slide15

Functions of Kidneys

Maintain stability of “internal environment”

Filtration

Reabsorption

Secretion

Hormone function

Renin

Erythropoietin

Calcitriol

Metabolic function

Gluconeogenesis

Metabolize drugs and endogenous substances

Slide16

Symptoms 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

Slide17

Management of CKD (from a PCP perspective)

CKD is Part of Primary Care

Slide18

Case 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

”

Slide19

Hypertension 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

Slide20

Slowing CKD Progression: ACEi

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.

Slide21

Diabetes 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.

Slide22

Modification 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

; statin or statin/ezetimibe combination when eGFR < 60 ml/min/1.73m

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.

Slide23

Interventions to Reduce Urine Albumin

Slide courtesy Dr

Argyropoulos

Slide24

Medications 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.

Slide25

Management 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)

Slide26

Management 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.

Slide27

Management 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

Slide28

Management of CKD- Mineral and Bone Disorder (CKD- MBD)

Target levels:

Phosphorus < 5.5 mg/dL

Calcium > 7.5 mg/dL

PTH < 150

/mL (varies with reference range)

Treat with D3 as indicated to achieve normal serum levels

2000 IU po

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

Slide29

A 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.

Slide30

Case 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

Slide31

Identification 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

Slide32

CKD 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.

Slide33

CKD 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..

Slide34

Common Medications Requiring Dose Reduction in CKD

Allopurinol

Gabapentin

CKD 4- Max dose 300mg

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

Slide35

Key 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

Slide36

When to Refer?

Slide37

Indications for Referral to Nephrology

Acute kidney injury or abrupt sustained fall in GFR

GFR <30 ml/min/1.73m

(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

Slide38

Kidney

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?

Slide39

When to Discuss Dialysis And When Not in your >75 year old patient

Rosansky

et al. BMC

Nephrology

(2017) 18:200

eGFR

ml/min/1.73m2

Low Comorbidity

High Comorbidity

< 3

Conservative