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CKD – Chronic Kidney Disease - for primary care

CKD – Chronic Kidney Disease - for primary care. Keith Dickerson, MD, MS. Objectives. Definition of CKD and recognition of Risk Factors Why CKD matters Initial Evaluation of CKD: GFR, proteinuria, other workup Appreciate significance of protein in urine Primary Care management of CKD

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CKD – Chronic Kidney Disease - for primary care

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  1. CKD – Chronic Kidney Disease - for primary care Keith Dickerson, MD, MS

  2. Objectives • Definition of CKD and recognition of Risk Factors • Why CKD matters • Initial Evaluation of CKD: GFR, proteinuria, other workup • Appreciate significance of protein in urine • Primary Care management of CKD • BP, proteinuria and baseline disease control • When to refer and anticipation of complications

  3. Chronic Kidney Disease (CKD) is defined as… • Evidence of kidney damage lasting more than 1 months • GFR less than 60 mL/min/1.73 m2 lasting more than 1 months • Either • Neither

  4. Lasting for 3 months or more…not just 1 month.

  5. The leading causes of chronic renal failure, in order, are…. • HTN, DM, glomerulonephritis (GM) • GM, HTN, DM • DM, HTN, GM • DM, GM, HT

  6. Patient JT’s Urine Spot Protein check shows the following:URINE TOTAL PROTEIN SPOT 297.7mg/dLURINE CREATININE SPOT 98.36mg/dL….What does this mean?…compared to a 24 hour urine collection for protein, it is roughly equivalent to… • 33 mg protein • 300 mg protein • 333 mg protein • 3 grams protein

  7. Proteinuria • Ratio of spot or random urine is remarkably equivalent to 24hr grams collected: 300/100=3grams protein • Has been called the ‘endotheliometer’ as well as the ‘nephrologicHgB A1C’ • By the time microalbuminuria is present, 50% of biopsies show established morphologic changes. • “Normal” – spot urine alb/creat less than 30mg/g • 10mg/day albumin is average amount in adults • 50mg/day protein

  8. Protein in UA Anything above 1+ on dipstick needs to be followed up or investigated

  9. Which of the following is worse in terms of progression of renal disease ? • Stage 2 CKD with macroproteinuria • Early stage 3a CKD with microalbuminuria • Stage 3b CKD with no microalbuminuria • All 3 are equally bad

  10. CKD - GFR vs proteinuria risk for progression • Which is worse: Stage 3 CKD without proteinuria, or Stage 1 with proteinuria? • http://cme.medscape.com/viewarticle/728679?src=cmemp&uac=130135AJ

  11. Relationship Between GFR, Albuminuria, and CV Disease

  12. Proteinuria and new classification scheme • https://www.kidney.org/sites/default/files/01-10-7027_ABG_HeatMap_Card_3_0.pdf

  13. Primary Care of CKD • Identify risk • Look for reversible causes • Delay onset – AVOID NEPHROTOXINS • Diagnose CKD • Reduce cardiovascular risk • Slow CKD progression JGIM April 2011 - CKD in Primary Care: An Opportunity for Generalists

  14. List of medications to renally dose • https://www.kidney.org/sites/default/files/02-10-6793_IBE_Meds-ImagingStudiesRiskv10.pdf

  15. Resources • http://www.aafp.org/afp/2011/1115/p1138.html • - figure 1 with albumin recheck algorhythm and great tables • http://www.aafp.org/afp/2012/1015/p749.html • https://www.kidney.org

  16. Management • https://www.kidney.org/sites/default/files/02-10-6800_ABG_PCPI_Algorithm2_0.pdf

  17. Semi-annual to yearly assessment of stage 3b or concerning 3a • BMP • H/H • PTH, Ca, Phos, Mag

  18. Does actively managing CKD matter? • Observational studies have shown worsening kidney function is associated with… • Risk of hospitalization • Increased rates of disability • Poorer quality of life • Greater cognitive decline • Increased rate of infections • CV events • Death

  19. ACP 2013 primary care recs • Do not screen asymptomatic adults without risk factors for CKD. There are too many false positive results if screening for albuminuria or calculating glomerular filtration rate on the basis of urine creatinine (weak recommendation, low-quality evidence). • Treat patients with CKD and hypertension with an ACEI or ARB -- but not both -- to decrease bad renal outcomes (strong recommendation). • Stop checking for proteinuria (macro or micro) in patients treated with and ACEI or ARB. You're already treating its cause (weak recommendation, low-quality evidence). • Treat high cholesterol in patients with CKD to lower their risk of cardiovascular outcomes (strong recommendation, moderate-quality evidence).

  20. In patients with Chronic Kidney disease (CKD), which of the following interventions shows clear cardiovascular morbidity or mortality benefit. • combined ACE-I and ARB treatment for patients with persistent proteinuria • statin therapy in accordance with NCEP-III guidelines for lipid management • using EPAs (erythropoiesis stimulating agents) to achieve a near-normal hemoglobin level. • A and B • B and C • A and C

  21. Initial Evaluation • Glomerular Filtration Rate (GFR) estimate from SCr (KDOQI-4) • Proteinuria assessment (KDOQI-5) • Other workup (KDOQI-6) • Urine sediment for casts, RBC, WBC • Imaging (mostly ultrasound) • Chronic viral hepatitis panel, ANA, SPEP, ANCA, complement levels, etc in select cases • New/novel markers under development

  22. Estimating GFR • “Gold Standards” (insulin clearance, Cr-EDTA, Tc-DTPA) not commonly used • Cockcroft-Gault – often used by pharmacists • MDRD SCr., age, gender, race • Extended version uses BUN, alb, body surface area • 24 hour urine Cr collection • CKD-EPI new standard under development • http://www.kidney.org/professionals/kdoqi/index.cfm

  23. A 58yo woman with type 2 DM has labwork showing microalbuminuria, but other indicators of renal function are normal. Which of the following interventions has not been definitively shown to prevent progression of early diabetic nephropathy? • Angiotensin-converting enyzme inhibitors • Tight control of blood pressure • Tight control of blood glucose

  24. Case Study - 89yo F with CHF and stage 3 CKD with SCr 1.6. Had recent skin infection treated with an antibioticAdmitted to hospital with K 7.3 and SCr 3.7, with CHF exacerbation/volume overloadWhich antibiotic was the likely culprit? • That nasty cephalexin, which is well known to cause hyperkalemia in patients with CKD • It was a random and capricious coincidence • That nasty trimethaprim-sulfamethoxazole, which is well known to cause hyperkalemia in patients with CKD • That nasty nitrofurantoin, which is well known to cause hyperkalemia in patients with CKD

  25. Management of CKD • Blood Pressure control (KDOQI-7) • Proteinuria control • Underlying disease/driver control • Limit nephrotoxins • Nutritional modifications • http://www.aafp.org/afp/2012/1015/p749.html

  26. Blood Pressure/Proteinuria control • ACE-I/ARBs • For all with microalbuminuria • Possibly even for those who are normotensive • Monitor for complications (SCr, K+ esp) • Most need 3 antihypertensives to achieve control • Reduction of BP reduces both cardiovascular and renal risk (see graphs)

  27. Underlying disease - DM • Glycemic Control in diabetes • Improvement in glycemic control generally decreases nephropathy risk • Stop metformin if SCr > 1.5? • Lipid control – nephroprotective? • TNT trial showed that for Stage 2 CKD, atorvastatin for 5 years led to less decline in renal function, and slight improvement.

  28. Anticipate Complications • When to refer to Nephrologist? • Anemia of CKD (KDOQI-8) • Dietary Protein/energy balance (KDOQI-9) • Refer to nutrition • Renal osteodystrophy and electrolyte abnormalities (KDOQI-10) • Risk Stratification in relation to cardiovascular disease

  29. How Well does primary care do at managing CKD? • 25% documentation rate of CKD • Poor implementation of evidence based care documented in multiple studies • How well do we do? • How would you devise a simple check? Medscape; JGIM April 2011 x 3

  30. SMFMR clinic data 2012

  31. Which of the following statements about ‘tight’ insulin control – to A1C target less than 7.0% - in patients with CKD is correct? • It reduces mortality from renal disease • It reduces CV events • It reduces progression to dialysis • It increases the risk of severe hypoglycemia

  32. Electrolyte Derangements and Renal Osteodystrophy • Complex • Controversial – March 16th 2011 JAMA metanalysis and commentary • http://smh/fp/Education%20Information/Adult%20Medicine/Nephrology/Index.htm

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