chronic kidney disease management - tafp · choi m: nephsap. ckd and safety 14(4): 344-348, 2015....
TRANSCRIPT
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Friday General Session
Chronic Kidney Disease Management Nishant Jalandhara, MD Clinical and Interventional Nephrologist Tarrant Nephrology Associates Fort Worth, Texas Educational Objectives By the end of this activity, the participant should be better able to: 1. Discuss the recent changes of Chronic Kidney Disease (CKD) classification. 2. Identify the complications related to CKD. 3. Implement the various treatment options for management of patients with CKD.
Speaker Disclosure Dr. Jalandhara has disclosed that he has no actual or potential conflict of interest in relation to this topic.
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Nishant Jalandhara, MD, FASN, [email protected]
Fort Worth TX
Chronic Kidney Disease Management
• Dr. Jalandhara has disclosed that he has not actual or potential conflict of interest in relation to this topic.
Disclosure
By the end of this activity, the participant will be better able to:
• Discuss the recent changes of CKD classification.
• Identify the complications related to CKD.
• Implement the various treatment options for management of patients with CKD.
Learning Objectives
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• Anatomical or Structural Defect• Functional Component• Time Component
Defining Chronic Kidney Diseases (CKD)
http://esciencenews.com/articles/2010/11/11/common.diabetes.drug.may.halt.growth.cysts.polycystic.kidney.diseasehttp://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/learn/causes-kidney-disease/testing/understand-gfr/Pages/understand-gfr.aspxhttps://commons.wikimedia.org/wiki/File:Time-management.jpg
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The Early NHANES III Study
- Adapted from NHANES III (2000)
Stage DescriptioneGFR Range
1Kidney damage with normal or
increase GFR≥ 90
2 Mildly decreased GFR 60-89
3Moderately decreased
GFR30-59
4 Severely decreased GFR 15-29
5 Kidney Failure < 15
Cases:
http://redbeans.tulane.edu/suggested-readings/aki/
Vs.
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• 40 y/o male• Initial clinic visit for feeling weak and
tired• Creatinine 4.5, no other complaints
Cases:
1. AKI 2. CKD
• 45 y/o male• DM and HTN for 15 years • Renal panel normal. Urine protein ++ • Sonogram normal
Cases:
1. AKI 2. CKD
• 49 y/o female with non specific abdominal pain
• Sonogram shows 10 cyst left kidney, 20 cyst right kidney
• 18 cm size kidneys
Cases:
1. AKI 2. CKD
• 71 y/o female• No complaints• Labs negative • Sonogram: 1 simple cyst 2cm
Cases:
1. AKI 2. CKD
• 92 y/o male• No complaints• Creatinine 0.9, GFR 52• Urine negative, sonogram normal
Cases:
1. AKI 2. CKD
• 31 y/o female surgical nurse. Slight SOB and Blood Pressure 160/98
• UA blood +, protein +• ACR: 5000 mg/gm
Cases:
1. AKI 2. CKD
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What is the major cause of concern in CKD patients?
1. Cardiovascular death2. Malignancies3. Need for dialysis4. Infections
CKD: Prognosis CKD: Prognosis
Keith D, et al: Arch Intern Med. 2004;164:659-663
CKD: Prognosis
0
10
20
30
40
50
60
70
80
90
100
GFR 60‐80 Pr‐ GFR 60‐80 Pr+ GFR 30‐59 GFR 15‐29
Death Dialysis Event Free Discontinued
Keith D, et al: Arch Intern Med. 2004;164:659-663
• 100 patients (eGFR < 60) in 10 years
• 8 ESRD• 27 CKD• 65 Death
CKD: Prognosis
25 y/o +++ pr
45 DM ++ pr
65 no protein
Levey AS et al. Kidney Int 2011; 80: 17-28
• Are all Coronary Artery Diseases same?
CKD: Prognosis
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CKD: Prognosis
Koji Kato et al. Circ Cardiovasc Imaging. 2013;6:448-456TCFA indicates thin-cap fibroatheromaKDIGO Kidney International Supplements (2013) 3, 19–62;
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CKD: Management
Treatment of reversible causes
Preventing or slowing the progression of CKD
Treatment of the complications of CKD
Adjusting drug doses
Preparation for renal replacement therapy
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CKD: Management
Treatment of reversible causes
Stop NSAIDs
Dose antibiotics correctly
Avoid hypotension
Avoid OTC meds
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CKD: Quiz
Have you or your family members taken over-the-counter supplements within past month?
1. YES2. NO
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CKD: Management
• OTC Supplements
• Included 21,169 non-pregnant, adult participants from NHANES 1999-2008
• 8.0% of U.S. adults reported potentially harmful supplement use within the last 30 days
Grubbs V et al. Am J Kidney Dis. 2013 May ; 61(5): 739–747
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CKD: Management
Grubbs V et al. Am J Kidney Dis. 2013 May ; 61(5): 739–747
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CKD: Management
Treatment of reversible causes
Preventing or slowing the progression of CKD
Treatment of the complications of CKD
Adjusting drug doses
Preparation for renal replacement therapy
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CKD: Management
• Treatment of reversible causes• Preventing or slowing the progression of
CKD• Blood pressure control• Protein intake• Smoking cessation
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CKD: Management
• Treatment of reversible causes• Preventing or slowing the progression of
CKD• Protein intake restriction
• A daily protein intake of 0.8 g/kg• A diet rich in vegetables• Plant based protein vs Animal based
protein
KDIGO Kidney International Supplements (2013) 3, 19–62;
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CKD: Management
• Treatment of reversible causes• Preventing or slowing the progression of
CKD• Smoking cessation
• Stopping smoking is associated with a slower rate of progression of CKD
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CKD: Management
• Treatment of reversible causes• Preventing or slowing the progression of
CKD• Lipid Management:
Baigent C et al. Lancet 2011; 377: 2181–92
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CKD: Management
Included 6247 patients with CKD, follow-up of 4.9 years
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CKD: Management
• Lipid Management:
Baigent C et al. Lancet 2011; 377: 2181–92
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CKD: Management
• Lipid Management: Guidelines• Recommend treating all individuals with
CKD ages ≥ 50 years with a statin, irrespective of LDL levels
• Check LDL levels once at initiation of therapy
KDIGO Kidney International Supplements (2013) 3, 19–62;
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CKD: Management
Treatment of reversible causes
Preventing or slowing the progression of CKD
Treatment of the complications of CKD
Adjusting drug doses
Preparation for renal replacement therapy
0 15 30 45 60
Hypertension
MBD‐PO4
Anemia
Acidosis
K, Edema
Uremia
Complication
GFR
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CKD: HTN Management
• CRIC study evaluated data on 3612 patients with CKD
Muntner P et al, AJKD, Vol 55, No 3 (March), 2010: pp 441-451
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CKD: HTN Management
• Both, Salt retention and peripheral resistance contribute
• BP accelerated decline in renal function• BP exacerbates proteinuria• ACE/ARB preferred agents
ACE: Angiotensin Converting Enzyme blockers. ARB: Aldosterone Receptor Blockers
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CKD: HTN Management
• Diabetic CKD < 140/90 mmHg• Proteinuric CKD < 130/80 mmHg• Hypertensive CKD < 130/80 mmHg• Proteinuria reduction has independent
benefit vs. BP reduction: ACE/ARB
KDIGO Kidney International Supplements (2013) 3, 19–62;JAMA. 2014;311(5):507J Hypertens. 2013;31(7):1281.
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CKD: HTN Management
• Use ACE/ARB as first line therapy• ACE/ARB help delay progression to ESRD• Proteinuria reduction has independent benefit• DO NOT combine ACE and ARB or Direct
renin inhibitors with ACE/ARB• More Hyperkalemia, AKI, and Mortality
0 15 30 45 60
HTN
MBD-PO4
Anemia
Acidosis
K, Edema
Uremia
Complication
Complication
• Kidneys regulate Calcium, Phosphorus, Parathyroid (PTH) and Vitamin D metabolism.
• Problems with any of these causes abnormalities in bone turnover, mineralization, volume and growth.
• Causes vascular and soft tissue calcification.
CKD: Mineral Bone Disorder
↑PO4, ↓Vit D ⇒ ↑PTHAbnormal bone turnover,
calcificationLVH, cardiac fibrosis, peripheral neuropathy
As CKD progresses, Vit D levels decrease
As CKD progresses, PO4 accumulation begins
CKD: Mineral Bone Disorder
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• Treatment: • Replace Vitamin D: Ergocalciferol 50000
units qweekly for 3 months then qmonthly
• Dietary phosphate restriction• Check and treat PTH as needed• Phosphate binders as needed
CKD: Mineral Bone Disorder CKD: Mineral Bone Disorder
Sucroferric oxyhydroxide low pill burden, new in market, expensive, diarrhea
0 15 30 45 60
HTN
MBD-PO4
Anemia
Acidosis
K, Edema
Uremia
Complication
Complication
McClellan et al. Curr Med Res Opin. 2004;20:1501-1510.
• Rule out other causes of anemia –bleeding, nutritional deficiencies.
• Once AOCD established• Evaluate for iron deficiency : Iron panel• Supplement Fe as needed: IV vs. PO• Consider ESA if unresponsive
• Goal Hemoglobin >10• DO NOT OVERTREAT
CKD: Anemia
AOCD: Anemia of Chronic Kidney Diseases; ESA: Erythropoeitin stimulating agents
0 15 30 45 60
HTN
MBD-PO4
Anemia
Acidosis
K, Edema
Uremia
Complication
Complication
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• Dietary intake: Acid• Hyperchloremic phase then high anion gap phase
• Acidosis • Protein wasting & bone lysis• CKD progression & mortality
CKD: Acidosis
Dobre M et al. J Am Soc Nephrol 26: 515–523, 2015.
CKD: Acidosis
Dobre M et al. J Am Soc Nephrol 26: 515–523, 2015.
0 15 30 45 60
HTN
MBD-PO4
Anemia
Acidosis
K, Edema
Uremia
Complication
Complication
CKD: Edema
• Diet: • Salt Restriction:
• A RCT dietary sodium intake on BP and proteinuria in pts with stages 3 or 4 CKD
• 24-hour UrNa excretion: 75 vs 168 mmol/L• BP decreased by a mean of 10/4 mmHg,
extracellular fluid volume decreased, and albuminuria and proteinuria decreased
McMohan EJ et al. J Am Soc Nephrol 24: 2096-2103, 2013.
CKD: Hyperkalemia
• K: Diet and diuretics• Sodium Zirconium Cyclosilicate
• Selective cation exchanger• 753 patient: K 5.3 to 4.8 vs 5.1 in placebo
• Patiromer• Nonabsorbed potassium binder• 237 patients: K 5.3 to 4.7 and 5.8 to 4.5
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• Malnutrition: very common in advanced CKD
• Uremia: • Nausea, vomiting, anorexia, weight loss• Pericarditis, encephalopathy,
neuropathy, coma
CKD: Uremia57
CKD: Management
Treatment of reversible causes
Preventing or slowing the progression of CKD
Treatment of the complications of CKD
Adjusting drug doses
Preparation for renal replacement therapy
• Avoid Contrast• Avoid PICC lines• Avoid NSAID’s • Drug dosing: Piperacillin/Tazobactan,
Vanc, etc.• Diet: Avoid Red meat, soft drinks (sodas)
CKD: Things to Watch
• Target A1c of approximately 7%• Watch and avoid hypoglycemia• Metformin:
• GFR >45: Continue• GFR 30-44: Review the need, avoid if
possible• GFR < 30: Discontinue
CKD: DM
• Half-life of insulin and a number of sulfonylureas are increased
• DPP-4 use in Diabetic CKD
CKD: DM
Choi M: NephSAP. CKD and safety 14(4): 344-348, 2015.
• 47 patients with stage 4 or 5 CKD given smartphone
• 60% had never used a smartphone • User adherence was high• Home BP readings between baseline and exit
were statistically significant • SBP, -3.4 mmHg; 95% CI -5.0 to -1.8 • DBP, -2.1 mmHg; 95% confidence interval, -2.9 to -1.2); • 27% with normal clinic BP readings had newly identified masked
hypertension.
• 127 medication discrepancies were identified
CKD: Smartphones
Onc S et al. CJASN ePress. Published on May 12, 2016 as doi: 10.2215/CJN.10681015
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CKD: Management
Treatment of reversible causes
Preventing or slowing the progression of CKD
Treatment of the complications of CKD
Adjusting drug doses
Preparation for renal replacement therapy
If you or your family had to go on dialysis, what would you choose
1. In center Hemodialysis (MWF or TThS)2. Peritoneal Dialysis3. Home Hemodialysis
CKD: Quiz
CKD: Renal Replacement
Hemodialysis
Peritoneal Dialysis
TransplantHospice
Nocturnal Dialysis
PatientPatient
Choosing the D?–Hemodialysis
• Nocturnal HD
• Home HD
• TIW (three times a week)
CKD: Renal Replacement HD
• Access
• Catheter
• Arterio-Venous Graft
• Arterio-Venous Fistula
CKD: Renal Replacement HD
• Peritoneal Dialysis
• Lifestyle
• Travel
• Catheter care
• Infection rate
CKD: Renal Replacement PD
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• Wait time
• No blood transfusion
• Paired cross over TX
Living Transplant
Living related
Living Unrelated
Cadaveric
Matched
CKD: Renal Replacement 70
CKD: When to Refer
AKI or abrupt sustained fall in GFR;
GFR <30 ml/min (GFR categories G4-G5)
Consistent finding of albuminuria
Rapid progression of CKD
Urinary red cell casts
CKD: When to Refer
CKD and HTN refractory to treatment with 3 or more antihypertensive agents;
Persistent abnormalities of serum potassium;
Hereditary kidney disease.
Thank You
• 28,497 patients with CKD stage 5• Prospective study• At 7 months, use of ACEIs/ARBs was
associated with:• Lower risk for long-term dialysis (HR, 0.94
[95% CI, 0.91-0.97]) • Lower risk for composite outcome of long-
term dialysis or death (0.94 [0.92-0.97]).
ACE/ARB in Advanced CKD
Hsu et al. JAMA Intern Med. 2014;174(3):347-354.
Astor B et al. Arch Intern Med. 2002;162(12):1401-1408.
CKD: Anemia
Medication Index
Chronic Kidney Disease Management
Generic Name Trade Name
Alogliptin Nesina
Ezetimibe Zetia
Linagliptin Tradjenta
Metformin Fortamet, Glucophage, Glumetza, Riomet
Piperacillin/Tazobactam Zosyn
Saxagliptin Onglyza
Simvastatin Zocor
Sitagliptin Januvia
Vancomycin None
The following medications were discussed in this presentation. The table below lists the
generic and trade name(s) of these medications.
Notes