managing kidney disease in the homeless population
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Managing Kidney Disease in the Homeless Population
E. Jennifer Weil, MD
Phoenix Epidemiology and Clinical Research Branch
in memory of Larry Coleman, my patient 10/18/99 – 4/31/04
Rest in Peace
Temple University, Philadelphia, PA
What Kidneys Do
Kidneys control the amount of water and other chemicals in blood.
Kidneys remove harmful substances Kidneys control blood pressure Kidneys help make red blood cells Kidneys promote strong bones
Chronic Kidney Disease Chronic kidney disease (CKD) is the permanent
loss of kidney function in both kidneys as a result of Physical injury or A disease that damages both kidneys, such as DIABETES
Damaged kidneys do not remove wastes do not remove extra water from the blood as well as they should.
What Else About CKD? CKD is a familial disease. Risk for CKD
increases if a blood relative has kidney failure.
CKD is a silent condition. In the early stages, there are no symptoms. CKD develops so slowly that people don't
realize they're sick until the disease is advanced and they are rushed to the hospital for life-saving dialysis.
Kidney Failure is Increasing in the US
Incident Counts & Adjusted Rates, by Race
Incident ESRD patients; rates adjusted for age & gender.
Incident Counts and Rates of ESRDby Primary Diagnosis
USRDS 2006
Kidney Disease Has 5 Stages
Stage Description Symptoms1 Slightly damaged NONE!
2 Cleaning reduced NONE!
3 Halfway to failure NONE!
4 On the edge of failing Could have swelling, nausea
5 KIDNEY FAILURE – starting DIALYSIS
Could have swelling, nausea, shortness of breath. Need blood test to know for sure.
A Familiar Filter
Pretend this Filter is in Kidneys..
BLOODBLOOD
ALBUMINALBUMIN
URINEURINE
A Familiar Filter is Damaged
Damaged Kidney Filters
microalbuminuria = micro (small) albumin (protein) uria (urine)
BLOODBLOOD
ALBUMINALBUMIN
URINEURINE
Failing Kidney Filters
SCARSSCARS
blood is clean (red)
urine removes waste (yellow)
NORMALplenty of urine
blood is clean (red)
urine removes waste (yellow)
plenty of urine
albumin orred blood cells
STAGES 1 & 2GFR > 59
kidneys don’t clean blood as well
urine removes less waste
less urine
albumin orred blood cells
STAGE 3GFR 30 - 59
scar
kidneys don’t clean blood as well
urine removes less waste
less urine
albumin orred blood cells
STAGE 4GFR 15-29
scars bigger
kidneys don’t clean blood
urine removes less waste
very little urine
albumin orred blood cells
STAGE 5GFR < 15
scars replacemost of kidneys
too much fluid in heart
Kidney Disease Has 5 Stages
Stage Description eGFR1 Slightly damaged ≥ 90 ml/min
2 Cleaning reduced 60 - 89 ml/min3 Halfway to failure 30 – 59 ml/min
4 On the edge of failing 15 – 29 ml/min
5 KIDNEY FAILURE – starting DIALYSIS
< 15 ml/min
Stages 1 & 2 Normal eGFR ≥ 60 ml/m Kidney damage for more than 3 months as
manifested by Abnormalities in the tissue of the kidney (biopsy) or Markers of kidney damage including
Abnormalities in the composition of urine or Changes seen by radiological images (x-ray, CT scan, ultrasound
etc.)
Risks associated Progression Heart disease
Stages 3, 4 & 5 Kidney damage getting worse
eGFR getting progressively lower Risks associated
Progressive kidney disease (dialysis) Increased cardiovascular risk Myocardial infarction (heart attack) Stroke Sudden death
How to Stage Calculate eGFR with age, sex, race, and
creatinine Find out if there are changes in kidneys for
more than 3 months: Urinalysis positive for protein or blood OR Urine albumin to creatinine ratio
(AKA: microalbumin, ACR): > 30 mg/g OR Ultrasound or other imaging test is abnormal
Look at the table
Kidney Disease Has 5 Stages
Stage Description eGFR1 Slightly damaged
MUST HAVE SIGNS OF DAMAGE
≥ 90 ml/min
2 Damaged and cleaning reduced MUST HAVE SIGNS OF DAMAGE
60 - 89 ml/min
3 Halfway to failure 30 – 59 ml/min4 On the edge of failing 15 – 29 ml/min5 KIDNEY FAILURE –
starting DIALYSIS< 15 ml/min
Quiyo, Tessie15009Urine creat 60.6 mg/dLUrine albumin 25.9 mg/dLMicroalbumin, random 426.9 mg/g
Serum creat 0.9 mg/dLEst GFR > 60 ml/m
How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR > 60 means Stage 1 or Stage 2. Our methods do not allow distinction between Stages 1 and 2.
Joe, Lalo12345Urine creat 85.2 mg/dLUrine albumin 2.4 mg/dLMicroalbumin, Random 28 mg/g
Serum creat 2.2 mg/dLEst GFR 34 ml/m
How to stage: no albuminuria but eGFR = 34 ml/m, Stage 3.
Cachora, Dale31434Urine creat 60.0 mg/dLUrine albumin 31.5 mg/dLMicroalbumin, Random 524.5 mg/g
Serum creat 2.8 mg/dLEst GFR 25 ml/m
How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR 25 means Stage 4.
Cachora, Dale31434Urinalysis Blood 3+
Protein 2+
Serum creat 1.4 mg/dLEst GFR 50 ml/m
How to stage: presence of blood and protein means there is kidney disease present. eGFR 50 means Stage 3.
Cachora, Dale31434
Renal ultrasound Single kidney
Serum creat 1.1 mg/dLEst GFR ≥ 60 ml/m
How to stage: single kidney is abnormal, and eGFR ≥ 60 means Stage 1 or 2.
Columbus Neighborhood Health Center Study, 2005
31.1
16
20.2
25.2
1.7 0.8
5
0
5
10
15
20
25
30
35
at risk Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 notstageable
People with Diabetes or Hypertension
Etiology of CKD Hypertension Diabetes Other
Bilateral renal artery stenosis (heart disease, stroke patient)
Kidney obstruction (stones, prostate, cancer patient) Interstitial nephritis (lithium, NSAIDs) Glomerulonephritis (heroin, HIV, hepatitis C, hepatitis B
patients) Congenital kidney disease (polycystic, Alport’s etc.) Multiple myeloma (older patient, anemia) Lupus (lots of other manifestations in joints, skin, brain)
Complete Work-Up for Etiology of CKD
Diabetes: duration, A1C, dilated retinal exam, sensory testing with monofilament
Hypertension: duration, number of meds Other diseases
Lupus: ANA, C3, C4 Vasculitis: ANCA, Anti-GBM, cryoglobulins Multiple Myeloma: SPEP with IFE, UPEP with IFE Infectious Diseases: HBSAg, HCV, HIV screens
Renal Ultrasound for obstruction, small kidneys or anything else
Core Labs for All Follow-Up CBC: more frequently in advanced stages Chem 7: more frequently in advanced stages Urinalysis: helpful for diagnosis, helpful for UTI Urine microalbuminuria: helpful at diagnosis and
to see if ACE inhibitor or ARB is working Lipid panel: check while adjusting lipid meds HbA1C: if diabetic – every three months
Blood pressure – every visit
When to slow CKD down?
Stage Description Symptoms1 Slightly damaged NONE!
2 Cleaning reduced NONE!
3 Halfway to failure NONE!
4 On the edge of failing Could have swelling, nausea
5 KIDNEY FAILURE – starting DIALYSIS
Could have swelling, nausea, shortness of breath. Need blood test to know for sure.
How to Slow CKD Educate patients on how they can control many of the things that
can make CKD worse and may lead to kidney failure.
Gain tight control of blood glucose to delay or prevent kidney failure, where appropriate.
Keep blood pressure below 130/80 mm Hg. A combination of two or more drugs may be necessary
ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) protect the kidneys better than other blood pressure medicines.
Dietary therapy when practicable, low protein, low sodium, and later low potassium and low phosphorus.
Renoprotective Drugs ACE inhibitors
Lisinopril (longest half-life) Captopril
ARBs Telmisartan (longest half-life) Candesartan
Dosage: maximal tolerated by blood pressure, serum creatinine and potassium
Combination of ACE inhibitor and ARB: almost always unnecessary (but combination with other anti-hypertensive drugs to be expected)
Contraindicated: women of childbearing potential, allergic patients
Enalapril Ramipril
Valsartan Losartan
Fosinopril (hepatic) others
Irbesartan others
Heart Disease in CKD Modification of risk
Lipid control Smoking cessation Diabetes control Blood pressure control Lower albumin or protein in urine
Medicines Statins, other lipid agents Anti-hypertensive drugs, especially ACE, ARB, beta-
blocker Aspirin
Lifestyle: diet and exercise
Behavioral Changes that Affect CKD Outcomes
Ask to get tested for kidney disease Ask questions about kidney disease Take medicines regularly Stop smoking Stop using illicit drugs Abstain from alcohol Lose weight if overweight or obese Exercise if sedentary Adjust diet Keep appointments with health care system
Adapting Practice for Homeless Diagnostic testing for diseases other than hypertension,
diabetes Expensive Difficult to do Set criteria: evaluate for all? Transmissable? Easy tests?
Diabetes (standard goal is A1C ≤ 7%) Check appropriateness of A1C target Hypoglycemia is dangerous
Hypertension (standard goal ≤ 130/80 mmHg) Avoid ACE inhibitors and ARBs in women of childbearing
potential Easier to get to goal, fewer risks than A1C, great results
Dietary management Difficult to control what / when patients eat
Follow-up labs Not so expensive
Complications of CKDrenal osteodystrophy Stage 3
Anemia: CBC, iron Metabolic bone disease: intact Pth, phosphorus,
vitamin D, calcium Stage 4
Anemia: as above Metabolic bone disease: as above Hyperkalemia: serum potassium Volume overload: edema, pulmonary edema Acidosis: bicarbonate, arterial blood gas
Stage 5 All of the above Uremia (nausea, vomiting, malnutrition, weight loss,
pericarditis, confusion, myoclonus, seizures): BUN and creatinine
When to Refer KDOQI Guidelines: Stage 3 Nephrotic syndrome Uncontrolled hypertension
NOT IDEAL (BUT IT HAPPENS)
When dialysis is necessary
Preparation for Dialysis Modality choice
Peritoneal Dialysis Hemodialysis
Access Fistula first Catheter Graft
Hepatitis immunization Vitamins Identification of dialysis unit
Dialysis Lifestyle Treatment
3 x per week 4 hours +/- per treatment Transportation for treatment
Medications: average of 9 Diet
Low sodium, low potassium, low phosphorus, high protein diet
Fluid restriction
Resources for Homeless Dialysis Patients
Medicare ESRD Program (Federal) Covers cost of dialysis treatment Does not cover food or shelter
Medicaid (Federal, administered by states) Each state has various rules cover cost of medication, for example Does not cover food or shelter Can cover disability, if patient meets criteria
Eligibility for programs: patients with no work history do not qualify.
Healthcare ResourcesAlameda County, CA, 2000
73
16 17
0
20
40
60
80
100
No HealthInsurance
Medi-Cal VeteransAdministartion
Perc
ent
Dialysis Team Physician Nurse Technician Dietician Social Worker Patient and family
Case of Larry Coleman 55 year old African-American gentleman Hypertension, untreated, then kidney failure At time he started dialysis
Living out of his car No stable food supply Functionally illiterate Using drugs
At the time I met him, “disabled” Living in an apartment Stable food supply and medicines paid for Still functionally illiterate Still using drugs, but much less and with good effect A great friend and an advocate for his fellow patients