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Managing Kidney Disease in the Homeless Population
 

Managing Kidney Disease in the Homeless Population

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  • At the bottom of this slide you can see some of the many topics in kidney disease for which the guidelines have already been published. The Guidelines we will be discussing today will actually be released in February 2007. I think that the top of this slide, however, is of even greater importance. The website of the National Kidney Foundation is where you can find these guidelines. You can also get them in the form of booklets. The website of the National Kidney Foundation is www.kidney.org
  • Incidence adjusted for age, sex, and race. Compared to the other causes of End Stage Renal Disease, you can see that diabetes is by far the most common and has been increasing over the past two decades.

Managing Kidney Disease in the Homeless Population Managing Kidney Disease in the Homeless Population Presentation Transcript

  • 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 ESRD by Primary Diagnosis lla illi lla illi USRDS 2006
  • Kidney Disease Has 5 Stages Could have swelling, nausea, shortness of breath. Need blood test to know for sure. Could have swelling, nausea NONE! NONE! NONE! Symptoms KIDNEY FAILURE – starting DIALYSIS 5 On the edge of failing 4 Halfway to failure 3 Cleaning reduced 2 Slightly damaged 1 Description Stage
  • A Familiar Filter
  • Pretend this Filter is in Kidneys.. BLOOD ALBUMIN URINE
  • A Familiar Filter is Damaged
  • Damaged Kidney Filters microalbuminuria = micro (small) albumin (protein) uria (urine) BLOOD ALBUMIN URINE
  • Failing Kidney Filters SCARS
  • blood is clean (red) urine removes waste (yellow) NORMAL plenty of urine
  • blood is clean (red) urine removes waste (yellow) plenty of urine albumin or red blood cells STAGES 1 & 2 GFR > 59
  • kidneys don’t clean blood as well urine removes less waste less urine albumin or red blood cells STAGE 3 GFR 30 - 59 scar
  • kidneys don’t clean blood as well urine removes less waste less urine albumin or red blood cells STAGE 4 GFR 15-29 scars bigger
  • kidneys don’t clean blood urine removes less waste very little urine albumin or red blood cells STAGE 5 GFR < 15 scars replace most of kidneys too much fluid in heart
  • Kidney Disease Has 5 Stages KIDNEY FAILURE – starting DIALYSIS On the edge of failing Halfway to failure Cleaning reduced Slightly damaged Description < 15 ml/min 15 – 29 ml/min 30 – 59 ml/min 60 - 89 ml/min ≥ 90 ml/min eGFR 5 4 3 2 1 Stage
  •  
  • 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 KIDNEY FAILURE – starting DIALYSIS On the edge of failing Halfway to failure Damaged and cleaning reduced MUST HAVE SIGNS OF DAMAGE Slightly damaged MUST HAVE SIGNS OF DAMAGE Description < 15 ml/min 15 – 29 ml/min 30 – 59 ml/min 60 - 89 ml/min ≥ 90 ml/min eGFR 5 4 3 2 1 Stage
  • Quiyo, Tessie 15009 Urine creat 60.6 mg/dL Urine albumin 25.9 mg/dL Microalbumin, random 426.9 mg/g Serum creat 0.9 mg/dL Est 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, Lalo 12345 Urine creat 85.2 mg/dL Urine albumin 2.4 mg/dL Microalbumin, Random 28 mg/g Serum creat 2.2 mg/dL Est GFR 34 ml/m How to stage: no albuminuria but eGFR = 34 ml/m, Stage 3.
  • Cachora, Dale 31434 Urine creat 60.0 mg/dL Urine albumin 31.5 mg/dL Microalbumin, Random 524.5 mg/g Serum creat 2.8 mg/dL Est GFR 25 ml/m How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR 25 means Stage 4.
  • Cachora, Dale 31434 Urinalysis Blood 3+ Protein 2+ Serum creat 1.4 mg/dL Est GFR 50 ml/m How to stage: presence of blood and protein means there is kidney disease present. eGFR 50 means Stage 3.
  • Cachora, Dale 31434 Renal ultrasound Single kidney Serum creat 1.1 mg/dL Est 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 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? Could have swelling, nausea, shortness of breath. Need blood test to know for sure. Could have swelling, nausea NONE! NONE! NONE! Symptoms KIDNEY FAILURE – starting DIALYSIS 5 On the edge of failing 4 Halfway to failure 3 Cleaning reduced 2 Slightly damaged 1 Description Stage
  • 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 CKD
    • 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
    renal osteodystrophy
  • 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 Resources Alameda County, CA, 2000
  • 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