Progressive Chronic Kidney Disease (ppt) 2mb

4,347 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
4,347
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
250
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Kidney Check Australia Taskforce CARI – caring for australians with renal impairment
  • Progressive Chronic Kidney Disease (ppt) 2mb

    1. 1. Progressive Chronic Kidney Disease <ul><li>Cherelle Fitzclarence </li></ul><ul><li>August 2009 </li></ul>
    2. 2. Overview <ul><li>Case studies </li></ul><ul><li>Discussion </li></ul><ul><li>Take home messages </li></ul>
    3. 3. Case 1 <ul><li>50 yo diabetic – 5 yr hx </li></ul><ul><li>Initial poor control but good last 3 years with combo of insulin and oral hypoglycaemics </li></ul><ul><li>Monitors own sugars </li></ul><ul><li>Post prandial BSL’s <10mmol/L </li></ul><ul><li>HbA1c – 5-7% </li></ul><ul><li>No peripheral neuropathy </li></ul><ul><li>No retinopathy </li></ul><ul><li>Albuminuria </li></ul><ul><li>Hypertension </li></ul>
    4. 4. Case 1 cont. <ul><li>In large epidemiological surveys for diabetes and chronic kidney disease, which of the following are correct? </li></ul><ul><ul><li>About 1 in 20 people have abnormalities on urinalysis </li></ul></ul><ul><ul><li>About 8% of the general population have evidence of diabetes mellitus </li></ul></ul><ul><ul><li>About 1 in 10 type 2 diabetics have evidence of diabetic nephropathy </li></ul></ul><ul><ul><li>Those with diabetes are at risk of end stage kidney disease </li></ul></ul>
    5. 5. Case 1 cont. <ul><li>Question 1 </li></ul><ul><li>In large epidemiological surveys for diabetes and chronic kidney disease, which of the following are correct? </li></ul><ul><ul><li>About 1 in 20 people have abnormalities on urinalysis </li></ul></ul><ul><ul><li>About 8% of the general population have evidence of diabetes mellitus </li></ul></ul><ul><ul><li>About 1 in 10 type 2 diabetics have evidence of diabetic nephropathy </li></ul></ul><ul><ul><li>Those with diabetes are at risk of end stage kidney disease </li></ul></ul>
    6. 6. Discussion Case 1 <ul><li>AusDiab 1 in 7 pts in Australia have diabetes. This can be as high as 1 in 3 in indigenous Australians </li></ul><ul><li>CKD was defined by presence of blood or protein on urinalysis and/or serum creatinine >150 </li></ul><ul><li>8% of the surveyed group had diabetes and half of them were unaware of Dx </li></ul><ul><li>30% of those surveyed had hypertension with half being unaware of Dx </li></ul><ul><li>1 in 3 type 2 diabetics will develop nephropathy </li></ul>
    7. 7. Take home message <ul><li>Type 2 Diabetes is now worldwide, the most common cause of end stage kidney disease </li></ul><ul><li>Indigenous populations have much higher rates of end stage kidney disease (ESKD) </li></ul><ul><li>Risk factors for ESKD </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Ethnicity </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Obesity </li></ul></ul>
    8. 8. Case 1 <ul><li>Question 2 </li></ul><ul><li>Which of the following is the most appropriate investigation when screening for CKD? </li></ul><ul><ul><li>24 hr urinary protein </li></ul></ul><ul><ul><li>24 hr urinary albumin excretion </li></ul></ul><ul><ul><li>Urinary prot/creat ratio on a spot urine </li></ul></ul><ul><ul><li>Urinary alb/creat ratio on a spot urine </li></ul></ul><ul><ul><li>MSU with dipstick, spot ACR, microscopy and culture </li></ul></ul>
    9. 9. Case 1 <ul><li>Question 2 </li></ul><ul><li>Which of the following is the most appropriate investigation when screening for CKD? </li></ul><ul><ul><li>24 hr urinary protein </li></ul></ul><ul><ul><li>24 hr urinary albumin excretion </li></ul></ul><ul><ul><li>Urinary prot/creat ratio on a spot urine </li></ul></ul><ul><ul><li>Urinary alb/creat ratio on a spot urine </li></ul></ul><ul><ul><li>MSU with dipstick, spot ACR, microscopy and culture </li></ul></ul>
    10. 10. Discussion <ul><li>CARI/KCAT reviewed evidence </li></ul><ul><li>Combo screening the best – </li></ul><ul><ul><li>U/A </li></ul></ul><ul><ul><li>MSU - m,c,s </li></ul></ul><ul><ul><li>ACR </li></ul></ul><ul><ul><li>BP </li></ul></ul><ul><ul><li>Serum creatinine (GFR) </li></ul></ul><ul><li>This should be done yearly in high risk groups – eg diabetics, ATSI </li></ul><ul><li>Further discussion </li></ul>
    11. 11. Take home message <ul><li>Single urine dipstick for protein – limitations false positives, false negatives </li></ul><ul><li>Kidney function should be measured at least yearly in those at increased risk CKD </li></ul><ul><li>Screening should include measurement of BP, serum creatinine (GFR), MSU </li></ul><ul><li>Protein creatinine ratio or albumin creatinine ration </li></ul>
    12. 12. Case 1 <ul><li>Question 3 </li></ul><ul><li>Which of the following is/are true statements concerning tests for assessing CKD? </li></ul><ul><ul><li>Serum creatinine is an accurate measure of renal function and if <120 excludes nephropathy </li></ul></ul><ul><ul><li>GFR estimated from a formula is an accurate measure of renal function </li></ul></ul><ul><ul><li>A deterioration in eGFR or more than 15% over a period of months is sign of acute renal failure </li></ul></ul><ul><ul><li>An eGFR of >20mls/min excludes clinically relevant renal disease </li></ul></ul>
    13. 13. Case 1 <ul><li>Question 3 </li></ul><ul><li>Which of the following is/are true statements concerning tests for assessing CKD? </li></ul><ul><ul><li>Serum creatinine is an accurate measure of renal function and if <120 excludes nephropathy </li></ul></ul><ul><ul><li>GFR estimated from a formula is an accurate measure of renal function </li></ul></ul><ul><ul><li>A deterioration in eGFR or more than 15% over a period of months is sign of acute renal failure </li></ul></ul><ul><ul><li>An eGFR of >20mls/min excludes clinically relevant renal disease </li></ul></ul>
    14. 14. Discussion <ul><li>Serum creatinine can stay in the normal range until more than 50% of GFR is lost </li></ul><ul><li>Serum creatinine is dependent on age, weight, gender and muscle mass </li></ul><ul><li>Small people with low muscle mass, elderly, female may have significant renal impairment despite a ‘normal’ creatinine </li></ul><ul><li>GFR falls over hours, days or weeks in acute renal failure </li></ul><ul><li>GFR falls over months, years in chronic renal failure </li></ul><ul><li>eGFR is used to stage kidney disease </li></ul>
    15. 15. Discussion Stage GFR mL/min/1.73 Expected CM’s 1 >90 None or the primary disease process 2 60-89 None, hyperparathyroidism, increased risk CVD 3 30-59 Nocturia, anaemia, increased creat, decreased vit D, dyslipidaemia, abN extracellular volume 4 15-29 Uraemic symptoms, abnomalities electrolytes 5 <15 Severe uraemic symptoms, dialysis
    16. 16. Take home message <ul><li>eGFR is useful as a screening tool for CKD </li></ul><ul><li>Should be used in conjunction with BP, U/A, ACR </li></ul><ul><li>eGFR can be used to stage CKD </li></ul>
    17. 17. Case 1 continues <ul><li>Over next 12 months, renal disease progresses </li></ul><ul><li>Creat 312 </li></ul><ul><li>Risk factors for cardiovascular disease poorly controlled </li></ul><ul><ul><li>BP >150 with 4 drug therapy on board </li></ul></ul><ul><ul><ul><li>ACEI, CCB, BB, Frusemide </li></ul></ul></ul><ul><ul><li>Hyperlipidaemia despite statin therapy </li></ul></ul><ul><ul><li>ACR increasing despite ACEI </li></ul></ul>
    18. 18. Case 1 <ul><li>Question 4 </li></ul><ul><li>In slowing the progression of renal disease and avoiding the development of malnutrition in CKD patients with an eGFR 15-30 mls/min, which of the following statements is/are correct? </li></ul><ul><ul><li>Nephrotic patients need a high protein diet </li></ul></ul><ul><ul><li>Reducing proteinuria to <1g/24 hours is associated with a reduction in rate of decline off renal function </li></ul></ul><ul><ul><li>Proteinuria is a good measure of renal dysfunction </li></ul></ul><ul><ul><li>Heavy proteinuria (>3g/24hrs) predicts the response to ACEI </li></ul></ul>
    19. 19. Case 1 <ul><li>Question 4 </li></ul><ul><li>In slowing the progression of renal disease and avoiding the development of malnutrition in CKD patients with an eGFR 15-30 mls/min, which of the following statements is/are correct? </li></ul><ul><ul><li>Nephrotic patients need a high protein diet </li></ul></ul><ul><ul><li>Reducing proteinuria to <1g/24 hours is associated with a reduction in rate of decline off renal function </li></ul></ul><ul><ul><li>Proteinuria is a good measure of renal dysfunction </li></ul></ul><ul><ul><li>Heavy proteinuria (>3g/24hrs) predicts the response to ACEI </li></ul></ul>
    20. 20. Discussion <ul><li>CARI guidelines advise against excessive protein restriction for slowing renal function decline </li></ul><ul><li>High protein diets do little to correct the malnourished state </li></ul><ul><li>Control of BP can signifcantly reduce proteinuria esp ACEI, AR2B, aldosterone antagonists </li></ul>
    21. 21. Take home message <ul><li>Low protein diets may slow progression CKD but only a small impact and may increase risk of malnutrition </li></ul><ul><li>High protein diets are not effective in treating malnutrition and may accelerate CKD </li></ul><ul><li>Lowering BP decreases proteinuria </li></ul><ul><li>Degree of preservation of renal function achieved with AHA directly proportional to decrease in proteinuria </li></ul><ul><li>ACEI/AR2B’s slow progression CKD more than explained just be AHA </li></ul>
    22. 22. Case 1 <ul><li>Question 5 </li></ul><ul><li>When a pt with T2DM is assessed for diabetic nephropathy, which of the following is correct? </li></ul><ul><ul><li>The absence of proteinuria excludes diabetic nephropathy </li></ul></ul><ul><ul><li>Hypertension usually indicates the presence of concomitant macrovascular disease </li></ul></ul><ul><ul><li>The severity of diabetic nephropathy is related to the severity of hypertension </li></ul></ul><ul><ul><li>The absence of diabetic retinopathy excludes diabetic nephropathy </li></ul></ul><ul><ul><li>Kimmelstiel-Wilson lesions must be present to diagnose diabetic nephropathy </li></ul></ul>
    23. 23. Case 1 <ul><li>Question 5 </li></ul><ul><li>When a pt with T2DM is assessed for diabetic nephropathy, which of the following is correct? </li></ul><ul><ul><li>The absence of proteinuria excludes diabetic nephropathy </li></ul></ul><ul><ul><li>Hypertension usually indicates the presence of concomitant macrovascular disease </li></ul></ul><ul><ul><li>The severity of diabetic nephropathy is related to the severity of hypertension </li></ul></ul><ul><ul><li>The absence of diabetic retinopathy excludes diabetic nephropathy </li></ul></ul><ul><ul><li>Kimmelstiel-Wilson lesions must be present to diagnose diabetic nephropathy </li></ul></ul>
    24. 24. Discussion <ul><li>NHANES 3 study – T2DM with creat > 150 -1/3 rd had no evidence of proteinuria </li></ul><ul><li>Due to more of a Vasculopathy (particularly microvascular) than by classic histological changes of glomerular basement membrane thickening and mesangial expansion </li></ul><ul><li>Vasculopathy is associated with hypertension and may not be associated with proteinuria </li></ul><ul><li>Vasculopathy leads to progressive CKD, accelerated by diabetic control, hypertension, proteinuria </li></ul>
    25. 25. Take home message <ul><li>Not all T2DM with CKD have proteinuria </li></ul><ul><li>Hypertension is common and is associated with progressive CKD </li></ul><ul><li>If hypertension is resistant, think RAS </li></ul><ul><li>Diabetic retinopathy and nephropathy are commonly but not always bound together </li></ul>
    26. 26. Case 1 <ul><li>Question 6 </li></ul><ul><li>Which of the following is true regarding treatment aimed at slowing the progression of CKD and at preventing cardiovascular events such as AMI and CVA? </li></ul><ul><ul><li>The target BP is <140/90 </li></ul></ul><ul><ul><li>Only ACEI and AR2B slow progression CKD </li></ul></ul><ul><ul><li>In large studies, ACEi have been shown to improve overall survival in diabetics with large and small vessel vasculopathy </li></ul></ul><ul><ul><li>The presence of renovascular diesease is a contraindication to the use of ACEI or AR2B </li></ul></ul>
    27. 27. Case 1 <ul><li>Question 6 </li></ul><ul><li>Which of the following is true regarding treatment aimed at slowing the progression of CKD and at preventing cardiovascular events such as AMI and CVA? </li></ul><ul><ul><li>The target BP is <140/90 </li></ul></ul><ul><ul><li>Only ACEI and AR2B slow progression CKD </li></ul></ul><ul><ul><li>In large studies, ACEi have been shown to improve overall survival in diabetics with large and small vessel vasculopathy </li></ul></ul><ul><ul><li>The presence of renovascular diesease is a contraindication to the use of ACEI or AR2B </li></ul></ul>
    28. 28. Discussion <ul><li>Target BP should be <130/80 </li></ul><ul><li>If diabetic with protenuria <1g/24 hours target should be <120/75 </li></ul><ul><li>BP decrease alone contributes to slowing CKD </li></ul><ul><li>All antihypertensives good for this but AR2B and ACEI have greatest efficacy </li></ul><ul><li>HOPE and PROGRESS show ACEI in high risk populations decrease cardiovascular events </li></ul><ul><li>Atherosclerotic renovascular disease with evidence of RAS is not an absolute contraindication to the use of ACEI or AR2B but you need to be very careful </li></ul>
    29. 29. Take home message <ul><li>Target BP </li></ul><ul><ul><li>Proteinuria <1g/24hours 130/80 </li></ul></ul><ul><ul><li>Proteinuria >1g/24hours 120/75 </li></ul></ul><ul><li>For diabetic CKD target BP <120/75 </li></ul><ul><li>AR2B and ACEI preferred but any agent ok as long as BP controlled </li></ul><ul><li>Atherosclerotic renovascular disease not absolute contraindication to ACEi </li></ul>
    30. 30. Case 1 <ul><li>Question 7 </li></ul><ul><li>In general, which of the following results in 50yo indicate need for referral to Nephrologist? </li></ul><ul><ul><li>Diabetic with eGFR <60 and poorly controlled hypertension </li></ul></ul><ul><ul><li>A non diabetic with an eGFR 30-60mls, proteinuria <0.5g/day, controlled BP </li></ul></ul><ul><ul><li>Proteinuria >1g/day with normal eGFR </li></ul></ul><ul><ul><li>Unexplained decline in kidney function (>15% drop GFR over 3 months) </li></ul></ul>
    31. 31. Case 1 <ul><li>Question 7 </li></ul><ul><li>In general, which of the following results in 50yo indicate need for referral to Nephrologist? </li></ul><ul><ul><li>Diabetic with eGFR <60 and poorly controlled hypertension </li></ul></ul><ul><ul><li>A non diabetic with an eGFR 30-60mls, proteinuria <0.5g/day, controlled BP </li></ul></ul><ul><ul><li>Proteinuria >1g/day with normal eGFR </li></ul></ul><ul><ul><li>Unexplained decline in kidney function (>15% drop GFR over 3 months) </li></ul></ul>
    32. 32. Discussion <ul><li>Late referral to Nephrologist associated with poorer outcomes, greater morbidity for RRT and pall care groups </li></ul><ul><li>Guidelines only and controversial – if not sure err on side of caution </li></ul><ul><li>In general, stable patients with eGFR >30 don’t require referral but a significant number can benefit from referral and progression may be able to be averted </li></ul>
    33. 33. Take home message <ul><li>Indications for referral to Nephrologist </li></ul><ul><ul><li>Proteinuria > 1g/24 hrs </li></ul></ul><ul><ul><li>eGFR < 30mls in non diabetics </li></ul></ul><ul><ul><li>eGFR < 60mls in diabetics </li></ul></ul><ul><ul><li>Unexplained decline in kidney function </li></ul></ul><ul><ul><li>Glomerular haematuria with proteinuria </li></ul></ul><ul><ul><li>CKD with difficult to control hypertension </li></ul></ul><ul><ul><li>Otherwise unexplained anaemia </li></ul></ul>
    34. 34. Case 1 <ul><li>Question 8 </li></ul><ul><li>Pt’s Hb dropped to 90 and treatment with epo commenced. Which of the following are true? </li></ul><ul><ul><li>Most common cause for anaemia in CKD with GFR<60 is bleeding from the upper GIT </li></ul></ul><ul><ul><li>If pt on EPO, iron therapy is not required if serum ferritin is >100 </li></ul></ul><ul><ul><li>Treating the anaemia of CKD is not required until HB<100 </li></ul></ul><ul><ul><li>Anaemia occurs earlier in the course of CKD in diabetic than non diabetic patients </li></ul></ul>
    35. 35. Case 1 <ul><li>Question 8 </li></ul><ul><li>Pt’s Hb dropped to 90 and treatment with epo commenced. Which of the following are true? </li></ul><ul><ul><li>Most common cause for anaemia in CKD with GFR<60 is bleeding from the upper GIT </li></ul></ul><ul><ul><li>If pt on EPO, iron therapy is not required if serum ferritin is >100 </li></ul></ul><ul><ul><li>Treating the anaemia of CKD is not required until HB<100 </li></ul></ul><ul><ul><li>Anaemia occurs earlier in the course of CKD in diabetic than non diabetic patients </li></ul></ul>
    36. 36. Discussion <ul><li>Small increased risk in GIH </li></ul><ul><li>Anaemia of CKD is due to relative erythropoietin deficiency and show up in stage 3 and is more severe in diabetics </li></ul><ul><li>Prior to epo, iron deficiency was rare due to blood transfusions </li></ul><ul><li>Now relative iron deficiency is a problem </li></ul><ul><li>EPO can only be prescribed once Hb <100 </li></ul><ul><li>Aim Hb 120 </li></ul><ul><li>Worse outcomes if Hb higher than this </li></ul><ul><li>Renal anaemia is often iron responsive </li></ul>
    37. 37. Discussion <ul><li>Aims </li></ul><ul><li>Prior to starting epo – ferritin >100 </li></ul><ul><li>Once epo started – ferritin 400-600 </li></ul><ul><li>Transferrin saturation >20% prior to epo therapy </li></ul><ul><li>Transferrin saturation 30-40% post epo starting </li></ul><ul><li>Adequate iron stores required for epo to work </li></ul><ul><li>Iron deficiency is most common cause of hyporesponsiveness to epo </li></ul>
    38. 38. Take home message <ul><li>Impaired absorption of oral iron and increased utilization of iron with EPO therapy have contributed to the development of iron deficiency </li></ul><ul><li>Optimize responsiveness to EPO – targets for ferritin 300-600 and saturation 30-40% </li></ul>
    39. 39. Case 1 <ul><li>CKD progresses and he needs dialysis. GP questions whether other therpay may have prevented such a rapid progression to ESKD </li></ul><ul><li>Question 9 </li></ul><ul><ul><li>For which of the following therapies is there level 1 evidence for efficacy in the CKD population </li></ul></ul><ul><ul><ul><li>Cholesterol lowering with statins both to slow progressive decline of renal function and to reduce the increased cardiovascular risk associated with CKD </li></ul></ul></ul><ul><ul><ul><li>Uric acid reduction slows progression </li></ul></ul></ul><ul><ul><ul><li>Exercise and weight loss improve insulin resistance and slow progression </li></ul></ul></ul><ul><ul><ul><li>Aldosterone blockade can further slow progression </li></ul></ul></ul><ul><ul><ul><li>AR2B can further slow progression in pts on ACEI </li></ul></ul></ul>
    40. 40. Case 1 <ul><li>CKD progresses and he needs dialysis. GP questions whether other therpay may have prevented such a rapid progression to ESKD </li></ul><ul><li>Question 9 </li></ul><ul><ul><li>For which of the following therapies is there level 1 evidence for efficacy in the CKD population </li></ul></ul><ul><ul><ul><li>Cholesterol lowering with statins both to slow progressive decline of renal function and to reduce the increased cardiovascular risk associated with CKD </li></ul></ul></ul><ul><ul><ul><li>Uric acid reduction slows progression </li></ul></ul></ul><ul><ul><ul><li>Exercise and weight loss improve insulin resistance and slow progression </li></ul></ul></ul><ul><ul><ul><li>Aldosterone blockade can further slow progression </li></ul></ul></ul><ul><ul><ul><li>AR2B can further slow progression in pts on ACEI </li></ul></ul></ul>
    41. 41. Discussion <ul><li>Decrease uric acid, cessation of smoking, weight loss all slow progression but evidence is poor; studies small, non randomised, case studies </li></ul><ul><li>Statins thought to help but again studies not good – no RCT </li></ul><ul><li>AR2B and ACEI combo thought to help if patient proteinuric – COOPERATE study </li></ul>
    42. 42. Take home message <ul><li>Allopurinol, weight loss, cessation of smoking, exercise may all slow progression of CKD but no level one evidence </li></ul><ul><li>Beneficial effect of lipid though to be present but still waiting level 1 evidence </li></ul><ul><li>AR2B and ACEi together can help delay progression in pt with proteinuria </li></ul>
    43. 43. Case 1 <ul><li>Question 10 </li></ul><ul><li>In type 2 DM ACEi and AR2B have been shown to slow the development of progression of nephropathy in pts who are </li></ul><ul><ul><li>Normoalbuminuric and normotensive </li></ul></ul><ul><ul><li>Normoalbuminuric and hpertensive </li></ul></ul><ul><ul><li>Microalbuminuric and hypertensive </li></ul></ul><ul><ul><li>Macroalbuminuric and hypertensive </li></ul></ul>
    44. 44. Case 1 <ul><li>Question 10 </li></ul><ul><li>In type 2 DM ACEi and AR2B have been shown to slow the development of progression of nephropathy in pts who are </li></ul><ul><ul><li>Normoalbuminuric and normotensive </li></ul></ul><ul><ul><li>Normoalbuminuric and hypertensive *** </li></ul></ul><ul><ul><li>Microalbuminuric and hypertensive </li></ul></ul><ul><ul><li>Macroalbuminuric and hypertensive </li></ul></ul>
    45. 45. Discussion <ul><li>BENEDICT study </li></ul><ul><ul><li>ACEi decreased albumuria in T2DM with hypertension and normal albumin excretion </li></ul></ul><ul><ul><li>RENAAL study </li></ul></ul><ul><ul><li>Similar results with AR2B </li></ul></ul>
    46. 46. Take home message <ul><li>ACEi and AR2B have been proven in hypertensive type 2 diabetics to slow progression of CKD, development of microalbuminuria, macroalbuminuria </li></ul><ul><li>Don’t use combination in patients who are simply hypertensive </li></ul>
    47. 47. Conclusion <ul><li>Keep your chronic disease protocols handy </li></ul>
    48. 48. Acknowledgements <ul><li>Information taken from chapter 11 Clinical Cases in Kidney Disease by David Harris and colleagues </li></ul>

    ×