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Approach to CKD
Patients
Dr Md Tahasanul Khair
Shahad
Diploma (Endocrinology And Metabolism)
BIRDEM General Hospital
Learning Objectives
• Facilitate timely testing and intervention in patients at-
risk for chronic kidney disease (CKD).
• Apply appropriate clinical measures to manage risk and
increase patient safety in CKD.
• Co-manage and refer patients to nephrology
specialists, when appropriate, in order to improve
outcomes in CKD.
Primary Care Providers –
First Line of Defense Against CKD
• Primary care professionals can play a significant role in
early diagnosis, treatment, and patient education.
• A greater emphasis on detecting CKD, and managing it
prior to referral, can improve patient outcomes.
CKD is Part of Primary Care
The Prevalence of CKD
Reference:Oxford
Handbook Of Nephrology
CKD-CVD-Diabetes Link: CKD is a
Disease Multiplier
Reference:Harrison
Nephrology
CKD Risk Factors*
Modifiable
• Diabetes
• Hypertension
• History of AKI
• Frequent NSAID use
Non-Modifiable
• Family history of
kidney disease,
diabetes, or
hypertension
• Age 60 or older (GFR
declines normally with
age)
• Race/U.S. ethnic
minority status
*Reference:Oxford Handbook of Nephrology
Diabetes and hypertension are
leading causes of kidney failure
Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.
Reference:Harrison Nephrology
CKD Screening and Evaluation
Reference:Oxford Handbook Of Nephrology
Reference:Oxford Handbook Of Nephrology
Reference:Davidson 24th
Edition
Gaps in CKD Diagnosis
.
% of Patients
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
50
40
30
20
10
0
Reference:Harrison
Nephrology
Improved Diagnosis…
Studies demonstrate that clinician behavior changes
when CKD diagnosis improves. Significant
improvements realized in:
⚬ Increased urinary albumin testing
⚬ Increased appropriate use of ACEi or ARB
⚬ Avoidance of NSAIDs prescribing among
patients with low eGFR
⚬ Appropriate nephrology consultation
Reference:Harrison
Nephrology
Screening Tools: eGFR
• Considered the best overall index of kidney function.
• Normal GFR varies according to age, sex, and body
size, and declines with age.
• The KDIGO guideline recommends using the CKD-
EPI Creatinine Equation to estimate GFR. Other
useful calculators related to kidney disease include
MDRD(Modification of Diet In Renal Disease) and
Cockroft Gault.
Reference:Oxford Handbook Of Nephrology
Reference:Davidson 24th Edition
Screening Tools: ACR
• Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing
albumin concentration in milligrams by creatinine concentration in
grams.
• Creatinine assists in adjusting albumin levels for varying urine
concentrations, which allows for more accurate results versus
albumin alone.
• Spot urine albumin-to-creatinine ratio for quantification of
proteinuria
⚬ New guidelines classify albuminuria as mild, moderately or
severely increased
• First morning void preferable
• 24hr urine test rarely necessary
Reference:Oxford Handbook of
Nephrology
Criteria for CKD
• Abnormalities of kidney structure or function,
present for >3 months, with implications for health
• Either of the following must be present for >3
months:
⚬ ACR >30 mg/g
⚬ Markers of kidney damage (one or more*)
⚬ GFR <60 mL/min/1.73 m²
Reference:KDIGO Guideline
Old Classification of CKD as Defined by Kidney Disease Outcomes
Quality Initiative (KDOQI) Modified and Endorsed by KDIGO
Note: GFR is given in mL/min/1.73² m²
Stage Description
Classification
by Severity
Classification
by Treatment
1
Kidney damage with
normal or increased GFR
GFR ≥ 90
2
Kidney damage with
mild decrease in GFR
GFR of 60-89
T if kidney
transplant
3 Moderate decrease in GFR GFR of 30-59 recipient
4 Severe decrease in GFR GFR of 15-29 D if dialysis
5 Kidney failure GFR < 15 D if dialysis
Reference:KDIGO
Guideline
Classification of CKD Based on GFR
and Albuminuria Categories: “Heat Map”
Reference:KDIGO Guideline
CKD Management
Goals of Care in CKD
• Slow decline in kidney function
• Blood pressure control
⚬ ACR <30 mg/g: ≤140/90 mm Hg
⚬ ACR 30-300 mg/g: ≤130/80 mm Hg*
⚬ ACR >300 mg/g: ≤130/80 mm Hg
⚬ Individualize targets and agents according to age,
coexistent CVD, and other comorbidities
Reference:
• Kidney Disease: Improving Global Outcomes (KDIGO) Guideline
Reference:Oxford Handbook Of Nephrology
Slowing CKD Progression: ACEi or ARB
• Risk/benefit should be carefully assessed in the elderly and
medically fragile
• Check labs after initiation
⚬ If less than 25% SCr increase, continue and monitor
⚬ If more than 25% SCr increase, stop ACEi and evaluate for
RAS
• Continue until contraindication arises, no absolute eGFR cutoff
• Better proteinuria suppression with low Na diet and diuretics
• Avoid volume depletion
• Avoid ACEi and ARB in combination1,2
⚬ Risk of adverse events (impaired kidney function,
hyperkalemia)
.Reference:KDIGO Guideline
Goals of Care in CKD: Glucose
Control
• Target HbA1c ~7.0%
• Can be extended above 7.0% with comorbidities or limited
life expectancy, and risk of hypoglycemia
• Risk of hypoglycemia increases as kidney function
becomes impaired
• Declining kidney function may necessitate changes to
diabetes medications and renally-cleared drugs
Reference:KDIGO Guideline
Modification of Other CVD Risk
Factors in CKD
• Smoking cessation
• Exercise
• Weight reduction to optimal targets
• Lipid lowering therapy
⚬ In adults >50 yrs, statin when eGFR ≥ 60
ml/min/1.73m²; statin or statin/ezetimibe combination
when eGFR < 60 ml/min/1.73m²
⚬ In adults < 50 yrs, statin if history of known CAD, MI,
DM, stroke
• Aspirin is indicated for secondary but not primary
prevention
Reference:Kidney Disease: Improving Global
Outcomes (KDIGO) Guideline
Detect and Manage CKD Complications
• Anemia
⚬ Initiate iron therapy if TSAT ≤ 30% and ferritin ≤ 500 ng/mL (IV
iron for dialysis, Oral for non-dialysis CKD)
⚬ Individualize erythropoiesis stimulating agent (ESA) therapy:
Start ESA if Hb <10 g/dl, and maintain Hb <11.5 g/dl. Ensure
adequate Fe stores.
⚬ Appropriate iron supplementation is needed for ESA to be
effective
• CKD-Mineral and Bone Disorder (CKD-MBD)
⚬ Treat with D3 as indicated to achieve normal serum levels
⚬ 2000 IU po qd is cheaper and better absorbed than 50,000 IU
monthly dose.
⚬ Limit phosphorus in diet (CKD stage 4/5), with emphasis on
decreasing packaged products - Refer to renal RD
⚬ May need phosphate binders
Reference:Oxford Handbook Of Nephrology
Detect and Manage CKD Complications
• Metabolic acidosis
⚬ Usually occurs later in CKD
⚬ Serum bicarb >22mEq/L
⚬ Correction of metabolic acidosis may slow CKD progression
and improve patients functional status1,2
• Hyperkalemia
⚬ Reduce dietary potassium
⚬ Stop NSAIDs, COX-2 inhibitors, potassium sparing diuretics
(aldactone)
⚬ Stop or reduce beta blockers, ACEi/ARBs
⚬ Avoid salt substitutes that contain potassium
Reference:Oxford Handbook Of Nephrology
What can primary care providers do?
• Recognize and test at-risk patients
• Educate patients about CKD and treatment
• Manage blood pressure and diabetes
• Address other CVD risk factors
• Monitor eGFR and ACR (encourage labs to report
these tests)
What can primary care providers do?
• Evaluate and manage anemia, malnutrition, CKD-MBD,
and other complications in at-risk patients
• Refer to dietitian for nutritional guidance
• Consider patient safety issues in CKD
• Consult or team with a nephrologist (co-management)
• Refer patient to nephrology when appropriate
Reference:KDIGO Guideline
Co-Management, Patient Safety,
and Nephrology Specialist Referral
Co-Management Model
• Collaborative care
⚬ Formal arrangement
⚬ Curbside consult
• Care coordination
• Clinical decision support
• Population health
⚬ Development of
treatment protocols
Reference:Harrison Nephrology
Collaborative Care Agreements
• Soft Contract between primary care and nephrologist
• Defines responsibilities of primary care
⚬ Provide pertinent clinical information to inform the consultation prior
to the scheduled visit.
⚬ Initiate a phone call if the condition is emergent
⚬ Provide timely referrals with adequate number of visits to treat the
condition.
• Defines responsibilities of nephrologist
⚬ Timely communication of consultation (7 days routine & 48 hours
emergent) .
⚬ No consultation to other specialist initiated without primary care
input.
Reference:Harrison Nephrology
Kidney
damage and
normal or GFR
Kidney
damage and
mild
GFR
Severe
GFR
Kidney
failure
Moderate
GFR
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Nephrologist
Primary Care Practitioner
The Patient (always)
and other subspecialists (as needed)
GFR 90 60 30 15
Who Should be Involved in the
Patient Safety Approach to CKD?
Patient safety
Consult?
Reference: KDIGO Guideline
CKD Patient Safety Issues
• Medication errors
⚬ Toxicity (nephrologic or other)
⚬ Improper dosing
⚬ Inadequate monitoring
• Electrolytes
⚬ Hyperkalemia
⚬ Hypoglycemia
⚬ Hypermagnesemia
⚬ Hyperphosphatemia
• Miscellaneous
⚬ Multidrug-resistant infections
⚬ Vessel preservation/dialysis access
CKD Patient Safety Issues
• Diagnostic tests
⚬ Iodinated contrast media: AKI
⚬ Gadolinium-based contrast: NSF
⚬ Sodium Phosphate bowel preparations: AKI, CKD
• CVD
⚬ Missed diagnosis
⚬ Improper management
• Fluid management
⚬ Hypotension
⚬ AKI
⚬ CHF exacerbation
Reference:KDIGO Guideline
Common Medications Requiring Dose
Reduction in CKD
• Allopurinol
• Gabapentin
⚬ CKD 4- Max dose 300mg qd
⚬ CKD 5- Max dose 300mg qod
• Reglan
⚬ Reduce 50% for eGFR< 40
⚬ Can cause irreversible EPS
with chronic use
• Narcotics
⚬ Methadone and fentanyl best
for ESRD patients
■ Lowest risk of toxic
metabolites
• Renally cleared beta blockers
⚬ Atenolol, bisoprolol, nadolol
• Digoxin
• Some Statins
⚬ Lovastatin, pravastatin,
simvastatin. Fluvastatin,
rosuvastatin
• Antimicrobials
⚬ Antifungals, aminoglycosides,
Bactrim, Macrobid
• Enoxaparin
• Methotrexate
• Colchicine
Reference:KDIGO Guideline
Key Points on Medications in CKD
• CKD patients at high risk for drug-related adverse events
• Several classes of drugs renally eliminated
• Consider kidney function and current eGFR (not just SCr) when
prescribing medicines
• Minimize pill burden as much as possible
• Remind CKD patients to avoid NSAIDs
• No Dual RAAS blockade
• Any medicine with >30% renal clearance probably needs dose
adjustment for CKD
• No bisphosphonates for eGFR <30
Reference:KDIGO Guideline
*Reference:Davidson Medicine(24th Edition)
Indications for Referral to Specialist Kidney Care
Services for People with CKD
* eGFR <30 mL/min/1.73 m2
*Rapid deterioration in renal function (>25% from previous or >15 mL/min/
1.73 m2/year)
* Significant proteinuria (PCR >100 mg/mmol or ACR >70 mg/mmol*), unless
known to be due to diabetes and patient is already on appropriate medications
* ACR >30 mg/mmol* with non-visible haematuria
* Hypertension that remains poorly controlled despite at least four
antihypertensive medications
* Suspicion of renal involvement in multisystem disease
Take Home Messages:
• Primary Care Providers play an important role.
• Identify risk factors.
• Know patient’s GFR using appropriate
screening tools.
• Help your patient adjust medication.
• Modify diet.
• Partner and refer to specialist.
Approach To CKD Patient....................pptx.pptx

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Approach To CKD Patient....................pptx.pptx

  • 1. Approach to CKD Patients Dr Md Tahasanul Khair Shahad Diploma (Endocrinology And Metabolism) BIRDEM General Hospital
  • 2. Learning Objectives • Facilitate timely testing and intervention in patients at- risk for chronic kidney disease (CKD). • Apply appropriate clinical measures to manage risk and increase patient safety in CKD. • Co-manage and refer patients to nephrology specialists, when appropriate, in order to improve outcomes in CKD.
  • 3. Primary Care Providers – First Line of Defense Against CKD • Primary care professionals can play a significant role in early diagnosis, treatment, and patient education. • A greater emphasis on detecting CKD, and managing it prior to referral, can improve patient outcomes. CKD is Part of Primary Care
  • 6. CKD-CVD-Diabetes Link: CKD is a Disease Multiplier Reference:Harrison Nephrology
  • 7. CKD Risk Factors* Modifiable • Diabetes • Hypertension • History of AKI • Frequent NSAID use Non-Modifiable • Family history of kidney disease, diabetes, or hypertension • Age 60 or older (GFR declines normally with age) • Race/U.S. ethnic minority status *Reference:Oxford Handbook of Nephrology
  • 8. Diabetes and hypertension are leading causes of kidney failure Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race. Reference:Harrison Nephrology
  • 9. CKD Screening and Evaluation
  • 13. Gaps in CKD Diagnosis . % of Patients Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis 50 40 30 20 10 0 Reference:Harrison Nephrology
  • 14. Improved Diagnosis… Studies demonstrate that clinician behavior changes when CKD diagnosis improves. Significant improvements realized in: ⚬ Increased urinary albumin testing ⚬ Increased appropriate use of ACEi or ARB ⚬ Avoidance of NSAIDs prescribing among patients with low eGFR ⚬ Appropriate nephrology consultation Reference:Harrison Nephrology
  • 15. Screening Tools: eGFR • Considered the best overall index of kidney function. • Normal GFR varies according to age, sex, and body size, and declines with age. • The KDIGO guideline recommends using the CKD- EPI Creatinine Equation to estimate GFR. Other useful calculators related to kidney disease include MDRD(Modification of Diet In Renal Disease) and Cockroft Gault. Reference:Oxford Handbook Of Nephrology
  • 17. Screening Tools: ACR • Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams. • Creatinine assists in adjusting albumin levels for varying urine concentrations, which allows for more accurate results versus albumin alone. • Spot urine albumin-to-creatinine ratio for quantification of proteinuria ⚬ New guidelines classify albuminuria as mild, moderately or severely increased • First morning void preferable • 24hr urine test rarely necessary Reference:Oxford Handbook of Nephrology
  • 18. Criteria for CKD • Abnormalities of kidney structure or function, present for >3 months, with implications for health • Either of the following must be present for >3 months: ⚬ ACR >30 mg/g ⚬ Markers of kidney damage (one or more*) ⚬ GFR <60 mL/min/1.73 m² Reference:KDIGO Guideline
  • 19. Old Classification of CKD as Defined by Kidney Disease Outcomes Quality Initiative (KDOQI) Modified and Endorsed by KDIGO Note: GFR is given in mL/min/1.73² m² Stage Description Classification by Severity Classification by Treatment 1 Kidney damage with normal or increased GFR GFR ≥ 90 2 Kidney damage with mild decrease in GFR GFR of 60-89 T if kidney transplant 3 Moderate decrease in GFR GFR of 30-59 recipient 4 Severe decrease in GFR GFR of 15-29 D if dialysis 5 Kidney failure GFR < 15 D if dialysis Reference:KDIGO Guideline
  • 20. Classification of CKD Based on GFR and Albuminuria Categories: “Heat Map” Reference:KDIGO Guideline
  • 22. Goals of Care in CKD • Slow decline in kidney function • Blood pressure control ⚬ ACR <30 mg/g: ≤140/90 mm Hg ⚬ ACR 30-300 mg/g: ≤130/80 mm Hg* ⚬ ACR >300 mg/g: ≤130/80 mm Hg ⚬ Individualize targets and agents according to age, coexistent CVD, and other comorbidities Reference: • Kidney Disease: Improving Global Outcomes (KDIGO) Guideline
  • 24. Slowing CKD Progression: ACEi or ARB • Risk/benefit should be carefully assessed in the elderly and medically fragile • Check labs after initiation ⚬ If less than 25% SCr increase, continue and monitor ⚬ If more than 25% SCr increase, stop ACEi and evaluate for RAS • Continue until contraindication arises, no absolute eGFR cutoff • Better proteinuria suppression with low Na diet and diuretics • Avoid volume depletion • Avoid ACEi and ARB in combination1,2 ⚬ Risk of adverse events (impaired kidney function, hyperkalemia) .Reference:KDIGO Guideline
  • 25. Goals of Care in CKD: Glucose Control • Target HbA1c ~7.0% • Can be extended above 7.0% with comorbidities or limited life expectancy, and risk of hypoglycemia • Risk of hypoglycemia increases as kidney function becomes impaired • Declining kidney function may necessitate changes to diabetes medications and renally-cleared drugs Reference:KDIGO Guideline
  • 26. Modification of Other CVD Risk Factors in CKD • Smoking cessation • Exercise • Weight reduction to optimal targets • Lipid lowering therapy ⚬ In adults >50 yrs, statin when eGFR ≥ 60 ml/min/1.73m²; statin or statin/ezetimibe combination when eGFR < 60 ml/min/1.73m² ⚬ In adults < 50 yrs, statin if history of known CAD, MI, DM, stroke • Aspirin is indicated for secondary but not primary prevention Reference:Kidney Disease: Improving Global Outcomes (KDIGO) Guideline
  • 27. Detect and Manage CKD Complications • Anemia ⚬ Initiate iron therapy if TSAT ≤ 30% and ferritin ≤ 500 ng/mL (IV iron for dialysis, Oral for non-dialysis CKD) ⚬ Individualize erythropoiesis stimulating agent (ESA) therapy: Start ESA if Hb <10 g/dl, and maintain Hb <11.5 g/dl. Ensure adequate Fe stores. ⚬ Appropriate iron supplementation is needed for ESA to be effective • CKD-Mineral and Bone Disorder (CKD-MBD) ⚬ Treat with D3 as indicated to achieve normal serum levels ⚬ 2000 IU po qd is cheaper and better absorbed than 50,000 IU monthly dose. ⚬ Limit phosphorus in diet (CKD stage 4/5), with emphasis on decreasing packaged products - Refer to renal RD ⚬ May need phosphate binders Reference:Oxford Handbook Of Nephrology
  • 28. Detect and Manage CKD Complications • Metabolic acidosis ⚬ Usually occurs later in CKD ⚬ Serum bicarb >22mEq/L ⚬ Correction of metabolic acidosis may slow CKD progression and improve patients functional status1,2 • Hyperkalemia ⚬ Reduce dietary potassium ⚬ Stop NSAIDs, COX-2 inhibitors, potassium sparing diuretics (aldactone) ⚬ Stop or reduce beta blockers, ACEi/ARBs ⚬ Avoid salt substitutes that contain potassium Reference:Oxford Handbook Of Nephrology
  • 29. What can primary care providers do? • Recognize and test at-risk patients • Educate patients about CKD and treatment • Manage blood pressure and diabetes • Address other CVD risk factors • Monitor eGFR and ACR (encourage labs to report these tests)
  • 30. What can primary care providers do? • Evaluate and manage anemia, malnutrition, CKD-MBD, and other complications in at-risk patients • Refer to dietitian for nutritional guidance • Consider patient safety issues in CKD • Consult or team with a nephrologist (co-management) • Refer patient to nephrology when appropriate Reference:KDIGO Guideline
  • 31. Co-Management, Patient Safety, and Nephrology Specialist Referral
  • 32. Co-Management Model • Collaborative care ⚬ Formal arrangement ⚬ Curbside consult • Care coordination • Clinical decision support • Population health ⚬ Development of treatment protocols Reference:Harrison Nephrology
  • 33. Collaborative Care Agreements • Soft Contract between primary care and nephrologist • Defines responsibilities of primary care ⚬ Provide pertinent clinical information to inform the consultation prior to the scheduled visit. ⚬ Initiate a phone call if the condition is emergent ⚬ Provide timely referrals with adequate number of visits to treat the condition. • Defines responsibilities of nephrologist ⚬ Timely communication of consultation (7 days routine & 48 hours emergent) . ⚬ No consultation to other specialist initiated without primary care input. Reference:Harrison Nephrology
  • 34. Kidney damage and normal or GFR Kidney damage and mild GFR Severe GFR Kidney failure Moderate GFR Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Nephrologist Primary Care Practitioner The Patient (always) and other subspecialists (as needed) GFR 90 60 30 15 Who Should be Involved in the Patient Safety Approach to CKD? Patient safety Consult? Reference: KDIGO Guideline
  • 35. CKD Patient Safety Issues • Medication errors ⚬ Toxicity (nephrologic or other) ⚬ Improper dosing ⚬ Inadequate monitoring • Electrolytes ⚬ Hyperkalemia ⚬ Hypoglycemia ⚬ Hypermagnesemia ⚬ Hyperphosphatemia • Miscellaneous ⚬ Multidrug-resistant infections ⚬ Vessel preservation/dialysis access
  • 36. CKD Patient Safety Issues • Diagnostic tests ⚬ Iodinated contrast media: AKI ⚬ Gadolinium-based contrast: NSF ⚬ Sodium Phosphate bowel preparations: AKI, CKD • CVD ⚬ Missed diagnosis ⚬ Improper management • Fluid management ⚬ Hypotension ⚬ AKI ⚬ CHF exacerbation Reference:KDIGO Guideline
  • 37. Common Medications Requiring Dose Reduction in CKD • Allopurinol • Gabapentin ⚬ CKD 4- Max dose 300mg qd ⚬ CKD 5- Max dose 300mg qod • Reglan ⚬ Reduce 50% for eGFR< 40 ⚬ Can cause irreversible EPS with chronic use • Narcotics ⚬ Methadone and fentanyl best for ESRD patients ■ Lowest risk of toxic metabolites • Renally cleared beta blockers ⚬ Atenolol, bisoprolol, nadolol • Digoxin • Some Statins ⚬ Lovastatin, pravastatin, simvastatin. Fluvastatin, rosuvastatin • Antimicrobials ⚬ Antifungals, aminoglycosides, Bactrim, Macrobid • Enoxaparin • Methotrexate • Colchicine Reference:KDIGO Guideline
  • 38. Key Points on Medications in CKD • CKD patients at high risk for drug-related adverse events • Several classes of drugs renally eliminated • Consider kidney function and current eGFR (not just SCr) when prescribing medicines • Minimize pill burden as much as possible • Remind CKD patients to avoid NSAIDs • No Dual RAAS blockade • Any medicine with >30% renal clearance probably needs dose adjustment for CKD • No bisphosphonates for eGFR <30 Reference:KDIGO Guideline
  • 39. *Reference:Davidson Medicine(24th Edition) Indications for Referral to Specialist Kidney Care Services for People with CKD * eGFR <30 mL/min/1.73 m2 *Rapid deterioration in renal function (>25% from previous or >15 mL/min/ 1.73 m2/year) * Significant proteinuria (PCR >100 mg/mmol or ACR >70 mg/mmol*), unless known to be due to diabetes and patient is already on appropriate medications * ACR >30 mg/mmol* with non-visible haematuria * Hypertension that remains poorly controlled despite at least four antihypertensive medications * Suspicion of renal involvement in multisystem disease
  • 40. Take Home Messages: • Primary Care Providers play an important role. • Identify risk factors. • Know patient’s GFR using appropriate screening tools. • Help your patient adjust medication. • Modify diet. • Partner and refer to specialist.

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