1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail
When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail
AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE AND NEW TREATMENT APPROACHESPARUL UNIVERSITY
Autosomal dominant polycystic kidney disease is the most common inherited kidney disease, results in progressive loss of renal function due to the development and growth of cysts. Advances in understanding the nature of the disease have led to increased awareness of ADPKD, improvements in imaging modalities for diagnosis and assessment and the availability of effective therapies because patients with ADPKD often experience a range of renal and extrarenal complications. Approximately 78% of cases of ADPKD arise from PKD1 mutations. PKD2 mutations account for another 15%. These mutation-driven changes produce the hallmark disease process of ADPKD: development of large, fluid-filled cysts in the kidney, which over time increase kidney size and volume and compromise kidney function, leading to decreased life expectancy, need for dialysis and/or transplantation, cardiovascular/cerebro-vascular disease, and intracranial aneurysms. The involvement of the vasopressin system makes it a target for therapy designed to slow progression of ADPKD. Steps are to taken to slow down the progression of disease by early diagnosis and symptomatic treatment approaches are needed to be followed to prevent the complications. As RAAS mechanisms are prime factors for progression and worsening of the condition, steps should be taken to prevent the over activity of RAAS by using many of the newer therapeutic agents show promise in preventing or stabilizing cyst growth, providing much needed hope in this currently relentless condition. Hypertension should be kept in check to prevent any chances of strokes. Making lifestyle changes such as dash diet and maintaining adequate hydration to maintain the normal renal sufficiency are some of the key approaches to control or to prevent the progression of this condition and help the patient to lead normal life and life expectancy
Case Presentation on Multiple Organ Dysfunction Syndrome with Diabetic Nephropathy, Hypertension, Severe Metabolic Acidosis and Acute Respiratory Distress Syndrome
AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE AND NEW TREATMENT APPROACHESPARUL UNIVERSITY
Autosomal dominant polycystic kidney disease is the most common inherited kidney disease, results in progressive loss of renal function due to the development and growth of cysts. Advances in understanding the nature of the disease have led to increased awareness of ADPKD, improvements in imaging modalities for diagnosis and assessment and the availability of effective therapies because patients with ADPKD often experience a range of renal and extrarenal complications. Approximately 78% of cases of ADPKD arise from PKD1 mutations. PKD2 mutations account for another 15%. These mutation-driven changes produce the hallmark disease process of ADPKD: development of large, fluid-filled cysts in the kidney, which over time increase kidney size and volume and compromise kidney function, leading to decreased life expectancy, need for dialysis and/or transplantation, cardiovascular/cerebro-vascular disease, and intracranial aneurysms. The involvement of the vasopressin system makes it a target for therapy designed to slow progression of ADPKD. Steps are to taken to slow down the progression of disease by early diagnosis and symptomatic treatment approaches are needed to be followed to prevent the complications. As RAAS mechanisms are prime factors for progression and worsening of the condition, steps should be taken to prevent the over activity of RAAS by using many of the newer therapeutic agents show promise in preventing or stabilizing cyst growth, providing much needed hope in this currently relentless condition. Hypertension should be kept in check to prevent any chances of strokes. Making lifestyle changes such as dash diet and maintaining adequate hydration to maintain the normal renal sufficiency are some of the key approaches to control or to prevent the progression of this condition and help the patient to lead normal life and life expectancy
Case Presentation on Multiple Organ Dysfunction Syndrome with Diabetic Nephropathy, Hypertension, Severe Metabolic Acidosis and Acute Respiratory Distress Syndrome
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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. A 50-year-old Hispanic female was diagnosed with type 2 diabetes
at age 30. She has taken medications as prescribed since diagnosis.
The fact that she has confirmed diabetes puts this patient at:
A. Higher risk for kidney failure and CVD
B. Higher risk for kidney failure only
C. Higher risk for CVD only
D. None of the above
Case Question 1
4. A 42-year-old African American man with diabetic nephropathy and
hypertension has a stable eGFR of 25 mL/min/1.73m2. Observational
Studies of Early as compared to Late Nephrology Referral have
demonstrated which of the following?
A. Reduced 1-year Mortality
B. Increase in Mean Hospital Days
C. No change in serum albumin at the initiation of dialysis or kidney
transplantation
D. Decrease in hematocrit at the initiation of dialysis or kidney
transplantation
E. Delayed referral for kidney transplantation
Case Question 2
5. 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
7. CKD as a Public Health Issue
• 26 million American affected
• Prevalence is 11-13% of adult population in the US
• 28% of Medicare budget in 2013, up from 6.9% in 1993
• $42 billion in 2013
• Increases risk for all-cause mortality, CV mortality,
kidney failure (ESRD), and other adverse outcomes.
• 6 fold increase in mortality rate with DM + CKD
• Disproportionately affects African Americans and
Hispanics
1. NKF Fact Sheets.
http://www.kidney.org/news/newsroom/factsheets/FastFa
cts. Accessed Nov 5, 2014.
2. USRDS. www.usrds.org. Accessed Nov 5, 2014.
3. Coresh et al. JAMA. 2007. 298:2038-2047.
ESRD, end stage renal disease
9. Overall expenditures for CKD in the
Medicare population age 65 & older
Point prevalent Medicare CKD patients age 65 & older; costs are total
expenditures per calendar year.
USRDS ADR, 2013
10. Per person per month (PPPM) expenditures
during the transition to ESRD, by dataset, 2011
Incident Medicare (age 67 & older) & Truven Health MarketScan (younger
than 65) ESRD patients, initiating in 2008.
USRDS ADR, 2013
Preventing progression
of CKD will help hold
down costs as the
treatment of kidney
failure is expensive.
ESRD requires some
type of replacement
therapy to maintain life.
11. 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
*Partial list
AKI, acute kidney injury
12. ESRD, end stage renal disease
USRDS ADR, 2007
Diabetes and hypertension are
leading causes of kidney failure
Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.
14. Gaps in CKD Diagnosis
Szczech, Lynda A, et al. "Primary Care Detection of Chronic Kidney Disease in Adults with Type-
2 Diabetes: The ADD-CKD Study (Awareness, Detection and Drug Therapy in Type-2 Diabetes
and Chronic Kidney Disease)." PLOS One - In press (2014).
0
10
20
30
40
50
60
Not Appropriately Tested Appropriately tested - no diagnosis Appropriately tested - accurate diagnosis
CKD Screening in Primary Care
(% of patients)
% of Patients
15. Improved Diagnosis…
Studies demonstrate that clinician behavior changes
when CKD diagnosis improves. Significant
improvements realized in:1-3
• Increased urinary albumin testing
• Increased appropriate use of ACEi or ARB
• Avoidance of NSAIDs prescribing among
patients with low eGFR
• Appropriate nephrology consultation
1. Wei L, et al. Kidney Int. 2013;84:174-178.
2. Chan M, et al. Am J Med. 2007:120;1063-1070.
3. Fink J, et al. Am J Kidney Dis. 2009,53:681-668.
16. 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 NKF recommends using the CKD-EPI Creatinine
Equation (2009) to estimate GFR. Other useful
calculators related to kidney disease include MDRD
and Cockroft Gault.
• GFR calculators are available online at
www.kidney.org/GFR.
Summary of the MDRD Study and CKD-EPI Estimating Equations:
https://www.kidney.org/sites/default/files/docs/mdrd-study-and-ckd-epi-gfr-estimating-equations-summary-ta.pdf
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
o New guidelines classify albuminuria as mild, moderately or
severely increased
• First morning void preferable
• 24hr urine test rarely necessary
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:
o ACR >30 mg/g
o Markers of kidney damage (one or more*)
o GFR <60 mL/min/1.73 m2
*Markers of kidney damage can include nephrotic syndrome, nephritic syndrome, tubular
syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic
radiologic abnormalities, hypertension due to kidney disease.m²
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
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266
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
KDIGO, Kidney
Disease: Increasing
Global Outcomes
20. Classification of CKD Based on GFR and
Albuminuria Categories: “Heat Map”
Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
22. Goals of Care in CKD
• Slow decline in kidney function
• Blood pressure control1
o ACR <30 mg/g: ≤140/90 mm Hg
o ACR 30-300 mg/g: ≤130/80 mm Hg*
o ACR >300 mg/g: ≤130/80 mm Hg
o Individualize targets and agents according to age,
coexistent CVD, and other comorbidities
o ACE or ARB
*Reasonable to select a goal of 140/90 mm Hg, especially for moderate albuminuria (ACR 30-300 mg/g.)2
1) Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. Kidney Int Suppl.
(2012);2:341-342.
2) KDOQI Commentary on KDIGO Blood Pressure Guidelines. Am J Kidney Dis. 2013;62:201-213.
23. Slowing CKD Progression: ACEi or ARB
• Risk/benefit should be carefully assessed in the elderly and
medically fragile
• Check labs after initiation
o If less than 25% SCr increase, continue and monitor
o 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
o Risk of adverse events (impaired kidney function,
hyperkalemia)
1) Kunz R, et al. Ann Intern Med. 2008;148:30-48.
2) Mann J, et al. ONTARGET study. Lancet. 2008;372:547-553.
24. 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
NKF KDOQI. Diabetes and CKD: 2012 Update.
Am J Kidney Dis. 2012 60:850-856.
25. Modification of Other CVD Risk
Factors in CKD
• Smoking cessation
• Exercise
• Weight reduction to optimal targets
• Lipid lowering therapy
o In adults >50 yrs, statin when eGFR ≥ 60
ml/min/1.73m2; statin or statin/ezetimibe combination
when eGFR < 60 ml/min/1.73m2
o In adults < 50 yrs, statin if history of known CAD, MI,
DM, stroke
• Aspirin is indicated for secondary but not primary
prevention
Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
26. Detect and Manage CKD Complications
• Anemia
o Initiate iron therapy if TSAT ≤ 30% and ferritin ≤ 500 ng/mL (IV
iron for dialysis, Oral for non-dialysis CKD)
o Individualize erythropoiesis stimulating agent (ESA) therapy:
Start ESA if Hb <10 g/dl, and maintain Hb <11.5 g/dl. Ensure
adequate Fe stores.
o Appropriate iron supplementation is needed for ESA to be
effective
• CKD-Mineral and Bone Disorder (CKD-MBD)
o Treat with D3 as indicated to achieve normal serum levels
o 2000 IU po qd is cheaper and better absorbed than 50,000 IU
monthly dose.
o Limit phosphorus in diet (CKD stage 4/5), with emphasis on
decreasing packaged products - Refer to renal RD
o May need phosphate binders
27. Detect and Manage CKD Complications
• Metabolic acidosis
o Usually occurs later in CKD
o Serum bicarb >22mEq/L
o Correction of metabolic acidosis may slow CKD progression
and improve patients functional status1,2
• Hyperkalemia
o Reduce dietary potassium
o Stop NSAIDs, COX-2 inhibitors, potassium sparing diuretics
(aldactone)
o Stop or reduce beta blockers, ACEi/ARBs
o Avoid salt substitutes that contain potassium
1) Mahajan, et al. Kidney Int. 2010;78:303-309.
2) de Brito-Ashurst I, et al. J Am Soc Nephrol.
2009;20:2075-2084.
28. A Balanced Approach to Nutrition in CKD:
Macronutrient Composition and Mineral Content*
Adapted from DASH (dietary approaches to stop hypertension) diet.
*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.
NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.
*(CKD Stages 1-4)
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
32. Co-Management Model
• Collaborative care
o Formal arrangement
o Curbside consult
• Care coordination
• Clinical decision
support
• Population health
o Development of
treatment protocols
33. Collaborative Care Agreements
• Soft Contract between primary care and nephrologist
• Defines responsibilities of primary care
o Provide pertinent clinical information to inform the consultation
prior to the scheduled visit.
o Initiate a phone call if the condition is emergent
o Provide timely referrals with adequate number of visits to treat the
condition.
• Defines responsibilities of nephrologist
o Timely communication of consultation (7 days routine & 48 hours
emergent) – fax if no electronic information sharing
o No consultation to other specialist initiated without primary care
input
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?
35. Impact of primary care CKD detection
with a patient safety approach
Fink et al. Am J Kidney Dis. 2009,53:681-668
Patient Safety
Following
CKD detection
Improved diagnosis creates opportunity for strategic
preservation of kidney function
36. CKD Patient Safety Issues
• Medication errors
o Toxicity (nephrologic or other)
o Improper dosing
o Inadequate monitoring
• Electrolytes
o Hyperkalemia
o Hypoglycemia
o Hypermagnesemia
o Hyperphosphatemia
• Miscellaneous
o Multidrug-resistant infections
o Vessel preservation/dialysis access
Fink JC, Brown J, Hsu, VD, et al. Am J Kidney Dis 2009;53:681-668.
37. CKD Patient Safety Issues
• Diagnostic tests
o Iodinated contrast media: AKI
o Gadolinium-based contrast: NSF
o Sodium Phosphate bowel preparations: AKI, CKD
• CVD
o Missed diagnosis
o Improper management
• Fluid management
o Hypotension
o AKI
o CHF exacerbation
AKI = acute kidney injury; CHF = congestive heart failure; NSF = nephrogenic systemic fibrosis.
Fink JC, Brown J, Hsu, VD, et al. Am J Kidney Dis 2009;53:681-668..
38. Common Medications Requiring Dose
Reduction in CKD
• Allopurinol
• Gabapentin
o CKD 4- Max dose 300mg qd
o CKD 5- Max dose 300mg qod
• Reglan
o Reduce 50% for eGFR< 40
o Can cause irreversible EPS
with chronic use
• Narcotics
o Methadone and fentanyl best
for ESRD patients
• Lowest risk of toxic
metabolites
• Renally cleared beta blockers
o Atenolol, bisoprolol, nadolol
• Digoxin
• Some Statins
o Lovastatin, pravastatin,
simvastatin. Fluvastatin,
rosuvastatin
• Antimicrobials
o Antifungals, aminoglycosides,
Bactrim, Macrobid
• Enoxaparin
• Methotrexate
• Colchicine
39. 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 meds
• Minimize pill burden as much as possible
• Remind CKD patients to avoid NSAIDs
• No Dual RAAS blockade
• Any med with >30% renal clearance probably needs dose
adjustment for CKD
• No bisphosphonates for eGFR <30
• Avoid GAD for eGFR <30
40. *Significant albuminuria is defined as ACR ≥300 mg/g (≥30 mg/mmol) or AER ≥300 mg/24 hours, approximately
equivalent to PCR ≥500 mg/g (≥50 mg/mmol) or PER ≥500 mg/24 hours
**Progression of CKD is defined as one or more of the following: 1) A decline in GFR category accompanied by a 25%
or greater drop in eGFR from baseline; and/or 2) rapid progression of CKD defined as a sustained decline in eGFR of
more than 5ml/min/1.73m2/year. KDOQI US Commentary on the 2012 KDIGO Evaluation and Management of CKD
Indications for Referral to Specialist Kidney Care
Services for People with CKD
• Acute kidney injury or abrupt sustained fall in GFR
• GFR <30 ml/min/1.73m
2
(GFR categories G4-G5)
• Persistent albuminuria (ACR > 300 mg/g)*
• Atypical Progression of CKD
**
• Urinary red cell casts, RBC more than 20 per HPF sustained
and not readily explained
• Hypertension refractory to treatment with 4 or more
antihypertensive agents
• Persistent abnormalities of serum potassium
• Recurrent or extensive nephrolithiasis
• Hereditary kidney disease
41. Observational Studies of Early vs. Late
Nephrology Consultation
Chan M, et al. Am J Med. 2007;120:1063-1070.
http://download.journals.elsevierhealth.com/pdfs/journals/
0002-9343/PIIS000293430700664X.pdf
KDIGO CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
42. Take Home Points
• PCPs 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
43. Additional Online Resources for
CKD Learning
• National Kidney Foundation: www.kidney.org
• United States Renal Data Service: www.usrds.org
• CDC’s CKD Surveillance Project: http://nccd.cdc.gov/ckd
• National Kidney Disease Education Program (NKDEP):
http://nkdep.nih.gov