2. • When would you request renal consult for
your CKD patient?
A.DM eGFR >60 ml/min , albuminuria 500 mg/g
B.DM eGFR 45 ml/min, albuminuria 50 mg/g
C.HTN eGFR 30 ml/min, albuminuria 30 mg/g
D.HTN eGFR 40 ml/min, albuminuria 2000 mg/g
3.
4. Prevalence of CKD
• 7% US adults over age 20 (eGFR <60)
• 12.3% (eGFR and albuminuria)
• Age – demographic factor most most strongly
associated with CKD
• 35% of Americans over age 60 have CKD
5. • What is the most common cause ESRD in US
a.HTN
b.Diabetes
c. Hepatitis related
d.SLE
e.ATN
6. Screening
• ACP – recommend against screening for CKD if
asymptomatic and without risk factors;
• USPSTF – insufficient evidence for screeining
CKD in asymptomatic patients
• ASN – screening recommended
7. Relationships between cardiac events and loss of life expectancy resulting from cardiovascular disease
(CVD) by stage of chronic kidney disease (CKD).
Marcello Tonelli et al. Circulation. 2016;133:518-536
9. • HTN
– Goal : JNC 8 <140/90 (vs 130/80 JNC 7)
- Acei/ARB – 1st
line for most pts with HTN and CKD
10. • What is the recommended initial tx for black
pts with proteinuria?
a.ACEi/ARB
b.Diuretic
c. Ca channel blocker
11. Dyslipidemia
Statins has been shown to reduce CV events
among the following group of pts except:
A. CAD
B. CKD eGFR < 60 ml/min
C. CKD eGF > 60 with albuminuria
D. ESRD on dialysis
15. KDIGO guidelines for CKD MBD
• Monitor iPTH, ca, phos and vit d 25 OH
• Replace vit d to >30
• Calcitriol or calcitriol analogues if PTH remains
high despite adequate vit D
• Low phos diet
• Phos binders
18. Anemia
• Causes of anemia among pts with CKD include
the following except
• Decreases erythropoietin production
• Erythropoietin resistance
• Reduced erythrocyte lifespan
• ACEi
20. When do we check EPO levels in CKD
• Hb 10
• Hb <8
• Hb not improved after iron replacement
• Hb not improved after 1 month of starting ESA
• Never
21. Black box warning for ESA
• Increased mortality and tumor progression
among pts with active malignancy
• Increased risk of thromboembolic events
• Increased CV events among pts with Hb >11 or
h/o CVA
23. OTC Medications to Avoid in CKD
• NSAIDs
• Decongestants (psudoephedrine;
oxymetalozine)
• Laxatives ( Mg Oxide; Na phosphate)
• Antacids ( Al OH; MgOH; sucralfate)
• Nutritional supplements (creatine; salt
substitues)
• Herbal remedies( aristolochia; ephedra)
24. Summary
• Identify and refer CKD pts with increased risk of progression to
nephrologist
• ACEi 1st
line agent for pts with HTN and CKD especially among those
with albuminuria
• Check ipth, phos and vit D. Correct to normal
• No utility in checking EPO for anemia work up among pts with CKD
• Treatment of acidosis delays progression of CKD
• Counsel pts on risks of certain OTC medications that should be
avoided in CKD
(A through E) Survival of treated and untreated patients in the overall propensity score–matched cohort (A) and according to quartiles of baseline serum phosphate: &lt;3.7 mg/dl (B), 3.7 to 4.5 mg/dl (C), 4.6 to 5.5 mg/dl (D), and ≥5.6 mg/dl (E).
We performed intention-to-treat analyses to compare patients who began treatment with phosphorus binders during the first 90 d after initiating hemodialysis (n = 3555) with those who remained untreated during that period (n = 5055).
Propensity scores try to identify factors that predict whether treatment given or not, and allow matching for “probability” of receiving treatment. i.e. treatment and control groups that would have the same likelihood of being treated.
