CKD Presentation - Maggie Watt

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  • KEY FEATURE = SUSTAINED FOR MAU OR PROTEINURIA. NEPHROTIC RANGE PROTEINURIA LESS TRANSIENT (ie. less likely to have transient elevations into this high of a range)
  • This is why early diagnosis is so important. Emphasize BP – not to be complacent. Target is 130/80 but in fact lower is better, try to go as low as symptoms will tolerate. State often need 3+ meds to control. Also state that even if BP below target, still give ACEi or ARB for proteinuria reduction.
  • CKD Presentation - Maggie Watt

    1. 1. CKD and CDM FYICKD and CDM FYI Dr. Maggie WattDr. Maggie Watt
    2. 2. Mr. H. E.Mr. H. E.  72 year old retired truck driver72 year old retired truck driver  New patient in April 2002New patient in April 2002  PMHxPMHx  MI 1983MI 1983  Pituitary Tumour 1983 resected and 6/12 XRTPituitary Tumour 1983 resected and 6/12 XRT  Panhypopituitarism (on Cortisone, Synthroid & TestosteronePanhypopituitarism (on Cortisone, Synthroid & Testosterone replacement)replacement)  Renal insufficiency following TUPRRenal insufficiency following TUPR  bilateral ureteral obstruction Oct 2001bilateral ureteral obstruction Oct 2001  Thickened bladder wall and outlet obstructionThickened bladder wall and outlet obstruction  Creat 150 (no GFR reported yet)Creat 150 (no GFR reported yet)
    3. 3. Mr. H.E. (cont’d)Mr. H.E. (cont’d)  55 pack year smoker – multiple attempts to quit55 pack year smoker – multiple attempts to quit  Past alcoholic (quit 1983)Past alcoholic (quit 1983)  HTNHTN  HypercholesterolemiaHypercholesterolemia  Type 2 DM (dx May 2004)Type 2 DM (dx May 2004)  Obesity (BMI 39.2)Obesity (BMI 39.2)
    4. 4. Mr. H.E. cont’dMr. H.E. cont’d  May 2003 – BP 180/110May 2003 – BP 180/110  Start Altace 2.5 mg daily, titrated to 10 mg over 2/12Start Altace 2.5 mg daily, titrated to 10 mg over 2/12  Cough on ACEI – change to CozaarCough on ACEI – change to Cozaar  Dec 2003 – BP 150/50Dec 2003 – BP 150/50  Add HCTZAdd HCTZ  April 2004April 2004  Creat 162, GFR 39 (Stable)Creat 162, GFR 39 (Stable)  Enroll in PROMIS (Kidney Care Initiative)Enroll in PROMIS (Kidney Care Initiative)
    5. 5. Mr. H.E. cont’dMr. H.E. cont’d  May 2004…my chart notes changeMay 2004…my chart notes change  Review bloodwork (FBS 12.7 = Type 2 DM)Review bloodwork (FBS 12.7 = Type 2 DM)  ““Stage 3 CKD” (GFR 41)Stage 3 CKD” (GFR 41)  Hyper PTH (secondary)Hyper PTH (secondary)  Urine ACR elevated (2.67) (normal < 2 males)Urine ACR elevated (2.67) (normal < 2 males)  Plan – Renal U/S, Refer NephroPlan – Renal U/S, Refer Nephro  New goal for Lipids in view of DM 2 and CKDNew goal for Lipids in view of DM 2 and CKD  LDL < 2.5 and TC/HDL <4LDL < 2.5 and TC/HDL <4
    6. 6. Further InvestigationsFurther Investigations  Renal ultrasound June 2004Renal ultrasound June 2004  Bilateral mild symmetric cortical thinningBilateral mild symmetric cortical thinning  Left kidney 11.4 cm, right kidney 9.2 cmLeft kidney 11.4 cm, right kidney 9.2 cm  No hydronephrosisNo hydronephrosis  Bladder normalBladder normal
    7. 7. And then he sees the nephrologistAnd then he sees the nephrologist  Dr. Stigant – October 2004Dr. Stigant – October 2004  3 page consult3 page consult  CKD moderate in severityCKD moderate in severity  Small vessel renovascular diseaseSmall vessel renovascular disease  Possibly component of macrovascular dzPossibly component of macrovascular dz (asymmetric kidney size on u/s)(asymmetric kidney size on u/s)  Twice yearly ACR and renal functionTwice yearly ACR and renal function  Follow up 1 yearFollow up 1 year
    8. 8.  Dr. Stigant November 2005Dr. Stigant November 2005  Stable moderate impairment in kidney functionStable moderate impairment in kidney function  Query right renal artery stenosisQuery right renal artery stenosis  Nuclear renal scan with lasix (Dec 2005)Nuclear renal scan with lasix (Dec 2005)  ““asymmetry of kidney function raises possibility of right renal arteryasymmetry of kidney function raises possibility of right renal artery stenosis”stenosis”  Feb 2006 – acute decline in renal fxn GFR 16Feb 2006 – acute decline in renal fxn GFR 16  Book MRA, possible dialysis, D/C antihypertensives, ASABook MRA, possible dialysis, D/C antihypertensives, ASA  Renal MRA - March 2006Renal MRA - March 2006  Severe stenosis at origin of right renal arterySevere stenosis at origin of right renal artery  Nov. 2006 - Angioplasty and Stent placement in Right RenalNov. 2006 - Angioplasty and Stent placement in Right Renal ArteryArtery  70% stenosis70% stenosis  Renal function unchanged but felt almost instantly betterRenal function unchanged but felt almost instantly better
    9. 9. Current Status Mr. H.E.Current Status Mr. H.E.  Q 3/12 Diabetes Check, CKD CheckQ 3/12 Diabetes Check, CKD Check  HTN, Sugars, Renal Fxn, Lipids, Self Care, etc.HTN, Sugars, Renal Fxn, Lipids, Self Care, etc.  Motivated re: self careMotivated re: self care  Recent weight lossRecent weight loss  Stable renal functionStable renal function  Upcoming knee replacement June 2008Upcoming knee replacement June 2008  Awaiting resection of parathyroid adenoma (hasAwaiting resection of parathyroid adenoma (has primary and secondary PTH)primary and secondary PTH)
    10. 10. BC CKD GUIDELINESBC CKD GUIDELINES  Identify high risk populations:Identify high risk populations:  Family history of kidney diseaseFamily history of kidney disease  vascular diseasevascular disease  DMDM  HTNHTN  high risk ethnicity (First Nations, S. Asian,high risk ethnicity (First Nations, S. Asian, Hispanic, African American, Pacific Islanders)Hispanic, African American, Pacific Islanders)  (age(age >60)>60)
    11. 11. BC CKD GuidelinesBC CKD Guidelines  ScreenScreen high riskhigh risk populations (q 1-2 years)populations (q 1-2 years)  Serum creatinine and eGFRSerum creatinine and eGFR  Urine ACRUrine ACR  Urinalysis ( to detect protein, WBC’s, RBC’s)Urinalysis ( to detect protein, WBC’s, RBC’s)  Evaluate patients withEvaluate patients with sustained impairmentssustained impairments  DetermineDetermine cause of CKDcause of CKD  Renal ultrasoundRenal ultrasound  Identify care objectivesIdentify care objectives  Involve patients inInvolve patients in self-managementself-management
    12. 12. Diagosis of CKDDiagosis of CKD  Sustained GFR < 60 mL/minSustained GFR < 60 mL/min Note: eGFR not accurate > 60Note: eGFR not accurate > 60  ProteinuriaProteinuria Microvascular +/- glomerularMicrovascular +/- glomerular diseasedisease
    13. 13. Symptoms of CKDSymptoms of CKD
    14. 14. Causes of CKDCauses of CKD  Diabetes (Type 1 and Type 2)*Diabetes (Type 1 and Type 2)*  Hypertension*Hypertension*  Other vascular diseasesOther vascular diseases  Large vessel disease, microangiopathyLarge vessel disease, microangiopathy  Glomerular diseases:Glomerular diseases:  Autoimmune, systemic infection, drugs, neoplasiaAutoimmune, systemic infection, drugs, neoplasia  Tubulointerstitial DisiasesTubulointerstitial Disiases  UTI, stones, obstruction, drug toxicityUTI, stones, obstruction, drug toxicity  Polycystic Kidney DiseasePolycystic Kidney Disease (*account for 2/3 of CKD and ESRD)(*account for 2/3 of CKD and ESRD)
    15. 15. PROTEINURIA - DefinitionsPROTEINURIA - Definitions  MICROALBUMINURIAMICROALBUMINURIA  24 hour urinary albumin excretion 30 - 300 mg24 hour urinary albumin excretion 30 - 300 mg  Urine ACRUrine ACR  < 2.0 mg/mmol (M)< 2.0 mg/mmol (M)  < 2.8 mg/mmol (F)< 2.8 mg/mmol (F)  Sustained (ie. 2/3 samples)Sustained (ie. 2/3 samples)  PROTEINURIA (‘overt’)PROTEINURIA (‘overt’)  24 hour urine protein excretion > 150 mg/day24 hour urine protein excretion > 150 mg/day  Transient, orthostatic, or persistentTransient, orthostatic, or persistent  NEPHROTIC RANGE PROTEINURIANEPHROTIC RANGE PROTEINURIA  > 3 grams/day> 3 grams/day  Typically associated with glomerular diseaseTypically associated with glomerular disease
    16. 16. WHEN TO REFERWHEN TO REFER  Sustained decline in GFR < 30mL/minSustained decline in GFR < 30mL/min  Acute renal failureAcute renal failure  Subacute decline in kidney functionSubacute decline in kidney function  >10 mL/min annually>10 mL/min annually  Sustained proteinuria > 1gram/24 hrsSustained proteinuria > 1gram/24 hrs  Active urine sedimentActive urine sediment  Cellular casts, sustained hematuria &/or proteinuriaCellular casts, sustained hematuria &/or proteinuria
    17. 17. DEFINITIONS /DEFINITIONS / CLARIFICATIONCLARIFICATION  Certain kidney diseases often requireCertain kidney diseases often require specificspecific management:management:  GlomerulonephritisGlomerulonephritis  Obstructive uropathyObstructive uropathy  Acute interstitial nephritisAcute interstitial nephritis  Renal artery stenosisRenal artery stenosis  Non-disease specificNon-disease specific therapies aimed at slowingtherapies aimed at slowing progressive nephropathy, regardless of:progressive nephropathy, regardless of:  Disease etiologyDisease etiology  Stage of CKDStage of CKD
    18. 18. A BRIEF REVIEW – CKDA BRIEF REVIEW – CKD TreatmentTreatment  Consider reversible factorsConsider reversible factors  Avoid nephrotoxinsAvoid nephrotoxins  NSAIDs, contrast, aminoglycosidesNSAIDs, contrast, aminoglycosides  Slow CKD progression:Slow CKD progression:  BP <130/80 (or 125/75 if proteinuria >1 gram/day)BP <130/80 (or 125/75 if proteinuria >1 gram/day)  Consider ACEi or ARB therapyConsider ACEi or ARB therapy  Control BG in diabetics (HgA1c <7%)Control BG in diabetics (HgA1c <7%)  +/- dyslipidemia therapy+/- dyslipidemia therapy  +/- dietary protein restriction+/- dietary protein restriction  Follow CHEP, CDA, CCS guidelines for secondaryFollow CHEP, CDA, CCS guidelines for secondary cardiovascular preventioncardiovascular prevention
    19. 19. END-STAGE KIDNEY DISEASE CAN BEEND-STAGE KIDNEY DISEASE CAN BE PREVENTED (OR SLOWED)PREVENTED (OR SLOWED)%ofnormalfunction Time Diagnosis and Treatment 100 ↓ Time on Dialysis
    20. 20. GFR DECLINES WITH AGEGFR DECLINES WITH AGE Normal decline 1 % per year
    21. 21. IMPLICATIONSIMPLICATIONS  Patients need information on CVD / mortality risk notPatients need information on CVD / mortality risk not just progressive nephropathyjust progressive nephropathy  Patients with progressive disease need info onPatients with progressive disease need info on preparation for RRTpreparation for RRT  Older patients may benefit less than younger fromOlder patients may benefit less than younger from intensive therapeutic effortsintensive therapeutic efforts  Male patients may require more aggressive evaluation,Male patients may require more aggressive evaluation, treatment, follow-up, and earlier referraltreatment, follow-up, and earlier referral  More predictors of progressive CKD requiredMore predictors of progressive CKD required
    22. 22. PROTEINURIA - SUMMARYPROTEINURIA - SUMMARY  Proteinuria is significant whenProteinuria is significant when  Sustained (>3mos)Sustained (>3mos)  High-gradeHigh-grade  Always warrants nephrology referralAlways warrants nephrology referral  TreatmentTreatment  Lower BP (ACEi or ARB first line)!Lower BP (ACEi or ARB first line)!  Treat diabetes to targetTreat diabetes to target  Attend to other CV risk factorsAttend to other CV risk factors
    23. 23. ANEMIA - SUMMARYANEMIA - SUMMARY  Increasing prevalence with reduced kidney functionIncreasing prevalence with reduced kidney function  Transferrin Saturation better gauge of iron stores thanTransferrin Saturation better gauge of iron stores than Ferritin at low GFRFerritin at low GFR  Prescribe erythropoietin therapy (Nephrology)Prescribe erythropoietin therapy (Nephrology)  After other causes of anemia ruled outAfter other causes of anemia ruled out  After iron stores repleteAfter iron stores replete  Monitor response to therapy monthlyMonitor response to therapy monthly  Therapy usually well tolerated but watch for HTN with rapidTherapy usually well tolerated but watch for HTN with rapid increases in Hgbincreases in Hgb  Maintain target hemoglobin 110-130 – increasedMaintain target hemoglobin 110-130 – increased mortality outside that rangemortality outside that range
    24. 24. Bone Mineral MetabolismBone Mineral Metabolism Objectives for Stage 3 CKDObjectives for Stage 3 CKD  Disease State :Disease State :  HyperphosphatemiaHyperphosphatemia  HypocalcemiaHypocalcemia  Decreased Calcitriol (activated Vit D)Decreased Calcitriol (activated Vit D)  all increase PTHall increase PTH
    25. 25. Treatment sequenceTreatment sequence (Not a medical emergency)(Not a medical emergency) 1. Dietary Phosphate restriction1. Dietary Phosphate restriction (target normal PO4 level)(target normal PO4 level) 2. Calcium-based binders with meals2. Calcium-based binders with meals (target normal Ca and P04 levels)(target normal Ca and P04 levels)  Start TUMS 1 tab with each meal (decrease P04 andStart TUMS 1 tab with each meal (decrease P04 and increase Ca2+)increase Ca2+) 3. Alpha Calcidiol (if PTH > 7.7 pmol / L)3. Alpha Calcidiol (if PTH > 7.7 pmol / L)  One-alpha 0.25 mg dailyOne-alpha 0.25 mg daily  Monitor labs q 6 mos in treatment phaseMonitor labs q 6 mos in treatment phase
    26. 26. Hyper PTH in CKDHyper PTH in CKD  Need to target progressively higher PTH toNeed to target progressively higher PTH to maintain normal bone turnover as CKDmaintain normal bone turnover as CKD progressesprogresses  Caused by skeletal resistance to PTHCaused by skeletal resistance to PTH * opinion based levels* opinion based levels CKD Stage GFR Target PTH * 3 30-60 3.8-7.7 4 15-29 7.7 - 12 5 < 15 (dialysis) 16.5 - 33
    27. 27. SUMMARY – MINERAL METABOLISMSUMMARY – MINERAL METABOLISM  Measure Ca / PO4 / PTH (and albumin) at leastMeasure Ca / PO4 / PTH (and albumin) at least yearlyyearly  Restrict dietary PO4 intakeRestrict dietary PO4 intake  When hyperphosphatemia occurs:When hyperphosphatemia occurs:  Reinforce dietary PO4 restrictionReinforce dietary PO4 restriction  start PO4 binders (typically Ca-based)start PO4 binders (typically Ca-based)  Maintain normal serum Ca levelsMaintain normal serum Ca levels  Rx Vitamin D if hypocalcemic or if PTH aboveRx Vitamin D if hypocalcemic or if PTH above targettarget
    28. 28. How has Toolkit/CDM been usefulHow has Toolkit/CDM been useful  Learn and follow guidelinesLearn and follow guidelines  Planned follow-upPlanned follow-up  need to develop recall systemneed to develop recall system  CDM visits are MY agendaCDM visits are MY agenda  Office visits more organized / less harriedOffice visits more organized / less harried  ““Shared care” with nephrologistShared care” with nephrologist  ease of billingease of billing

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