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Chronic Kidney Disease (CKD) in the Hospitalized Patient

Chronic Kidney Disease (CKD) in the Hospitalized Patient. Catherine Staffeld-Coit, MD. No disclosures. Objectives. Explain the scope of CKD and its stages. Discuss options for renal replacement therapy. Review commonly seen problems in renal patients.

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Chronic Kidney Disease (CKD) in the Hospitalized Patient

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  1. Chronic Kidney Disease (CKD) in theHospitalized Patient Catherine Staffeld-Coit, MD

  2. No disclosures.

  3. Objectives • Explain the scope of CKD and its stages. • Discuss options for renal replacement therapy. • Review commonly seen problems in renal patients. • Explore the reasons for markedly higher incidence of cardiovascular disease in the renal population.

  4. Estimating Severity of CKD • Can use many formulas. • ALL require steady state, BUT not on dialysis. • MDRD Calculator available @ many sites:

  5. Staging of CKD National Kidney Foundation

  6. USRDS Projected Growth of Prevalent Dialysis and Transplant Populations U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008

  7. Geographic variations in adjusted incident rates of ESRD per million population, 2009, by HAS Fig 1.4 (Vol 2) Adj: age/gender/race; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

  8. Prevalent counts & adjusted rates of ESRD, by raceFig 1.12 (Vol 2) December 31 point prevalent ESRD patients. Adj: age/gender; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

  9. Prevalent Counts & adjusted rates of ESRD, by diagnosisFig 1.14 (Volume 2) December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

  10. DM 30-40% HTN 25-35% GN Genetic Polycystic Kidney Disease Alport’s Obstructive nephropathy Drug-induced Unknown Causes of Renal Failure U.S. Renal Data System, USRDS 2008 Annual Data Report, NIH, NIDDK, 2008

  11. Adjusted all-cause mortality in the ESRD & general populations, by age, 2009 Fig 5.2 (Vol 2) Prevalent ESRD & general Medicare (non-ESRD) patients. Adj: gender/race; ref: Medicare patients, 2009. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

  12. FIGURE 17-15 Causes of death among U.S. transplant recipients with a functioning graft. CVD, cardiovascular disease.  (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 152.)

  13. Overview of Dialysis Therapy • Outpatient (in-center) Hemodialysis (HD) – usually done 3 times a week. Most common type. • Home therapies: • Daily or nocturnal HD. • Chronic Ambulatory Peritoneal Dialysis (CAPD) • Cyclic Peritoneal Dialysis usually performed at night. • Require patient or caregiver be thoroughly trained to perform independently. • Less common as in-center hemodialysis.

  14. Renal Replacement Therapy NIDDK

  15. Treatment, not cure. Usually performed w/o nephrectomy. Requires lifelong immunosuppression. Immunos may cause side effects (DM, HTN, hyperlipidemia, CVD, cancer, infection). Renal Transplantation NIDDK

  16. Complications of Renal Failure (partial) • Intradialytic Hypotension (during HD) • Malnutrition • GI Bleed • Nephrogenic Systemic Fibrosis • Neurologic • Cardiovascular disease (CVD) • Infection • Acquired Cystic Disease • Anemia

  17. Hypotension Occurs in 20-30 % of HD treatments Causes: • Rapid reduction of plasma osmolality causing extracellular water to shift into cells. • Rapid fluid removal/ultrafiltration (UF) of>1.5 L/hr. • Poor cardiac reserve. • Autonomic neuropathy. • BP meds. • Eating before or during dialysis. • May present 1-2 hours post-treatment. Therapies- Volume replacement, adjust meds, UF slowly, check EF.

  18. Hypertension • Seen in 85% of renal patients. • Salt/water excess usual cause. • Elevated renin secretion from diseased kidneys is common.

  19. Hypertension • ESA side effect • Sympathetic over activity. • Non-compliance with meds or withholding prior to dialysis. • Salt and water restriction not followed.

  20. MalnutritionAssociated with decreased survival Causes: • Drug effects. • Chronic constipation. • Lack of understanding of renal nutrition. • Low income. • Malabsorption and GI motility disorders. • Impaired taste. All Patients are evaluated and followed by dietician in dialysis unit. CKD patients should receive dietary education as part of CKD care.

  21. GI Bleed • Don’t assume anemia is simply from CKD. Check iron levels and w/u when deficient. • Gastritis - most common. • Angiodysplasia - second most common. • Uremic platelet dysfunction contributes to the severity- DDAVP can help short-term. • If patient is possible transplant candidate, use WBC filter with PRBC transfusions when blood products needed… decreases HLA antibody formation.

  22. Typically starts with patients reporting swelling and a “tight” feeling in extremities. Skin changes may be red or dark patches, papules, plaques, or nodules. Progressing over days to weeks to inhibit flexion and contraction of joints & contractures. Skin becomes “woody” with peu d’orange consistency Lesions often symmetrical, involving LE first, then UE. Most common with GFR < 30 and Gadolinium exposure. Nephrogenic Systemic Fibrosis From Cowper NFD/NSF Website.

  23. Nephrogenic Systemic Fibrosis Raised and erythematous nodular plaques, & linear and confluent regions of fibrosis Soft tissue swelling & contractures From nephrogenic-systemic-fibrosis.info

  24. Neurologic Complications of Uremia • Uremic neuropathy is the most common neurologic finding. • Uremic encephalopathy (UE) develops when GFR < 10% of normal. • Rare in well dialyzed patients. • Seizures are seen in 25% of patients with UE. • Restless legs syndrome is reported in > 40% of uremic patients. • Myopathy, optic neuropathy and mononeuropathies noted. • Hyperkalemia can cause flaccid quadriparesis. Goetz: Textbook of Clinical Neurology, 3rd ed

  25. Neurologic Complications of Uremia (cont.) • Vestibulocochlear and neuromuscular junction disturbances can be seen in association with aminoglycoside atb. • Loop diuretics can cause tinnitus. • Amyloid fibrils (b2 microglobulin deposits) can cause carpal tunnel syndrome. Goetz: Textbook of Clinical Neurology, 3rd ed

  26. Neurologic Complications of Uremia (cont.) • Subdural hemorrhage. • Dialysis headaches. • Exacerbation of migraine headaches. • Ischemic monomelic neuropathy. Goetz: Textbook of Clinical Neurology, 3rd ed

  27. Neurologic Complications of Uremia (cont.) • Dysequilibrium Syndrome • Cerebral edema d/t rapid reduction of omolality during hemodialysis. • Dialysis dementia (vascular, b2- macroglobulin). Goetz: Textbook of Clinical Neurology, 3rd ed

  28. Neurologic Complications of Uremia (cont.) • Vitamin deficiency • Water soluble vitamins dialyzed out. • Poor nutrition common. • Nephrology vitamins available. Goetz: Textbook of Clinical Neurology, 3rd ed

  29. Neurologic Complications of Uremia (cont.) • Phenytoin has decreased plasma binding and higher free (active) drug. • Check free phenytoin level. • Usually the same loading and maintenance dosed used. • Since half-life decreased, TID dosing regimen is favored over BID. Goetz: Textbook of Clinical Neurology, 3rd ed

  30. Syncope in Renal Disease • Arrhythmias • Intrinsic • Electrolyte induced (K, Calcium, Mg.) • Acidemia, or rarely alkalemia. • Intra- or post-dialytic hypotension. • Common causes occur commonly. • Given CVD risk, need thorough evaluation for vascular disease. Barbour et al. Semin Nephrol 2001; 21 (1) : 66-78.

  31. CVD and CKD • Primary cause of death is accelerated CVD • AHA: ESRD should be considered highest risk.1 Considered a CV risk equivalent. • Entire spectrum of CKD associated with increased risk. 2-4 • Very high prevalence of traditional CKD risks. • HTN & cholesterol have U-shaped relationship. 1. Sarnak et al. Circulation  2003;  108: 2154-2169. 2. Collins et al. Kidney Int suppl  2003. S24-S31. 3. Henry et al. Kidney Int  2002; 62:1402-1407. 4. Muntner et al.  J Am Soc Nephrol  2002; 13:745-753

  32. Dyslipidemia • Lipids combine with apolipoproteins to form lipoproteins. • Lipoprotein profiles are affected by CKD • HDL, LDL and total cholesterol decline with worsening renal function.1 • Dense LDL and lipoprotein (a) are increased. 2 • Elevated lipoprotein(a) is an independent risk factor for CVD in hemodialysis patients and is associated with vascular events. 3 • Kanske BL. Am. J Kidney Dis, 1988; 32 (suppl 3) : S142-56. • Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61. • Cressman et al. Circulation 1992; 86 (2) : 475-82.

  33. CV Mortality Foley et al. Am J Kidney Dis 32 (suppl):S112–S115, 1998 Brenner and Rector's The Kidney, 8th ed.

  34. CVD in patients with or without CKD, 2009fig 4.1 (Vol 1) December 31 point prevalent Medicare enrollees age 66 & older, with fee-for-service coverage for all of 2009. U.S. Renal Data System, USRDS 2011 Annual Data Report, NIH, NIDDK, 2011

  35. Effects of CKD on Cardiovascular System McCullough PA: Why is chronic kidney disease the “spoiler” for cardiovascular outcomes? J Am Coll Cardiol 41;725, 2003

  36. Albuminuria Malnutrition Hyperhomocysteinemia Elevated Lp(a) Low GFR Anemia Inflammation ECF overload Endothelial dysfunction Metabolic syndrome Abnormal Ca/PO4 metabolism Hyperparathyroidism Non-Traditional CVD Risk Factors in Renal Disease

  37. Dyslipidemia (cont.) • Triglycerides tend to increase with CKD, especially NS and those on dialysis.1 • NFK recommends lifestyle modifications for those with CKD. • Target LDLC is < 100 mg/dl for all renal patients. 1. Kwan et al. J. Am. Soc Nephrol 2007; 18 (4) : 1246-61.

  38. Dyspnea in ESRD • Pulmonary edema, often non-cardiogenic. • Failure to decrease est dry weight (EDW) in those losing weight. • Excess intake, exceeding capacity for UF. • Peritoneal dialysate leakage. • High output cardiac failure can develop from AV grafts or fistulae which can have blood flow of >20-30% of cardiac output . • Pneumothorax or hemothorax after catheter placement. • Pericardial effusion or cardiac tamponade.

  39. Initial Rx of Pulmonary Edema in Renal Failure • Supplemental oxygen. • Morphine. • High dose loop Diuretic (if significant residual UO). • May work as vasodilator. • Preload reduction with nitrates. • Rx of HTN. • Definitive rx is fluid & salt removal with dialysis- not always “urgent.”

  40. Chest Pain in CKD • 50% of renal deaths are related to ischemic heart disease, so ACS has to be in Ddx. • Baseline EKG often abnormal d/t LVH, e-lyte disturbances or fluid overload. • ST segment elevation is indicative of ACS.1 • Chronic troponin elevations are misleading. • Uremic Pericarditis • Pulmonary embolus, 12.5% incidence in ESRD vs 22% in general population.2 • Goldsmith et al, Kidney Int 2001; 60 : 2059-78. • Wiesholder et al, Am J Kidney Dis 1999; 33:702-8.

  41. Chest Pain in Renal Disease (cont) • Higher prevalence of silent ischemia. • Patient with CKD presenting with chest discomfort has 40% cardiac event rate @ 30 days.1 • ESRD patients have highest mortality after AMI. 2 • McCullough et al:  Arch Intern Med   2002; 162:2464. • Braumwald

  42. Approach to ESRD patient with Suspicion of CAD McCullough PA: Kidney Int Suppl 95:s51-58, 2005

  43. Long-term survival by CAD management strategy in patients with CKD or ESRD. Keely et al. Am J Cardiol 92:509-514, 2003

  44. Management of CVD in Renal Failure • Lifestyle modification, as per general population. • Including physical activity when possible. • Control BP. • Goal LDL < 100. JNC7 recognizes CKD as independent risk factor • Have low threshold to evaluate atypical findings: • Worsening fatigue. • Hypotension in someone with hx HTN. • Atypical chest discomfort. • Dyspnea not related to pulmonary edema.

  45. Calcifications of the pelvic arteries. London GM, et al. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant. 2003;18(9):1731-1740, by permission of Oxford University Press . Calcification & vasculature

  46. Infections and Renal Disease • Renal failure = immunocompromised state. • Hypothermia common in renal failure. • Fever often absent. • Low grade temps can indicate serious infection. • Catheters and grafts are often source. • Higher incidence of HCV. • Note many antibiotics are dialyzable and require dose adjustment .

  47. Fatal Bacterial Infections in HD & PDin Australia and New Zealand 1995-2005 Johnson et al. AM J Kidney Dis 53:290-297.

  48. Acquired Renal Cystic Disease (ARCD) • Renal neoplasms seen in 10% of chronic HD patients. Adenomas most common. • With ARCD, prevalent incidence is 20-25%. • Present silently or w flank pain and hematuria. • RCC has 3-7X higher incidence in ESRD than general population. • ARCD may regress post-tx. Wein: Campbell-Walsh Urology, 9th ed.

  49. Acquired Renal Cystic Disease (ARCD) Wein: Campbell-Walsh Urology, 9th ed.

  50. Secondary Hyper-parathyroidism (SPTH) • CKD is the most common cause of SPTH. • Failing kidneys do not convert enough vitD to its active form. • Failing kidneys inadequately excrete phosphorus. This results in (insoluble) ca-phos complexes that remove calcium from the circulation. • Both processes leads to hypocalcemia & secondary hyperparathyroidism. • Vascular calcification common.

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