Chronic Kidney Disease: A Silent Epidemic (Case Review)

1. Chronic Kidney Disease: A Silent Epidemic (Case Review) Naima Ogletree, MSN, APRN, BC Nephrology & Hypertension Henry Ford Health System

2. Case Study History of Present Illness: Mrs. A is a 50 year old African American female She is seeking care from a new physician No complaints today Compliant with her previously prescribed medications regularly Remainder of her HPI is unremarkable Past Medical History: Type 2 diabetes mellitus (of 5 years duration) hypertension (of 10 years duration) Obesity No history of stroke or CV disease. The remainder of her past medical history is unremarkable.

3. Past Laboratory Studies:(4 months prior to this visit) Serum chemistries, cholesterol indices, and hematological studies (complete blood count) were normal at that time. BUN 18 mg/dL, SCr 1.8 mg/dL Hb Alc was 6.3% UA: normal pH, normal specific gravity, negative glucose, negative bilirubin, negative ketones, 1+ protein, negative leukocyte esterase, and negative nitrite EKG: 1 year ago, which is normal Case Study

4. Social History: Married, with 3 children Works as an administrative assistant She is a smoker Review of Systems: Ophthalmology annually Medications: Metformin 1 GM twice a day, Losartan 50 mg PO once QD Case Study

5. Physical Examination: BP140/88, WT. 170 pounds, height 5'2“ Remainder of her examination (including eye, cardiovascular, and neurologic exams) is unremarkable The PCP orders routine labs and reviews them with her one week later Case Study

6. Case Study Labs one week ago • CBC, NA, K, CO2, CL, -NL • UA: protein 1+, otherwise WNL • BUN 18 mg/dL • Serum Creatinine: 1.9 mg/dL • HbA1c 7.0 % • Serum cholesterol: 220 mg/dL, Triglycerides: 200 mg/dL, LDL: 110 mg/dL, HDL: 44 mg/dL 6

7. Issues: Does she have CKD? Stage of CKD How would you code her disease? What is her risk of progression of kidney disease? How can we safely slow her progression of kidney disease? What are her cardiovascular risks? How do we manage this pt?

8. Case Study #2 • This is a 70 y.o. AAF who was referred for evaluation of an  SCr • Records: Baseline SCr (2001) at that time was 2.1 mg/dL w/ GFR of 28 • Upon referral to the department her initial BP reading was 139/79 mmHg

9. Case review Medication List • Simvastatin 20 mg ONCE DAILY • Diltiazem 240 mg ONCE DAILY • HCTZ 25 mg ONCE DAILY • Losartan 100 mg ONCE DAILY • Metoprolol 200 mg TWICE DAILY • ASA 325 mg ONCE DAILY • Aleve OTC as needed (she takes at least once a month).

10. Case Review: Risk Factors • Cigarettes: 40 pk-yrs • PMH • PAD • High cholesterol • NSAID use • Hypertension • Uncontrolled SBP due to non-compliance with drug regimen secondary to non-adherence to her anti-hypertensive regime • “Could not afford medications” • Relied heavily on sample medications

11. Case Review • Kidney US • Lt 9.6 cm ; Rt 9.4 cm • UA dipstick — >300 mg/dL (06/01) • PCP Tx — ACEI • Angioedema • ARB substitution

12. Case Review • She was referred to the CKD clinic in October 2004 for further management of her chronic kidney disease. She was asymptomatic for uremic symptoms. BP at time of referral: 116/68.

13. Case Review • Lab review: There was a slow progressive decline in her renal function • BUN/Cr: (46/3.66) • UPC 0.38 (2004) • GFR 15 ml/min/1.73 m² (Stage 4) • K 5.3 meq/L • Lipid panel: TC: 128 TG: 61 HDL: 46 LDL: 70 • Hgb/Hct: 9.7/29.0 • P 4.6 / PTH 128 / 1,25(OH)2D 45, 25(OH)D 25Ca x P: 42.32

14. Case Review Interventions • Attend the CKD education class (modality) • Placed on individualized renal diet (low Na, low K, low phosphorus) by renal dietician • Monthly darbepoetin alfa (Aranesp) 60 mcg, sub-Q, initiated (10/04), with prn iron, p.o. • Vascular Surgery referral • AVF construction (02/15/05)

15. Case Review • Evaluated by the renal transplant team on April 25, 2005. Placed on waiting list. Also has a willing living related donor whose work up is in progress. • Phosphorus binding agent started in Oct. 2004. • Started on monthly ergocalciferol for her hypovitaminosis D in Feb. 2005. • Referred to the renal dietician for quarterly assessments. • Fistula was cleared for use in March 2005. • Deemed a suitable candidate for renal transplant by the transplant surgeon May 2006.

16. Case Review • Pt has remained clinically stable. Her most recent office visit was July 13, 2007. Her BP was 124/64. She remains asymptomatic for uremia, normokalemic, and euvolemic. She has a patent AV fistula whenever the need arises. Follows routinely with renal dietician. She does not require HD at this time

17. Case Review • Current lab data: She is noted with stable renal function: BUN/Cr (59.4/3.85). Normal protein excretion rate. Pro:Cr ratio was 0.22 mg/dL. Her estimated GFR was 14 ml/min/1.73m² (stage 5). Potassium: 4.9 Lipid panel: Total-C: 137 TG: 76 HDL: 51 LDL: 71. PTH: 83 Vit D 1,25: 29, VIt D 25: 56, Ca × P: 39.6 Hgb/Hct: 11.5/33.0

18. Case Review • Meds: simvastatin 20 mg QD, diltiazem 240 mg BID, furosemide 40 mg BID, losartan 100 mg QD, calcitriol 0.25 mcg QD, clonidine 0.1 mg BID, ASA 81 mg QD, monthly Aranesp per protocol

19. Case Review: Discussion • Noted with stable renal function • Asymptomatic for uremia. Has not required RRT in 5 years • Permanent access placed in timely manner • All therapeutic targets have been met • Active vitamin D sterol initiated- PTH:83 pg/mL (Goal <150) • Treated with binder- Phos: 4.4 mg/dL (Goal 3.5-5.5)

20. Case Review: Discussion • No proteinuria - maintained on anti-RAAS therapy for renal preservation • Ca x P product: 39.6 (Goal <55) • Cholesterol optimally controlled: LDL: 71 TG: 76 (Goal LDL<100, TG <150) • Anemia corrected. Hgb within target range (11.4)