Chronic Kidney Disease for the General Internist

1. Selma Durakovic & Parker Gregg Chronic Kidney Disease for the General Internist

2. Learning Objectives How do you diagnose CKD? What is the basic workup of CKD in the primary care setting? What do you monitor in your patients who have CKD? When do you refer your patient to nephrology?

3. NEW PATIENT IN PCC 63 M, IMMIGRANT FROM ETHIOPIA (IN 2008) 8/2013 – Cr 1.3, eGFR 56, HbA1c 7.8% – LOST TO FOLLOW UP PMH: DM 2 WITH RETINOPATHY, HTN, AND HLD 2/2014 – BP 148/95, Cr 1.4, eGFR 51 DOES HE HAVE CHRONIC KIDNEY DISEASE?

4. Chronic Kidney Disease ≥ 3 months Renal Abnormalities • Functional - eGFR < 60 mL/min/1.73m2 OR • Structural - Kidney damage (albuminuria, cystic changes, etc) - “Catch all category” for any renal abnormality It is not all about GFR!

5. Staging: CKD and GFR 60 30

6. Staging: CKD and Albuminuria 300 30

7. Why is Albuminuria so Important? Diagnosis Does the patient have albuminuria? • YES: Think Diabetes OR Glomerular Disease • NO: HTN, cystic diseases, drug toxicites, TI disease, etc Prognosis • Inversely related to prognosis Management • Decrease the albuminuria and slow the progression of CKD Can you diagnose CKD in a patient with a GFR of 95?

8. CKD Staging : Putting It All Together * 60 30 300 30

9. CKD – Primary Diagnoses

10. Prevalence? HTN DM CKD More US Adults have CKD than DM! 73 Mil 31 Mil 26 Mil

11. Prevalence HTN DM CKD 28% due to HTN 44% due to DM 31 Mil U.S. Adults

12. BACK TO OUR PATIENT 63 M, IMMIGRANT FROM ETHIOPIA (IN 2008) PMH – DM2 WITH RETINOPATHY, HTN, AND HLD, TODAY WITH NEWLY DIAGNOSED CKD. HE WANTS TO KNOW WHY HE HAS KIDNEY DISEASE AND WHAT CAN BE DONE ABOUT IT. WHAT WORKUP SHOULD BE DONE FOR NEWLY DIAGNOSED CKD?

13. Learning Objectives How do you diagnose CKD? What is the basic workup of CKD in the primary care setting? What do you monitor in your patients who have CKD? When do you refer your patient to nephrology?

14. Workup for every patient with newly diagnosed CKD baseline creatinine UA and ACR renal ultrasound What can you learn from the ultrasound?

15. “Medical Renal Disease” Increased echogenicity Thin cortex “Normal” length 11-14 cm < 9 cm indicative of CKD Renal Parenchymal Disease Normal Ultrasound

16. Dilated Calyces

17. Cysts and Masses

18. Workup for every patient with newly diagnosed CKD baseline creatinine UA and ACR renal ultrasound What other workup do you do for newly diagnosed CKD?

19. Differential and Comprehensive Workup for CKD

20. Differential and Comprehensive Workup for CKD

21. Differential and Comprehensive Workup for CKD

22. Differential and Comprehensive Workup for CKD

23. Differential and Comprehensive Workup for CKD • Multiple myeloma/paraproteinemias can cause CKD in several ways: • Glomerular: amyloid, IG deposition • Tubular: cast nephropathy, Fanconi’s syndrome • Interstitial: plasma cell infiltration, interstitial nephritis • The following patients are at increased risk for multiple myeloma: • Over 40 w/o other cause of CKD • Other manifestations of MM • Hypercalcemia • Bone Pain • Radiographic lesions • Anemia >> CKD

24. Differential and Comprehensive Workup for CKD

25. Differential and Comprehensive Workup for CKD

26. BACK TO OUR PATIENT 63 M, IMMIGRANT FROM ETHIOPIA (IN 2008) LABS – Cr 1.8, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE SPEP/UPEP NORMAL RENAL US – BILAT 8 CM KIDNEYS, 1.2 CM ECHOGENIC CORTEX WHAT SEQUELAE OF CKD DO YOU WANT TO MONITOR? HOW DO YOU INTERPRET THIS ULTRASOUND?

27. Learning Objectives How do you diagnose CKD? What is the basic workup of CKD in the primary care setting? What do you monitor in your patients who have CKD? When do you refer your patient to nephrology?

28. CKD Sequelae – It’s as easy as ABC

29. Albuminuria, Anemia Albuminuria • Monitor ACR based on patient’s stage • Yearly if ACR < 300 • Q6 months if ACR > 300 Anemia • EPO deficiency -> normochromic, normocytic • First step: exclude non-renal causes • Fe supplementation • Refer to start EPO at Hb < 10 g/dL

30. Blood pressure, Bone health Blood pressure • <130/80 for diabetics • <140/90 for non-diabetics • Treat as you would: ACE, thiazide Bone health • Vit D, calcium, PO4, PTH • Follow calcium and PO4 with each visit

31. So … who doesn’t get a statin? Cholesterol Age > 50 eGFR > 60 with CKD eGFR < 60 & not on HD Age 18-49 with CKD + ANY OF: CAD DM prior CVA 10 year risk for CAD > 10% Dialysis or Renal transplant? Treatment statin statin ± ezetimibe statin statin statin statin Don’t start it! Don’t stop it!

32. Diet/Drug Avoidance Diet • Low protein, Low salt Drugs • NSAIDs • Aminoglycosides • Cocaine/illicits • Tobacco

33. Electrolytes Hyperkalemia • Often severe when eGFR < 10 mL/min/1,73 m2 -or- • Impaired K+ metabolism (ACEi/ARB/NSAIDs) Hyperphosphatemia • Excretion of PO4 drops as kidney function decreases • PTH is compensatory until ~ eGFR 30 mL/min/1,73 m2

34. Chronic Kidney Disease (.ckd) Date, type, biopsy? ACR, eGFR Consult required Hct, Fe panel, on EPO? Ca, PO4, Vit D, PTH Don’t start/stop if on HD or transplant Low protein, low salt, nutrition consult K+, on kayexelate? Access, schedule, plan for transplant Diagnosis: Stage: Nephrology: Anemia: Bones: Cholesterol: Diet: Electrolytes: Dialysis:

35. BACK TO OUR PATIENT 63 M, IMMIGRANT FROM ETHIOPIA (IN 2008) PMH – DM2 WITH RETINOPATHY, HTN, AND HLD LABS – Cr 1.8, eGFR 45, ACR 500 mg/g, A1c 7.9% HIV, HBV, HCV NEGATIVE Hct 39, K 4.8, Phos 5.1 WOULD YOU REFER TO NEPHROLOGY?

36. Learning Objectives How do you diagnose CKD? What is the basic workup of CKD in the primary care setting? What do you monitor in your patients who have CKD? When do you refer your patient to nephrology?

37. Refer sooner rather than later! • Delayed nephrology referral (<3-6 months prior to initiation of dialysis) Increased mortality • Preferably patients will should be referred 1 year prior to needing dialysis to allow them time to choose their option, have a fistula placed and allow that fistula to mature, and get dialysis teaching.

38. When to Refer

39. Other Reasons to Refer Complications of CKD Unclear etiology Refer to nephrology A: anemia B: bone/mineral disorders, resistant HTN E: electrolyte abnormalities Rapid decline in eGFR Hematuria (> 3 RBC/hpf)

40. Take Home Points Know how to stage CKD based on GFR (30-60) and albuminuria (30-300) Tailor your workup to your patient Monitor the ABCs Early referral saves lives

41. Questions?

42. Sources • Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 38: The Genitourinary Tract; Techniques and Anatomy. 2008. Accessed electronically 5 Feb 2014. • Adam, Andy and Adrian K. Dixon. Grainger and Allison’s Diagnostic Radiology, Fifth Edition. Chapter 39: Renal Parenchymal Disease, Including Renal Failure, Renovascular Disease and Transplantation. Accessed electronically 5 Feb 2014. • Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. 2012. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf • KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease. Nov 2013. http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf • National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, section on Approach to Chronic Kidney Disease Using These Guidelines. 2002. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p9_approach.htm • National Kidney Foundation KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002. http://www.kidney.org/professionals/kdoqi/pdf/ckd_evaluation_classification_stratification.pdf • Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2013. http://annals.org/article.aspx?articleid=1757302&resultClick=3