When to Call Nephrology

1. 1 When to Call Nephrology Mike Henning MSN, ANP-C Southside Kidney Specialists Petersburg, VA

2. 2 Objectives To help you determine when to refer a patient to nephrology Information about what nephrology does with your patients Help you manage Stage 1 & 2 patients in your office Thanks to Dr. Gibson and Dr. Damodar for reviewing the presentation.

3. 3 When to Call Nephrology � �delayed referral of patients with late-stage chronic kidney disease is associated with suboptimal outcomes, including increased mortality.� New England Journal of Medicine, 362;1, p 58, 2/3/2010

4. 4 Case 1 Mr. Smith is a 64 year old African American male who is a retired Army recruiter. He has a long standing history of hypertension and minimal trips to the provider. He has been referred to the practice by the provider at the local Army base. He currently has no complaints and wonders why he is at our office. His labs at the time of the initial visit are:

5. 5 Case 1 (continued) Hgb � 8.8 Hct � 27.0 BUN � 82 Creat � 11.3 eGFR � 6.28 Sodium � 140 Chloride � 113 CO2 � 20 K+ � 5.4 Phos � 6.7 Albumin � 3.9 ALT � 12 AST � 10

6. 6 Case 1 (continued) Vital Signs � BP � 128/81 HR - 100 R � 16 Wgt � 218 Hgt � 72� BMI � 29.6 Subjective: Patient denies any current problems. Physical Exam : 64 yo male, moderately built, muscular physique, in no apparent distress. Neck: no JVD, no carotid bruit. Lungs: clear to auscultation, full excursion. Cardiac: S1S2, RRR, no rubs, clicks, or murmurs. Extremities: warm/dry, no cyanosis, no edema.

7. 7 Case 1 (continued) What do you think? His referral is the result of a well visit check up.

8. 8 Case Study 2 Mr. Jones is a 52 year old male without complaint, appearing fit. He states that he trains daily with both strength training and cardio-vascular workouts. Mr. Jones was referred to our office when routine labwork showed a rise in serum creatinine and subsequent decrease in eGFR.

9. 9 Case 2 (continued) BUN � 15 Creat � 1.42 eGFR � 53 Sodium � 139 Chloride � 101 CO2 � 25 K+ � 4.5 Phos � 6.7 Albumin � 4.7 ALT � 23 AST � 22

10. 10 Case 2 (cont) Vital Signs � BP � 126/72 HR - 76 R � 18 Wgt � 170 Hgt � 69� Subjective: Patient denies any current problems. During the interview the patient stated previous use of excessive NSAIDS and use of creatinine supplements. Physical Exam : 52 yo male, moderately built, muscular physique, in no apparent distress. Neck: no JVD, no carotid bruit. Lungs: clear to auscultation, full excursion. Cardiac: S1S2, RRR, no rubs, clicks, or murmurs. Extremities: warm/dry, no cyanosis, no edema.

11. 11 Case 3 Ms. Williams is a 72 year old female who is referred to the office. She is very knowledgeable of her medical condition and states a history of 20+ years with the rescue squad. She is currently retired and has a history of hypertension, DJD, prolapsed bladder, and recently nephrotic syndrome.

12. 12 Case 3 (continued) Hgb � 14.6 Hct � 42.5 BUN � 16 Creat � .71 eGFR - > 59 Sodium � 135 Chloride � 96 CO2 � 32 K+ � 4.7 Albumin � 3.1 ALT � 30 AST � 29 Urine Protein � 211 (mg/dl)

13. 13 Case 3 (continued) Vital Signs � BP � 157/86 HR - 82 R � 16 Wgt � 150 Subjective: Complains of exertional dsypnea, lower extremity edema, nocturia. Physical Exam : 72 yo female, moderately built, in no apparent distress. Neck: no JVD, no carotid bruit. Lungs: clear to auscultation, full excursion. Cardiac: S1S2, RRR, no rubs, clicks, or murmurs. Extremities: warm/dry, no cyanosis, +2 LE edema.

14. 14 Stages of Chronic Kidney Disease

15. 15 Prevalence of CKD

16. 16 Why? The question that remains unanswered is why there are so many people with CKD and so few on dialysis? Part of the answer is late referrals to nephrology. Another problem is losing patients to cardiovascular disease before being treated for kidney disease.

17. 17 Common Causes of CKD These two make up almost 70% of CKD cases Diabetes Hypertension Focal Segmental Glomerular Sclerosis (FSGS) Polycystic Kidney Disease (PKD) Lupus Sickle Cell Disease Cancer HIV Connective Tissue Disorders

18. 18 GFR & the prevalence of cardiovascular risk factors

19. 19 Common Complications of CKD Anemia of CKD Erythropoetin production Reduced iron stores Secondary Hyperparathyroidism High bone turnover Hyperphosphotemia Calcium deposits in soft tissues Affects cardiac and cerebral arteries Metabolic Acidosis Bone demineralization disorders Dysrhythmias, coma

20. 20 Diagnosis of CKD Abnormal eGFR Most labs normal is > 59 Elevated BUN Elevated Creatinine Proteinuria (Nephrotic Syndrome) Even in Stages I and II Family history of CKD

21. 21 Azotemia Pre-renal Dehydration Reduce renal perfusion Fractional excretion of Na of < 1% Renal Renal vascular obstruction Acute tubular necrosis Glomerular disease Interstitial nephritis Tubular obstruction (endogenous, exogenous) Post-renal Obstruction

22. 22 Common Causes of ARF Oliguria Proteinuria Hyperphosphatemia Hyperkalemia Hypoalbuminuria Elevated Uric Acid Dehydration Hyperglycemia Ethylene glycol ingestion

23. 23 Referral for ARF Azotemia (pre-renal, renal, post-renal) Absolute indications for acute dialysis Hyperkalemia, refractory to medical therapy Volume overload/Pulmonary edema, refractory to medical therapy Uremic pericarditis Uremic encephalopathy Severe metabolic acidosis Some toxic ingestions (MUDPILES)

24. 24 MUDPILES Methanol Uremia Diabetic Ketoacidosis Paraldehyde Iron Isoniazid Lactic acid Ethanol Ethylene Glycol Salicylates

25. 25 Referral for CKD Most important thing is to let your patient know that kidney disease is present Think of GFR as a percent and then let patient know functional percent Can be handled by PCP for stages 1,2 Referred in stage 3 Management can be by PCP Stage 4 and 5 handled by nephrology

26. 26 Sequelae of CKD Uremia Anemia of CKD Hypertension Secondary Hyperparathyroidism Hyperphosphotemia Hyperkalemia Hypoalbumenemia Metabolic acidosis Fluid retention

27. 27 Uremia Uremia is a clinical condition associated with elevated nitrogenous wastes and fluid, hormone, electrolyte and metabolic imbalances. Symptoms include nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritus, and changes in mental status.

28. 28 Anemia Lack of production or loss of erythropoeitin Replaced with Procrit/Epogen Goal for CKD Hgb between 11.0 and 12.0 Iron deficiency Increase in erythrocytes Abnormalities in MCV and RDW Platelet abnormalities

29. 29 Hypertension BP goal in CKD < 130/80 (125/75 in diabetics) Difficult to achieve in a lot of patients because of kidney disease, a downward spiral. Often requires coordination of efforts between providers. Screening for sleep apnea. Medication Classes ACEI, ARB, Alpha Agonists, Beta Blocker, CCB, Diuretics, Vasodilators/Nitrates, Other ACEI, ARB, and NSAIDS can raise creatinine ACEI, ARB can raise K+

30. 30 Secondary Hyperparathyroidism Controls bone turnover High Pth leads to caliphylaxis Studies show that it probably starts in stage III but is under diagnosed Also affects calcium and phosphorous levels Controlled by activated vitamin D

31. 31 Hyperkalemia Symptoms include generalized fatigue, weakness, paresthesias, paralysis, and palpitations Most CKD patients with hyperkalemia are asymptomatic Potassium restricted diet In severe cases control with SPS

32. 32 Hypoalbumenemia Malnutrition from CKD side effects Proteinuria contributes to hypoalbumenemia Protein in CKD patient is often reduced to decrease the workload on the kidneys K/DOQI suggests 0.6 to 0.75 gm/kg/d of protein for Stages I-IV Albumin increases systemic osmolality and decreases edema

33. 33 Metabolic Acidosis Diagnosed by low CO2 Inability of kidneys to produce HCO3 and/or secrete H+ Secondary to uremia

34. 34 Fluid Overload Hypertension Anasarca Lower extremity edema CHF Orthopnea

35. 35 Diabetes Control Goals are the same as ADA or ASE guidelines. For some patients diabetic control becomes easier in CKD because of an increase in insulin secretion and utilization.

36. 36 Medications for CKD Patients Limited/no use of NSAIDS for patients suspected with CKD NSAIDS affect kidney blood flow and can cause/exacerbate CKD Many antibiotics need to be reduced to prevent toxicity Caution with medications that might increase serum potassium The use of IV dye has to be weighed against the diagnosis and potential kidney injury.

37. 37 Baseline Work-up Renal panel or CMP with phosphorous CBC Iron studies (iron, iron sat, TIBC, Ferritin) Pth 25 Hydroxy (OH)Vitamin D 24� urine for creatinine clearance and protein (Creatinine clearance calculated based on a 24 hour urine collection tends to over-estimate true GFR, especially in patients with more advanced chronic kidney disease. *) Kidney Ultrasound (maybe) EKG (for LVH) Sleep study for OSA (if elevated BP)

38. 38 Medications Used in CKD Erythropoetin Venofer Zemplar Hectorol Calcitriol Renal vitamins Sodium Bicarbonate Sensipar Furosemide Metolazone Sodium Polystyrene Sulfonate

39. 39 Case Review Case 1 � eGFR � 6 This is a �no brainer� immediate referral Still has not gone on dialysis � exhibits all symptoms of CKD except he states he feels okay Case 2 � eGFR � 53 Referral but not immediate Measured GFR 101 Case 3 � eGFR � 130 4 - 8 + proteinuria Trying to get proteinuria in control before kidney damage.

40. 40 Summary Prompt referral for ARF Usually in hospital with azotemia Referral in stage III for CKD patients Tell the patient they have suspected kidney disease The more work-up that you have done the faster treatment can begin

41. 41 Questions

42. 42 Most Recent Text/PPT www.southsidekidney.com Contact Information: Mike Henning ANP-C Southside Kidney Specialists 3400 S. Crater Rd. B Petersburg, VA 23805 804-733-6960 Mike.Henning@southsidekidney.com