RENAL AND PROSTATE DISEASE

1. RENAL AND PROSTATE DISEASE Bill Lyons, M.D. UNMC Geriatrics & Gerontology

2. RENAL AND PROSTATE DISEASE: OBJECTIVES • Prevention and management of chronic renal disease, including ESRD • Diagnosis and treatment of benign prostatic hyperplasia • An approach to management of prostate cancer in the elderly male

3. CHRONIC KIDNEY DISEASE: OBJECTIVES • Why it’s important – prevalence, complications • Screening • Management to slow/prevent progression • ESRD for the non-nephrologist

4. BACKGROUND: CKD AND ESRD • Over 372,000 in ESRD Medicare program as of end of 2000, of whom 35% age 65+ • Highest rates ESRD in older persons and African-Americans • Annual mortality rates in US for ESRD >20% • About 43% new ESRD patients have DM

5. RISKS OF CHRONIC KIDNEY DISEASE • Hospitalization (3x vs. general population) • All-cause mortality • Cardiovascular mortality, especially • Increasing proteinuria • Decreasing GFR • CKD underdiagnosed, undertreated

6. PROGRESSION AMONG DIABETICS • Microalbuminuria  overt proteinuria  renal insufficiency  ESRD • Established nephropathy in majority of diabetics progresses up to 10 mL/min per year • Demographics: get ready

7. PROGRESSION AMONG DIABETICS, cont. • Risk factors for development and progression: • Degree, duration of glycemic control • Hypertension • Male sex • Higher total cholesterol • Smoking

8. SCREENING FOR CKD • Healthy (nondiabetic)? No commonly accepted screening guidelines • Diabetics • Screen for microalbuminuria • Early morning spot urine sample • Urine alb/Cr ratio > 30 mg/g is abnormal • Stand to benefit from agents that decrease intraglomerular pressure

9. MANAGEMENT PRINCIPLES • Start treatment early in CKD to slow or prevent progression to kidney failure • Regardless of cause of CKD, hypertension increases risk of adverse outcomes: • Progression of kidney failure to ESRD • Cardiovascular disease • Premature death

10. MANAGEMENT PRINCIPLES, cont. • For some elders with CKD, makes sense to prevent/treat complications of CKD and comorbidities; worry less about progression to ESRD. • Avoid renal insults: • IV contrast • Nephrotoxic drugs • Hypotension

11. MANAGEMENT OF CKD • In diabetic patients, intensive control of blood glucose can slow or prevent progression of CKD (at least in early stages). • Good control of BP probably most important intervention in slowing progression • Goal <130/80 for CKD or DM • Perhaps modify if orthostatic signs/symptoms

12. MANAGEMENT OF CKD, cont. • ACEi and ARB slow progression to ESRD better than other antihypertensives • Start in diabetics with microalbuminuria or proteinuria, even if BP within goal • Monitor renal function and potassium closely after starting these drugs • Renovascular disease common; risk of ARF • Don’t mix with NSAID

13. MANAGEMENT OF CKD, cont. • Restrict protein in diet? • Evidence from clinical trials mixed • No recommendation for/against

14. BONE AND MINERAL DISEASE IN ADVANCED CKD • Worse kidney function  phosphate retention  hypocalcemia and low calcitriol  secondary hyperparathyroidism • Metabolic acidosis also  bone disease • Management: • Modify diet (refer to Nutritionist) • Phosphate binders • Calcitriol • NaHCO3 650-1300 mg bid-tid • Nephrology referral

15. ADVANCED CKD MANAGEMENT • Serially monitor calcium, phosphorus, PTH to determine whether bicarb or calcitriol should be dose-adjusted. • Consider low-dose ASA • Epoetin alfa (perhaps with IV iron) to maintain Hct in range 33-36%

16. END-STAGE RENAL DISEASE • Start discussing need for RRT at least 6-12 months before anticipated date • When initiate dialysis? • Classic: severe hyperkalemia, acidosis, refractory volume overload, encephalopathy, bleeding diathesis, serositis (pericarditis) • Consider also: severe fatigue, pruritus, cognitive impairment, weight loss

17. ESRD, cont. • If RRT not chosen, • Consider dietary protein restriction • Diuretics, nitrates, opiates • Antiemetics • HD vs. PD? • Patient preference probably paramount • PD more challenging in setting of cognitive problems, poor vision, physical disabilities

18. HEMODIALYSIS • Plan for AVF when CrCl below 25 or when anticipate ESRD within one year • Fistula should be in place for several months before time of need to allow for arterialization • Major complications: • Vascular access: thrombosis, infection • Other: arrhythmia, sudden death, hemodynamic instability, anticoag problems

19. CANCER SCREEN IN ESRD? • Chertow: ?Benefit in finding early occult cancer in patient with 3-4 year life expectancy • Probably better to focus on • Optimizing dialysis • Primary and secondary prevention of cardiovascular disease

20. REFERENCES AND READINGS • Levey AS, Mulrow CD. Ann Intern Med 2005;143:79-81. • Chertow GM. JAMA 2004;291(10):1252-1259. • Kausz AT. Clinical Geriatrics 2004;12(7):39-46.

21. Post-test question one • All of the following statements regarding chronic kidney disease are true EXCEPT: (a) Lower values of glomerular filtration rate correlate with increased risk of cardiovascular mortality. (b) Smoking is a risk factor for the progression of kidney disease among diabetics. (c) Patients aged 65 and older should be routinely screened for chronic kidney disease with a spot early morning urine test for microalbuminuria. (d) The blood pressure for patients with chronic kidney disease should be maintained below 130/80 using antihypertensive therapy. (e) Patients with advanced chronic kidney disease may benefit from erythropoietin, dosed to maintain hematocrit between 33 and 36%.

22. Correct Answer:    (c) Patients aged 65 and older should be routinely screened for chronic kidney disease with a spot early morning urine test for microalbuminuria. Feedback:(c).Answers (a), (b), (d), and (e) are all correct statements, based on the material covered in this module. Answer (c) is not a true statement, as there is not a consensus that all patients > aged 65 and older or otherwise should undergo screening for proteinuria. Diabetic patients are another matter. They should indeed be screened for microalbuminuria, using an early morning spot urine test.