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Managing the Chronic Kidney Disease Patient

Managing the Chronic Kidney Disease Patient. Donna Birbrager, MD Nephrologist Lakeridge Health Oshawa Clinic May 15, 2013. Overview. Assessment of kidney function Chronic kidney disease definition screening

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Managing the Chronic Kidney Disease Patient

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  1. Managing the Chronic Kidney DiseasePatient Donna Birbrager, MD Nephrologist Lakeridge Health Oshawa Clinic May 15, 2013

  2. Overview • Assessment of kidney function • Chronic kidney disease definition screening classification management • Identify high risk patients in your practice • Who should be referred to a nephrologist

  3. Assessment of Kidney Function • Lab: • serum creatinine, urea • CrCl • GFR • Urinalysis • Assessment of proteinuria • ACR, PCR • Functions of Kidney • Anemia • Salt and water balance • Acid Base balance • Potassium excretion • Bone disease/mineral metabolism

  4. Why use eGFR? It gives the health care practitioner a different sense as to a patient’s level of renal function that they may not have appreciated by using simple serum creatinine measurements. • Glomerular filtration rate (GFR): is the volume of fluid filtered from the renal glomerular capillaries into the Bowman’s space per unit time. • Normal for a 20 year old is ~ 120ml/min

  5. Problems with creatinine Stevens L et al, NEJM 2006; 354:2473-2483

  6. Relation Between SCr and GFR 1120 560 280 140 70 Y=1/x SCr 6 12.5 25 50 100 GFR ml/min

  7. Problems with timed collections • Cumbersome • Prone to error • No longer recommended in most situations • ie STOP DOING 24-Hour Urines!!!!!!

  8. Creatinine based approximations of GFR (eGFR) 1) Cockcroft-Gault equation CrCl (ml/min)= (140-age) x actual weight (kg) x 1.2 (if male) SCreat (µmol/L) 2) MDRD (Modification of Diet in Renal Disease) 6 variable or abbreviated version GFR(ml/min/1.73m2)=170 (PCr)-0.999 x (Age)-0.176 x (0.762 if female) x (1.21 if African American) x (serum urea)-0.170 x (Albumin)+0.318 Weight probably not available for lab to calculate Lab has patient age and gender – can do abbreviated version

  9. eGFR equation provisos • eGFR calculations may be less reliable in: • individuals with near normal GFR (>60 ml/min/1.73m2) • individuals with markedly abnormal body composition • extreme obesity • cachexia • paralysis • amputations • Controversies exist as to the applicability of these formulae to various ethnic groups and the elderly

  10. Blood Pressure Targets • General < 140/90 mmHg • ISH < 140 mmHg • Diabetes mellitus < 130/80 mmHg • Chronic renal < 130/80 mmHginsufficiency CHEP 2008 Recommendations.

  11. NUMBER OF ANTIHYPERTENSIVE AGENTS How to Reach the Target Blood Pressure? 1 2 3 4 TARGET BP (mmHg) STUDY UKPDS ABCD MDRD HOT AASK IDNT VALUE DBP <85 DBP <75 MAP <92 DBP <80 MAP <92 SBP/DBP 135/85 SBP/DBP 140/90 Haller H. Int J Clin Pract 2008;62:781-90.

  12. Diabetes Hypertension The Most Common Causes of ESRD 27% 50.1% Primary Diagnosis for Patients Who Start Dialysis Glomerulonephritis Other No. of patients 10% 13% 700 Projection 95% CI 600 500 No. of Dialysis Patients (Thousands) 400 High incidence of Cardiovascular Disease 520,240 300 281,355 200 243,524 100 r2=99.8% 0 1984 1988 1992 1996 2004 2000 2008 United States Renal Data System. Annual data report. 2000.

  13. BP Hemodynamics in KDDM Raised intraglomerular pressure BP Normal Systemic Hypertension & Afferent Dilation

  14. 1) BP Renal Effects of ACEi/ARB Net: lowers intraglomerular pressure ACEi/ARB BP 2) Efferent Dilation Normal

  15. What is Microalbuminuria?

  16. Anatomy - Glomerulus

  17. Stages of Renal Involvement According to the Urinary Albumin Level

  18. Evaluation: Renal Condition

  19. Evaluation: Renal Condition Stages of Progression to Diabetic Nephropathy

  20. Typical Course of Diabetic Nephropathy 8 6 4 2 0 160 120 80 40 0 Stage I Stage II Stage III Stage IV Stage V Protein Excretion (g/24 h) Glomular Filtration Rate (mL/min) Proteinuria Microalbuminuria Duration of diabetes Primaryprevention Secondary prevention Life support Adapted from Mogenson; Pylypchuk GB. Can Fam Phys 2000

  21. Diabetes Vascular Risk - Microalbuminuria Odds Ratios OR CV DEATH Eastman RC et al, Lancet, 1997;350(Supl 1):29-32

  22. Microalbuminuria as a Risk Factor for Death in Type 2 Diabetes Urinary albumin concentration (μg/mL) 1.0 ≤ 15 16-40 41-200 Survival 0.5 0.0 5 10 Years after diagnosis Schmitz A et al. Diab Med 1988

  23. Proteinuria Is an Independent Risk Factorfor Mortality in Type 2 Diabetes 1.0 Normoalbuminuria (n=191) 0.9 Microalbuminuria (n=86) 0.8 Survival (all-cause mortality) 0.7 Macroalbuminuria (n=51) 0.6 0.5 0 1 2 3 4 5 6 Years Gall et al. Diabetes. 1995;44:1303.

  24. CKD is common

  25. Definition of CKD Structural or functional abnormalities of the kidneys for >3 months, as manifested by either: 1. Kidney damage, with or without decreased GFR, as defined by • pathologic abnormalities • markers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests 2. GFR <60 ml/min/1.73 m2, with or without kidney damage

  26. Chronic Kidney Disease (CKD)Classification (NKF-K/DOQI-2002)

  27. Who Should be Screened for CKD Patients with • Diabetes mellitus • Hypertension • Vascular disease • Heart failure • Family history of CKD • Unexplained anemia • First nations people

  28. What is Involved in Screening for CKD • Assessment of kidney function • Serum creatinine • eGFR, CrCl • Quantification of Protein • Urinalysis • Albumin to creatinine or protein to creatinine ratios

  29. Stages of Renal and CD Disease ESRD Death End Stage Progression CKD (↓ GFR) Albuminuria ASCVD, MI CVA, HF CVD, PVD LVH Initiation DM, HTN DM, HTN At Risk CV Disease Chronic Kidney Disease

  30. Classification of Chronic Kidney Disease • CKD Population 5-100x more likely • to die than develop ESRD • CVD is 2x as common and advances • at 2x the rate of CKD • Premature CHD Death is Major • issue for CKD patient Expected Outcomes Chronic Renal Insufficiency is a Cardiovascular Risk Equivalent National Kidney Foundation 1999 American Heart Association 2001 MI, CHF, CV Death Stage I CKD Risk Factors/Damage with preserved GFR Stage II Mild ↓ Kidney Function Stage III Moderate ↓ Kidney Function Stage IV Severe ↓ Kidney Function Stage V Kidney Failure ESRD 130 120 110 100 90 80 70 60 50 40 30 20 15 10 0 Kidney Function Glomerular Filtration Rate (ml/min/1.73m2 )

  31. Age • Gender • Ethnicity • Socioeconomic Status • Diabetes • Hypertension • Tobacco Use • ↑ LDL C and ↓ HDL C Chronic Renal Insufficiency • Inflammation • Homocysteine • Hemoglobin • ↑ LV mass • Hemostasis • Lipoprotein (a) • ADMA • Vascular calcification Renal Mechanisms Demographic Characteristics Traditional Risk Factors Cardiovascular Disease

  32. Estimated prevalence of CKD in Canadians ≥ 20 years old Stage 1 CKD > 90 ml/min 792,000 Stage 2 CKD 60 – 89 ml/min 720,000 Stage 3 CKD 30 – 59ml/min 1,032,000 Stage 4 CKD 15 – 29 ml/min 48,000 Stage 5 CKD < 15 ml/min 24,000 ESRD is not common Stigant, C, et al. CMAJ 2003;168:1553-60.

  33. What are normal GFR values for adults?NHANES III In patients >70 an eGFR b/w 60 and 90 could be normal Coresh AJKD 41(1) 1-12 NHANES III, .

  34. Prevent Decline of Renal Function Interventions to slow progression of CKD: • Proven benefit in RCTs: • BP Control (< 130/80) • ACEi or ARBs • BS control • May be of benefit: • Protein restriction • Lipid control • Anemia control • HCO3 supplementation • Control of 2° hyperparathyroidism • Vitamin D therapy

  35. Consider reversible factors • Intercurrent illness • Volume depletion • Medications • NSAIDs, aminoglycosides, IV contrast dye • Obstruction • An abdominal ultrasound may be indicated at eGFRs <60ml/min/1.73m2

  36. CSN recommends that most patients with non-progressive CKD can be managed by non-nephrologists without referral. The recognition that many patients with an eGFR between 30 and 60 ml/min/1.73m2 do not have a high risk of progressive kidney disease is important. • High risk Factors: • Diabetes with increasing MAU • High levels of MAU, PCR • Hypertension not controlled with ACEi/ARB • Significant decline in eGFR serially

  37. Identify patients in your practice at high risk for Chronic Kidney Disease • Patients with hypertension • Patients with diabetes mellitus • Patients with atherosclerotic coronary, • cerebral or peripheral vascular disease • Patients with heart failure • Patients with unexplained anemia • Family history of end stage renal disease • First nations peoples eGFR 30-60 eGFR >60 eGFR <30 • Consider reversible factors: • Medication - Volume depletion • Intercurrent illness - Obstruction • Repeat tests in 2 - 4 weeks Individualized follow up and treatment CKD is diagnosed in this group only if other renal abnormalities are present (i.e. proteinuria, hematuria, anatomical) eGFR <30 eGFR 30-60 Nephrology referral recommended Follow eGFR at 3 months then serially Assess for persistent significant proteinuria Implement risk reduction Stable eGFR 30-60 and no significant proteinuria eGFR < 30 or progressive decline in eGFR or persistent significant proteinuria or inability to attain treatment targets

  38. Who should be referred to a Nephrologist? • Patients with acute renal failure • Patients with eGFR <30ml/min/1.73m2 • Patients with progressive loss of renal function • Persistent significant proteinuria (present on 2 out of 3 samples) • on dipstick or • quantified PCR >100mg/mmol or • quantified ACR >60 mg/mmol. • Inability to achieve treatment targets or other difficulties in the management of the CKD patient

  39. Quick Tips on Management of CKD Implement measures to slow rate of CKD progression • Treat to target BP <130/80; most will need 3 or more meds, diuretics and salt restriction are very useful • Target urine ACR <40 or PCR <60. ACEI and/or ARB are first line therapies for albuminuria or proteinuria • Control blood sugar in diabetes, target HbA1C <7% Implement measures to modify CV risk factors • Follow guidelines as per groups at highest risk for CV disease

  40. The End Questions?

  41. Thank you

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