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CLINICAL LEARNING DAY
NEPHROLOGY UPDATE
Arasu Gopinath, MDNephrology Associates of Utah
• BP targets• Albuminuria
• Screening and monitoring• Intermountain data• iCentra• Metformin and Radiocontrast administration
Delaying CKD progression
9/29/2016 2
CKD classification and prognosis
9/29/2016 3
Management of CKD progressionIHC CKD CPM
9/29/2016 4
CKD Patient Counts by Stage and Category as of August 2016
A1 A2 A3Missing Test
Grand Total
Normal to Mildly
Increased
Moderately
Increased
Severely Increased
<30 30‐300 >300
G1 Normal >90 284 3,842 596 225 4,947
G2 Mildly Decreased 60‐89 1,865 6,721 1,000 1,748 11,334
G3aMild to Moderately Decreased
45‐59 4,221 7,526 598 9,545 21,890
G3bModerately to Severely Decreased
30‐44 3,843 7,729 708 5,890 18,170
G4 Severely Decreased 15‐29 1,286 4,028 523 1,568 7,405
G5 Kidney Failure <15 291 2,265 285 562 3,403
Missing Test 65 507 78 428 1,078
Grand Total 11,855 32,618 3,788 19,966 68,227
INTERMOUNTAIN (and affiliates) data
9/29/2016 5
• BP control
Goal BP < 130/80, if patient has UACR more than 30 mg/g
Goal BP < 140/90, if patient has UACR less than 30 mg/g
Delaying CKD progression
9/29/2016 6
Evidence supporting BP target
9/29/2016 7
©2016 by American Diabetes Association
Data from prospective clinical trials on nephropathy progression in relation to systolic BP
9/29/2016 8
Blood Pressure Control in CKD
68%n=22,987
71%n=24,498
32%n=2,103
32%n=2,391
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jan‐16 Aug‐16
Percent of CKD Patients Whose Blood Pressureis in Recommended Range
CKD w/ACR ≤ 300: Target 140/90 CKD w/ACR > 300: Target 130/80
INTERMOUNTAIN (and affiliates) data9/29/2016 9
68%n=17,562
72%n=18,723
30%n=1,471
29%n=1,712
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jan‐16 Aug‐16
Percent of CKD Who Have Known Hypertension Whose Blood Pressure is in Recommended Range
CKD&HTN w/ACR ≤ 300: Target 140/90 CKD&HTN w/ACR > 300: Target 130/80
INTERMOUNTAIN (and affiliates) data9/29/2016 10
• Albuminuria reduction
• ACEI or ARB in all adults with UACR > 300 mg/g
• ACEI or ARB in diabetics with UACR > 30 mg/g
Delaying CKD progression
9/29/2016 11
Albuminuria in relation to the percentage of clinical visits in which blood pressure (BP) values were reduced to <140/90 mmHg or to <130/80 mmHg.
Guido Grassi et al. Dia Care 2016;39:S228-S233©2016 by American Diabetes Association
ONTARGET data
9/29/2016 12
INTERMOUNTAIN (and affiliates) data9/29/2016 13
86%n=7,876
85%n=8,642
25%n=8,747
26%n=8,722
37%n=25,977
38%n=27,221
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan‐16 Aug‐16
CKD Patients Receiving Labs
CKD w/ACR ≥ 30: eGFR prior 12 months
CKD w/eGFR <60: ACR prior12 months
INTERMOUNTAIN (and affiliates) data9/29/2016 14
CKD checklist
9/29/2016 15
iCentra
9/29/2016 16
iCentra
9/29/2016 17
iCentra
9/29/2016 18
iCentra
9/29/2016 19
Metformin and radiocontrast
• Background:– causes lactic acidosis (rare but life threatening)– risk is higher in AKI or CKD G5– radiocontrast risks AKI (small but significant)
9/29/2016 20
ACR recommendations:
•Category I: If eGFR ≥30 and no AKI, continue Metformin. No need to check Creatinine following contrast.•Category II: If CKD G4 or G5 or AKI, and/or undergoing arterial catheter studies that might result in emboli (atheromatous or other) to the renal arteries, hold metformin during or prior to the procedure, and for 48 hours after, until Creatinine has been re‐checked and found to be normal.
9/29/2016 21
FDA press release 4/8/2016
•Discontinuemetformin at the time of or before an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/minute/1.73 m2 ; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra‐arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable.
9/29/2016 22
Metformin and Radiocontrast in CKD
* iCentra advisories being created.* Will likely review eGFR level if available or prompt its estimation when a contrast study is ordered.* PCP’s responsibility to discontinue Metformin when eGFR is < 30 ml/min
9/29/2016 23
Questions1. 48 yr old male with type 2 diabetes, hypertension and
dyslipidemia, is seen on routine follow up. His weight is stable. He smokes ½ ppd, does not drink and walks 3 miles every other day. He is on Metformin 1000 mg bid, Glimepiride 2 mg daily, Ramipril 10 mg daily, HCTZ 25 mg qd, and Atorvastatin 20 mg daily.
BMI 28, BP 128/74, ACR 320 mg/g, A1c 6.8. His ACR 4 months prior was 15 mg/g.
Which of the following might be the reason for his worsening albuminuria?a. BP 128/74b. Smoking ½ pack a day of cigarettesc. HCTZ 25 mg qdd. Atorvastatin 20 mg daily
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Answer:
Which of the following might be the reason for his worsening albuminuria?a. BP 128/74b. Smoking ½ pack a day of cigarettesc. HCTZ 25 mg qdd. Atorvastatin 20 mg daily
9/29/2016 25
Questions
2. Which of the following anti‐hypertensives can worsen proteinuria?1. Carvedilol2. Amlodipine3. Ramipril4. Candesartan5. Verapamil
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Answer:
2. Which of the following anti‐hypertensives can worsen proteinuria?1. Carvedilol2. Amlodipine3. Ramipril4. Candesartan5. Verapamil
9/29/2016 27
Questions
3. Which of the following is not an appropriate strategy to reduce proteinuria?1. Losartan + Diltiazem2. Lisinopril + HCTZ3. Valsartan + Spironolactone4. Lisinopril + Valsartan
9/29/2016 28
Questions
3. Which of the following is not an appropriate strategy to reduce proteinuria?1. Losartan + Diltiazem2. Lisinopril + HCTZ3. Valsartan + Spironolactone4. Lisinopril + Valsartan
9/29/2016 29
Summary
•Test regularly (monitor progression, complications and treatment)• Control BP
• < 140/90, if ACR < 30• < 130/80 if ACR> 300 and perhaps 30‐300 as well
• Prescribe ACEI/ ARB for ACR > 30 in Diabetics or ACR > 300 in others
9/29/2016 30
CKD Clinical Learning Day
9/29/2016 31
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