Chronic Kidney Disease Management - TAFP · Choi M: NephSAP. CKD and safety 14(4): 344-348, 2015. • 47 patients with stage 4 or 5 CKD given smartphone • 60% had never used a smartphone

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Friday General Session

Chronic Kidney Disease Management Nishant Jalandhara, MD Clinical and Interventional Nephrologist Tarrant Nephrology Associates Fort Worth, Texas Educational Objectives By the end of this activity, the participant should be better able to: 1. Discuss the recent changes of Chronic Kidney Disease (CKD) classification. 2. Identify the complications related to CKD. 3. Implement the various treatment options for management of patients with CKD.

Speaker Disclosure Dr. Jalandhara has disclosed that he has no actual or potential conflict of interest in relation to this topic.

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Nishant Jalandhara, MD, FASN, [email protected]

Fort Worth TX

Chronic Kidney Disease Management

• Dr. Jalandhara has disclosed that he has not actual or potential conflict of interest in relation to this topic.

Disclosure

By the end of this activity, the participant will be better able to:

• Discuss the recent changes of CKD classification.

• Identify the complications related to CKD.

• Implement the various treatment options for management of patients with CKD.

Learning Objectives

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• Anatomical or Structural Defect• Functional Component• Time Component

Defining Chronic Kidney Diseases (CKD)

http://esciencenews.com/articles/2010/11/11/common.diabetes.drug.may.halt.growth.cysts.polycystic.kidney.diseasehttp://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/learn/causes-kidney-disease/testing/understand-gfr/Pages/understand-gfr.aspxhttps://commons.wikimedia.org/wiki/File:Time-management.jpg

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The Early NHANES III Study

- Adapted from NHANES III (2000)

Stage DescriptioneGFR Range

1Kidney damage with normal or

increase GFR≥ 90

2 Mildly decreased GFR 60-89

3Moderately decreased

GFR30-59

4 Severely decreased GFR 15-29

5 Kidney Failure < 15

Cases:

http://redbeans.tulane.edu/suggested-readings/aki/

Vs.

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• 40 y/o male• Initial clinic visit for feeling weak and

tired• Creatinine 4.5, no other complaints

Cases:

1. AKI 2. CKD

• 45 y/o male• DM and HTN for 15 years • Renal panel normal. Urine protein ++ • Sonogram normal

Cases:

1. AKI 2. CKD

• 49 y/o female with non specific abdominal pain

• Sonogram shows 10 cyst left kidney, 20 cyst right kidney

• 18 cm size kidneys

Cases:

1. AKI 2. CKD

• 71 y/o female• No complaints• Labs negative • Sonogram: 1 simple cyst 2cm

Cases:

1. AKI 2. CKD

• 92 y/o male• No complaints• Creatinine 0.9, GFR 52• Urine negative, sonogram normal

Cases:

1. AKI 2. CKD

• 31 y/o female surgical nurse. Slight SOB and Blood Pressure 160/98

• UA blood +, protein +• ACR: 5000 mg/gm

Cases:

1. AKI 2. CKD

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What is the major cause of concern in CKD patients?

1. Cardiovascular death2. Malignancies3. Need for dialysis4. Infections

CKD: Prognosis CKD: Prognosis

Keith D, et al: Arch Intern Med. 2004;164:659-663

CKD: Prognosis

0

10

20

30

40

50

60

70

80

90

100

GFR 60‐80 Pr‐ GFR 60‐80 Pr+ GFR 30‐59 GFR 15‐29

Death Dialysis Event Free Discontinued

Keith D, et al: Arch Intern Med. 2004;164:659-663

• 100 patients (eGFR < 60) in 10 years

• 8 ESRD• 27 CKD• 65 Death

CKD: Prognosis

25 y/o +++ pr

45 DM ++ pr

65 no protein

Levey AS et al. Kidney Int 2011; 80: 17-28

• Are all Coronary Artery Diseases same?

CKD: Prognosis

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CKD: Prognosis

Koji Kato et al. Circ Cardiovasc Imaging. 2013;6:448-456TCFA indicates thin-cap fibroatheromaKDIGO Kidney International Supplements (2013) 3, 19–62;

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CKD: Management

Treatment of reversible causes

Preventing or slowing the progression of CKD

Treatment of the complications of CKD

Adjusting drug doses

Preparation for renal replacement therapy

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CKD: Management


Stop NSAIDs

Dose antibiotics correctly

Avoid hypotension

Avoid OTC meds

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CKD: Quiz

Have you or your family members taken over-the-counter supplements within past month?

1. YES2. NO

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CKD: Management

• OTC Supplements

• Included 21,169 non-pregnant, adult participants from NHANES 1999-2008

• 8.0% of U.S. adults reported potentially harmful supplement use within the last 30 days

Grubbs V et al. Am J Kidney Dis. 2013 May ; 61(5): 739–747

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CKD: Management

Grubbs V et al. Am J Kidney Dis. 2013 May ; 61(5): 739–747

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CKD: Management






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CKD: Management

• Treatment of reversible causes• Preventing or slowing the progression of

CKD• Blood pressure control• Protein intake• Smoking cessation

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CKD: Management


CKD• Protein intake restriction

• A daily protein intake of 0.8 g/kg• A diet rich in vegetables• Plant based protein vs Animal based

protein

KDIGO Kidney International Supplements (2013) 3, 19–62;

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CKD: Management


CKD• Smoking cessation

• Stopping smoking is associated with a slower rate of progression of CKD

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CKD: Management


CKD• Lipid Management:

Baigent C et al. Lancet 2011; 377: 2181–92

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CKD: Management

Included 6247 patients with CKD, follow-up of 4.9 years

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CKD: Management

• Lipid Management:

Baigent C et al. Lancet 2011; 377: 2181–92

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CKD: Management

• Lipid Management: Guidelines• Recommend treating all individuals with

CKD ages ≥ 50 years with a statin, irrespective of LDL levels

• Check LDL levels once at initiation of therapy

KDIGO Kidney International Supplements (2013) 3, 19–62;

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CKD: Management






0 15 30 45 60

Hypertension

MBD‐PO4

Anemia

Acidosis

K, Edema

Uremia

Complication

GFR

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CKD: HTN Management

• CRIC study evaluated data on 3612 patients with CKD

Muntner P et al, AJKD, Vol 55, No 3 (March), 2010: pp 441-451

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CKD: HTN Management

• Both, Salt retention and peripheral resistance contribute

• BP accelerated decline in renal function• BP exacerbates proteinuria• ACE/ARB preferred agents

ACE: Angiotensin Converting Enzyme blockers. ARB: Aldosterone Receptor Blockers

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CKD: HTN Management

• Diabetic CKD < 140/90 mmHg• Proteinuric CKD < 130/80 mmHg• Hypertensive CKD < 130/80 mmHg• Proteinuria reduction has independent

benefit vs. BP reduction: ACE/ARB

KDIGO Kidney International Supplements (2013) 3, 19–62;JAMA. 2014;311(5):507J Hypertens. 2013;31(7):1281.

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CKD: HTN Management

• Use ACE/ARB as first line therapy• ACE/ARB help delay progression to ESRD• Proteinuria reduction has independent benefit• DO NOT combine ACE and ARB or Direct

renin inhibitors with ACE/ARB• More Hyperkalemia, AKI, and Mortality

0 15 30 45 60

HTN

MBD-PO4

Anemia

Acidosis

K, Edema

Uremia

Complication

Complication

• Kidneys regulate Calcium, Phosphorus, Parathyroid (PTH) and Vitamin D metabolism.

• Problems with any of these causes abnormalities in bone turnover, mineralization, volume and growth.

• Causes vascular and soft tissue calcification.

CKD: Mineral Bone Disorder

↑PO4, ↓Vit D ⇒ ↑PTHAbnormal bone turnover,

calcificationLVH, cardiac fibrosis, peripheral neuropathy

As CKD progresses, Vit D levels decrease

As CKD progresses, PO4 accumulation begins

CKD: Mineral Bone Disorder

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• Treatment: • Replace Vitamin D: Ergocalciferol 50000

units qweekly for 3 months then qmonthly

• Dietary phosphate restriction• Check and treat PTH as needed• Phosphate binders as needed

CKD: Mineral Bone Disorder CKD: Mineral Bone Disorder

Sucroferric oxyhydroxide low pill burden, new in market, expensive, diarrhea

0 15 30 45 60

HTN

MBD-PO4

Anemia

Acidosis

K, Edema

Uremia

Complication

Complication

McClellan et al. Curr Med Res Opin. 2004;20:1501-1510.

• Rule out other causes of anemia –bleeding, nutritional deficiencies.

• Once AOCD established• Evaluate for iron deficiency : Iron panel• Supplement Fe as needed: IV vs. PO• Consider ESA if unresponsive

• Goal Hemoglobin >10• DO NOT OVERTREAT

CKD: Anemia

AOCD: Anemia of Chronic Kidney Diseases; ESA: Erythropoeitin stimulating agents

0 15 30 45 60

HTN

MBD-PO4

Anemia

Acidosis

K, Edema

Uremia

Complication

Complication

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• Dietary intake: Acid• Hyperchloremic phase then high anion gap phase

• Acidosis • Protein wasting & bone lysis• CKD progression & mortality

CKD: Acidosis

Dobre M et al. J Am Soc Nephrol 26: 515–523, 2015.

CKD: Acidosis

Dobre M et al. J Am Soc Nephrol 26: 515–523, 2015.

0 15 30 45 60

HTN

MBD-PO4

Anemia

Acidosis

K, Edema

Uremia

Complication

Complication

CKD: Edema

• Diet: • Salt Restriction:

• A RCT dietary sodium intake on BP and proteinuria in pts with stages 3 or 4 CKD

• 24-hour UrNa excretion: 75 vs 168 mmol/L• BP decreased by a mean of 10/4 mmHg,

extracellular fluid volume decreased, and albuminuria and proteinuria decreased

McMohan EJ et al. J Am Soc Nephrol 24: 2096-2103, 2013.

CKD: Hyperkalemia

• K: Diet and diuretics• Sodium Zirconium Cyclosilicate

• Selective cation exchanger• 753 patient: K 5.3 to 4.8 vs 5.1 in placebo

• Patiromer• Nonabsorbed potassium binder• 237 patients: K 5.3 to 4.7 and 5.8 to 4.5

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• Malnutrition: very common in advanced CKD

• Uremia: • Nausea, vomiting, anorexia, weight loss• Pericarditis, encephalopathy,

neuropathy, coma

CKD: Uremia57

CKD: Management






• Avoid Contrast• Avoid PICC lines• Avoid NSAID’s • Drug dosing: Piperacillin/Tazobactan,

Vanc, etc.• Diet: Avoid Red meat, soft drinks (sodas)

CKD: Things to Watch

• Target A1c of approximately 7%• Watch and avoid hypoglycemia• Metformin:

• GFR >45: Continue• GFR 30-44: Review the need, avoid if

possible• GFR < 30: Discontinue

CKD: DM

• Half-life of insulin and a number of sulfonylureas are increased

• DPP-4 use in Diabetic CKD

CKD: DM

Choi M: NephSAP. CKD and safety 14(4): 344-348, 2015.

• 47 patients with stage 4 or 5 CKD given smartphone

• 60% had never used a smartphone • User adherence was high• Home BP readings between baseline and exit

were statistically significant • SBP, -3.4 mmHg; 95% CI -5.0 to -1.8 • DBP, -2.1 mmHg; 95% confidence interval, -2.9 to -1.2); • 27% with normal clinic BP readings had newly identified masked

hypertension.

• 127 medication discrepancies were identified

CKD: Smartphones

Onc S et al. CJASN ePress. Published on May 12, 2016 as doi: 10.2215/CJN.10681015

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CKD: Management






If you or your family had to go on dialysis, what would you choose

1. In center Hemodialysis (MWF or TThS)2. Peritoneal Dialysis3. Home Hemodialysis

CKD: Quiz

CKD: Renal Replacement

Hemodialysis

Peritoneal Dialysis

TransplantHospice

Nocturnal Dialysis

PatientPatient

Choosing the D?–Hemodialysis

• Nocturnal HD

• Home HD

• TIW (three times a week)

CKD: Renal Replacement HD

• Access

• Catheter

• Arterio-Venous Graft

• Arterio-Venous Fistula

CKD: Renal Replacement HD

• Peritoneal Dialysis

• Lifestyle

• Travel

• Catheter care

• Infection rate

CKD: Renal Replacement PD

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• Wait time

• No blood transfusion

• Paired cross over TX

Living Transplant

Living related

Living Unrelated

Cadaveric

Matched

CKD: Renal Replacement 70

CKD: When to Refer

AKI or abrupt sustained fall in GFR;

GFR <30 ml/min (GFR categories G4-G5)

Consistent finding of albuminuria

Rapid progression of CKD

Urinary red cell casts

CKD: When to Refer

CKD and HTN refractory to treatment with 3 or more antihypertensive agents;

Persistent abnormalities of serum potassium;

Hereditary kidney disease.

Thank You

• 28,497 patients with CKD stage 5• Prospective study• At 7 months, use of ACEIs/ARBs was

associated with:• Lower risk for long-term dialysis (HR, 0.94

[95% CI, 0.91-0.97]) • Lower risk for composite outcome of long-

term dialysis or death (0.94 [0.92-0.97]).

ACE/ARB in Advanced CKD

Hsu et al. JAMA Intern Med. 2014;174(3):347-354.

Astor B et al. Arch Intern Med. 2002;162(12):1401-1408.

CKD: Anemia

Medication Index

Chronic Kidney Disease Management

Generic Name Trade Name

Alogliptin Nesina

Ezetimibe Zetia

Linagliptin Tradjenta

Metformin Fortamet, Glucophage, Glumetza, Riomet

Piperacillin/Tazobactam Zosyn

Saxagliptin Onglyza

Simvastatin Zocor

Sitagliptin Januvia

Vancomycin None

The following medications were discussed in this presentation. The table below lists the

generic and trade name(s) of these medications.

Notes

Documents

Chronic Kidney Disease Management - TAFP · Choi M: NephSAP. CKD and safety 14(4): 344-348, 2015. • 47 patients with stage 4 or 5 CKD given smartphone • 60% had never used a smartphone