Managing Kidney Disease in the Homeless Population

E. Jennifer Weil, MD

Phoenix Epidemiology and Clinical Research Branch

in memory of Larry Coleman, my patient 10/18/99 – 4/31/04

Rest in Peace

Temple University, Philadelphia, PA

What Kidneys Do

Kidneys control the amount of water and other chemicals in blood.

Kidneys remove harmful substances Kidneys control blood pressure Kidneys help make red blood cells Kidneys promote strong bones

Chronic Kidney Disease Chronic kidney disease (CKD) is the permanent

loss of kidney function in both kidneys as a result of Physical injury or A disease that damages both kidneys, such as DIABETES

Damaged kidneys do not remove wastes do not remove extra water from the blood as well as they should.

What Else About CKD? CKD is a familial disease. Risk for CKD

increases if a blood relative has kidney failure.

CKD is a silent condition. In the early stages, there are no symptoms. CKD develops so slowly that people don't

realize they're sick until the disease is advanced and they are rushed to the hospital for life-saving dialysis.

Kidney Failure is Increasing in the US

Incident Counts & Adjusted Rates, by Race

Incident ESRD patients; rates adjusted for age & gender.

Incident Counts and Rates of ESRDby Primary Diagnosis

USRDS 2006

Kidney Disease Has 5 Stages

Stage Description Symptoms1 Slightly damaged NONE!

2 Cleaning reduced NONE!

3 Halfway to failure NONE!

4 On the edge of failing Could have swelling, nausea

5 KIDNEY FAILURE – starting DIALYSIS

Could have swelling, nausea, shortness of breath. Need blood test to know for sure.

A Familiar Filter

Pretend this Filter is in Kidneys..

BLOODBLOOD

ALBUMINALBUMIN

URINEURINE

A Familiar Filter is Damaged

Damaged Kidney Filters

microalbuminuria = micro (small) albumin (protein) uria (urine)

BLOODBLOOD

ALBUMINALBUMIN

URINEURINE

Failing Kidney Filters

SCARSSCARS

blood is clean (red)

urine removes waste (yellow)

NORMALplenty of urine

blood is clean (red)

urine removes waste (yellow)

plenty of urine

albumin orred blood cells

STAGES 1 & 2GFR > 59

kidneys don’t clean blood as well

urine removes less waste

less urine

albumin orred blood cells

STAGE 3GFR 30 - 59

scar

kidneys don’t clean blood as well

urine removes less waste

less urine

albumin orred blood cells

STAGE 4GFR 15-29

scars bigger

kidneys don’t clean blood

urine removes less waste

very little urine

albumin orred blood cells

STAGE 5GFR < 15

scars replacemost of kidneys

too much fluid in heart

Kidney Disease Has 5 Stages

Stage Description eGFR1 Slightly damaged ≥ 90 ml/min

2 Cleaning reduced 60 - 89 ml/min3 Halfway to failure 30 – 59 ml/min

4 On the edge of failing 15 – 29 ml/min

5 KIDNEY FAILURE – starting DIALYSIS

< 15 ml/min

Stages 1 & 2 Normal eGFR ≥ 60 ml/m Kidney damage for more than 3 months as

manifested by Abnormalities in the tissue of the kidney (biopsy) or Markers of kidney damage including

Abnormalities in the composition of urine or Changes seen by radiological images (x-ray, CT scan, ultrasound

etc.)

Risks associated Progression Heart disease

Stages 3, 4 & 5 Kidney damage getting worse

eGFR getting progressively lower Risks associated

Progressive kidney disease (dialysis) Increased cardiovascular risk Myocardial infarction (heart attack) Stroke Sudden death

How to Stage Calculate eGFR with age, sex, race, and

creatinine Find out if there are changes in kidneys for

more than 3 months: Urinalysis positive for protein or blood OR Urine albumin to creatinine ratio

(AKA: microalbumin, ACR): > 30 mg/g OR Ultrasound or other imaging test is abnormal

Look at the table

Kidney Disease Has 5 Stages

Stage Description eGFR1 Slightly damaged

MUST HAVE SIGNS OF DAMAGE

≥ 90 ml/min

2 Damaged and cleaning reduced MUST HAVE SIGNS OF DAMAGE

60 - 89 ml/min

3 Halfway to failure 30 – 59 ml/min4 On the edge of failing 15 – 29 ml/min5 KIDNEY FAILURE –

starting DIALYSIS< 15 ml/min

Quiyo, Tessie15009Urine creat 60.6 mg/dLUrine albumin 25.9 mg/dLMicroalbumin, random 426.9 mg/g

Serum creat 0.9 mg/dLEst GFR > 60 ml/m

How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR > 60 means Stage 1 or Stage 2. Our methods do not allow distinction between Stages 1 and 2.

Joe, Lalo12345Urine creat 85.2 mg/dLUrine albumin 2.4 mg/dLMicroalbumin, Random 28 mg/g

Serum creat 2.2 mg/dLEst GFR 34 ml/m

How to stage: no albuminuria but eGFR = 34 ml/m, Stage 3.

Cachora, Dale31434Urine creat 60.0 mg/dLUrine albumin 31.5 mg/dLMicroalbumin, Random 524.5 mg/g

Serum creat 2.8 mg/dLEst GFR 25 ml/m

How to stage: presence of macroalbuminuria means there is kidney disease present. eGFR 25 means Stage 4.

Cachora, Dale31434Urinalysis Blood 3+

Protein 2+

Serum creat 1.4 mg/dLEst GFR 50 ml/m

How to stage: presence of blood and protein means there is kidney disease present. eGFR 50 means Stage 3.

Cachora, Dale31434

Renal ultrasound Single kidney

Serum creat 1.1 mg/dLEst GFR ≥ 60 ml/m

How to stage: single kidney is abnormal, and eGFR ≥ 60 means Stage 1 or 2.

Columbus Neighborhood Health Center Study, 2005

31.1

16

20.2

25.2

1.7 0.8

5

0

5

10

15

20

25

30

35

at risk Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 notstageable

People with Diabetes or Hypertension

Etiology of CKD Hypertension Diabetes Other

Bilateral renal artery stenosis (heart disease, stroke patient)

Kidney obstruction (stones, prostate, cancer patient) Interstitial nephritis (lithium, NSAIDs) Glomerulonephritis (heroin, HIV, hepatitis C, hepatitis B

patients) Congenital kidney disease (polycystic, Alport’s etc.) Multiple myeloma (older patient, anemia) Lupus (lots of other manifestations in joints, skin, brain)

Complete Work-Up for Etiology of CKD

Diabetes: duration, A1C, dilated retinal exam, sensory testing with monofilament

Hypertension: duration, number of meds Other diseases

Lupus: ANA, C3, C4 Vasculitis: ANCA, Anti-GBM, cryoglobulins Multiple Myeloma: SPEP with IFE, UPEP with IFE Infectious Diseases: HBSAg, HCV, HIV screens

Renal Ultrasound for obstruction, small kidneys or anything else

Core Labs for All Follow-Up CBC: more frequently in advanced stages Chem 7: more frequently in advanced stages Urinalysis: helpful for diagnosis, helpful for UTI Urine microalbuminuria: helpful at diagnosis and

to see if ACE inhibitor or ARB is working Lipid panel: check while adjusting lipid meds HbA1C: if diabetic – every three months

Blood pressure – every visit

When to slow CKD down?

Stage Description Symptoms1 Slightly damaged NONE!

2 Cleaning reduced NONE!

3 Halfway to failure NONE!

4 On the edge of failing Could have swelling, nausea

5 KIDNEY FAILURE – starting DIALYSIS

Could have swelling, nausea, shortness of breath. Need blood test to know for sure.

How to Slow CKD Educate patients on how they can control many of the things that

can make CKD worse and may lead to kidney failure.

Gain tight control of blood glucose to delay or prevent kidney failure, where appropriate.

Keep blood pressure below 130/80 mm Hg. A combination of two or more drugs may be necessary

ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) protect the kidneys better than other blood pressure medicines.

Dietary therapy when practicable, low protein, low sodium, and later low potassium and low phosphorus.

Renoprotective Drugs ACE inhibitors

Lisinopril (longest half-life) Captopril

ARBs Telmisartan (longest half-life) Candesartan

Dosage: maximal tolerated by blood pressure, serum creatinine and potassium

Combination of ACE inhibitor and ARB: almost always unnecessary (but combination with other anti-hypertensive drugs to be expected)

Contraindicated: women of childbearing potential, allergic patients

Enalapril Ramipril

Valsartan Losartan

Fosinopril (hepatic) others

Irbesartan others

Heart Disease in CKD Modification of risk

Lipid control Smoking cessation Diabetes control Blood pressure control Lower albumin or protein in urine

Medicines Statins, other lipid agents Anti-hypertensive drugs, especially ACE, ARB, beta-

blocker Aspirin

Lifestyle: diet and exercise

Behavioral Changes that Affect CKD Outcomes

Ask to get tested for kidney disease Ask questions about kidney disease Take medicines regularly Stop smoking Stop using illicit drugs Abstain from alcohol Lose weight if overweight or obese Exercise if sedentary Adjust diet Keep appointments with health care system

Adapting Practice for Homeless Diagnostic testing for diseases other than hypertension,

diabetes Expensive Difficult to do Set criteria: evaluate for all? Transmissable? Easy tests?

Diabetes (standard goal is A1C ≤ 7%) Check appropriateness of A1C target Hypoglycemia is dangerous

Hypertension (standard goal ≤ 130/80 mmHg) Avoid ACE inhibitors and ARBs in women of childbearing

potential Easier to get to goal, fewer risks than A1C, great results

Dietary management Difficult to control what / when patients eat

Follow-up labs Not so expensive

Complications of CKDrenal osteodystrophy Stage 3

Anemia: CBC, iron Metabolic bone disease: intact Pth, phosphorus,

vitamin D, calcium Stage 4

Anemia: as above Metabolic bone disease: as above Hyperkalemia: serum potassium Volume overload: edema, pulmonary edema Acidosis: bicarbonate, arterial blood gas

Stage 5 All of the above Uremia (nausea, vomiting, malnutrition, weight loss,

pericarditis, confusion, myoclonus, seizures): BUN and creatinine

When to Refer KDOQI Guidelines: Stage 3 Nephrotic syndrome Uncontrolled hypertension

NOT IDEAL (BUT IT HAPPENS)

When dialysis is necessary

Preparation for Dialysis Modality choice

Peritoneal Dialysis Hemodialysis

Access Fistula first Catheter Graft

Hepatitis immunization Vitamins Identification of dialysis unit

Dialysis Lifestyle Treatment

3 x per week 4 hours +/- per treatment Transportation for treatment

Medications: average of 9 Diet

Low sodium, low potassium, low phosphorus, high protein diet

Fluid restriction

Resources for Homeless Dialysis Patients

Medicare ESRD Program (Federal) Covers cost of dialysis treatment Does not cover food or shelter

Medicaid (Federal, administered by states) Each state has various rules cover cost of medication, for example Does not cover food or shelter Can cover disability, if patient meets criteria

Eligibility for programs: patients with no work history do not qualify.

Healthcare ResourcesAlameda County, CA, 2000

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16 17

0

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60

80

100

No HealthInsurance

Medi-Cal VeteransAdministartion

Perc

ent

Dialysis Team Physician Nurse Technician Dietician Social Worker Patient and family

Case of Larry Coleman 55 year old African-American gentleman Hypertension, untreated, then kidney failure At time he started dialysis

Living out of his car No stable food supply Functionally illiterate Using drugs

At the time I met him, “disabled” Living in an apartment Stable food supply and medicines paid for Still functionally illiterate Still using drugs, but much less and with good effect A great friend and an advocate for his fellow patients