Update in Nephrology

Delaying CKD progression

1/29/2016

Arasu Gopinath, MD Nephrology Associates of Utah

Clinical Learning Day

Declaration of Independence

I am not indebted to anyone except…. My parents My family My teachers My friends My colleagues My bank My credit union ………….

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• CKD staging • Our at risk population • KDIGO guidelines

– BP control – Proteinuria management – Lipids

• Monitoring • iCentra prompts • Summary • Questions

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Delaying CKD progression

CKD classification and prognosis

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INTERMOUNTAIN DATA

68,723

11,563

25,398

16,829

32,470

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Unique Patients PROBLEM_LIST DIAGNOSIS ACR30 GFR60

System Wide CKD Cohort Counts

The CKD population in Intermountain

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The CKD population in Intermountain

32470 30216

10906

5025

0

5000

10000

15000

20000

25000

30000

35000

GFR<60 GFR<45 GFR<30 GFR<20

GFR<60GFR<45GFR<30GFR<20

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A1 A2 A3

Normal to Mildly Increased

Moderately Increased

Severely Increased

G1 Normal 241 3,623 561 222 4,647

G2 Mildly Decreased 1,717 6,556 946 1,715 10,934

G3aMild to Moderately Decreased

4,064 7,266 591 9,595 21,516

G3bModerately to Severely Decreased

3,696 7,499 693 5,939 17,827

G4 Severely Decreased 1,239 3,901 466 1,530 7,136

G5 Kidney Failure 267 2,197 255 551 3,270

57 484 81 6,689 7,311

11,281 31,526 3,593 26,241 72,641Grand Total

Grand TotalMissing Test

Missing Test

Intermountain data as of 1/26/2016

Management of CKD progression IHC CKD CPM

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• 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

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Delaying CKD progression

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63%n = 2,304

71%n = 24,469

0%10%20%30%40%50%60%70%80%90%

100%

IMG PCP

CKD Patient Blood Pressure In Control

ACR>=300 All other CKD

INTERMOUNTAIN DATA

Blood Pressure Control in CKD

Targets: • ACR > 300 (goal < 130/80): 63 % at goal • All other CKD (goal < 140/90): 71 % at goal

• ACR>=300 in control : <130/80 • All other CKD in control : <140/90

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62%n = 1,658

72%n = 18,769

0%10%20%30%40%50%60%70%80%90%

100%

IMG PCP

CKD & HTN Patient Blood Pressure In Control

ACR>=300 All other CKD

INTERMOUNTAIN DATA

Blood Pressure Control in CKD

• Albuminuria reduction

• ACEI or ARB in all adults with UACR > 300 mg/g

• ACEI or ARB in diabetics with UACR > 30 mg/g

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Delaying CKD progression

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57%n = 2,304

67%n = 7,133

0%10%20%30%40%50%60%70%80%90%

100%

IMG PCP

Patients on an ACE/ARB

CKD with ACR>=300 CKD and Diabetes with ACR>=30

Proteinuric CKD on RAAS blockade

INTERMOUNTAIN DATA

Indications for treating dyslipidemia in CKD

1. In adults < 50 yrs use statin if history of known CAD, MI, DM, stroke or CV risk > 10 %

2. In adults > 50 yrs with CKD 1-2, use statin alone

3. In adults > 50 yrs with CKD 3-5 (ND), use statin or statin/ ezetimibe combo

4. In ESRD, do not initiate statins. If already on statin or statin/ezetimibe, continue.

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Dyslipidemia in CKD patients age ≥50

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55%n = 14,425

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

IMG PCP

CKD Patients on a Statin

INTERMOUNTAIN DATA

Suggested Algorithm (IHC CKD CPM)

KDIGO suggests 10% but we have adopted Intermountain lipid CPM guidelines

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Frequency of monitoring

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3%n = 17,741

27%n = 23,652

10%n = 26,773

0%5%

10%15%20%25%30%35%40%45%50%

IMG PCP

CKD Patients with ACR and eGFR Test

ACR with no eGFR eGFR with no ACR Neither Tests

IMG Patient Counts

eGFR

Y N

ACR Y 17,188 553

N 6,464 2,568

1/29/2016 INTERMOUNTAIN DATA

Testing for CKD in the previous 12 months

Prompts in iCentra

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Patient advisory that suggests prescribing ACEI/ARB for UACR > 300 - Prescribe meds and order labs directly from this screen.

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Care Process Model – showing labs, vitals, Radiology reports etc.

Prompts in iCentra

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Care Process Model – showing meds/ common doses that can be ordered from the CPM itself.

Prompts in iCentra

NSAIDs in CKD

1. Impair glomerular autoregulation/ ATN 2. Resistant hypertension and make anti hypertensives less effective 3. Acute interstitial nephritis 4. Nephrotic syndrome (Minimal Change Disease and Membranous

Nephropathy) 5. Acute papillary necrosis and hematuria 6. Edema/ heart failure 7. Distal RTA and nephrolithiasis 8. Hyperkalemia 9. Chronic use associated with CKD and its progression

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dos and don’ts in CKD

1. Medications (+ RAAS blockade / - NSAIDs ) 1. Vein preservation

- Preserve veins in non dominant arm - Avoid PICC and Mid lines

2. Contrast (minimize contrast in Stage 3-5) - Avoid Gadolinum for MRI in stage G4-5

3. Anemia - Minimize blood draws (coordinate with others where possible)

4. Malnutrition - Do not limit protein intake if malnourished

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Delaying CKD progression

• Avoiding AKI • Avoid NSAIDs • Stop nephrotoxic agents prior to contrast • In GFR < 60 ml/min, avoid high osmolar

contrast, use lowest dose possible, hydrate with saline and repeat labs in 48-96 hours.

• Avoid phosphate containing bowel preparations

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Delaying CKD progression

• Limiting protein intake 0.8 g/kg/day in CKD G5 categories

• Salt intake

< 2.0 gram of Sodium or < 5 g of salt per day

• Lifestyle changes ~ exercise 30 minutes 5 x week, goal BMI 20-25, quit smoking

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Summary

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•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 • Nutrition (MNT) consult • Avoid nephrotoxins • advise smoking cessation • advise regular exercise • statins if age > 50 and eGFR < 60 • Nephrology consult

Questions

1. Efforts to retard progression of CKD include all of the following except

1. Control of BP 2. Limit proteinuria 3. Treat dyslipidemia 4. Control hyperuricemia

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Questions

2. Which of the following statements is correct? 1. In a diabetic with ACR 500 mg/g, target BP <

130/80 2. In a diabetic with ACR 200 mg/g, target BP <

140/90 3. In a diabetic with ACR 10 mg/g, target BP <

130/80 4. In a non diabetic with ACR 200 mg/g, target BP <

130/80

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Questions

3. 58 yr old M, with eGFR 37 ml/min, ACR 500 mg/g and the following levels (TC 190, HDL 45, LDL 97, Trigly 240). What is the best lipid strategy in this CKD patient?

1. Start Statin 2. Start Fenofibrate 3. Start Ezetimibe 4. Start Fish Oil

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Questions

4. All of the following are recommended strategies in managing the CKD patient except:

1. Avoid NSAIDs 2. Consult dietitian 3. Minimize blood draws 4. Preserve veins in the dominant arm

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Answer keys

1. 4 2. 1 3. 1 4. 4

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CKD Clinical Learning Day

• Thank You for listening – Arasu Gopinath, MD

1/29/2016