CKD FOR PRIMARY CARE MINNESOTA ACADEMY OF PHYSICIANS 2017 HEATHER ANN MUSTER, MD MS

Transcription

1 CKD FOR PRIMARY CARE MINNESOTA ACADEMY OF PHYSICIANS 2017 HEATHER ANN MUSTER, MD MS

2 PLoS One Nov 26;9(11):e Of the 445 PCPs who enrolled at least 10 patients, 19 (4.3%) had >50% likelihood of identifying patients with CKD, 217 (48.8%) had a likelihood of < 50%, and 209 (47.0%) didn t identify any of their CKD patients (had a 0% sensitivity).

3 A 45 yo AA man is referred to renal clinic for newly diagnosed CKD. Labs: BUN: 24mg/dL, Cr: 1.4 mg/dl. MDRD 55 Height 72 inches, 190 pounds. Exam was normal. Blood pressure was 129/82. UA: SG: 1025, 0 RBC s, 0 WBC s, trace protein. Pr:cr: <30 mg/g Which of the following statements is MOST CORRECT regarding his reported MDRD? It is adjusted for his BSA It isn t valid for him It represents CKD stage 3 It is based upon a non-standardized creatinine

4 Serum Creatinine: Serum Cystatin C: Age: Gender: Race: Standardized Assays: Remove body surface adjustment: mg/dl μmol/ L mg/l Years Male Female Black Other Yes No Not Sure Yes No Not Sure BSA MDRD study equation 55 ml/min/1.73m2 MDRD study equation 66 ml/min/1.73m2 MDRD study equation 80 ml/min

5 83 yo woman 155 cm tall, 41.5 kg, BMI of 17.3 diagnosed with a pathologic sternal fracture and multiple myeloma. Chemotherapy is planned. Reported labs are as follows: Cr: 1.2, BUN: 12, MDRD: 41. Which of the following statements regarding her renal function for drug dosing is MOST correct? The MDRD equation will underestimate renal function The CKD-epi equation is the most valid in this population The Cockroft-Gault equation should not be used A cystatin C is required to accurately estimate function A 24 hour urine must be performed prior to drug dosing

6 For Drug Dosing: If High risk drug, obtain measurement If unstable creatinine, no estimation equation is valid Equations less valid in extremes of size Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation. Pharmacotherapy. 2012; 32(7):60 Two Novel Equations to Estimate Renal Function in persons aged 70 or older. Ann Intern Med Oct 2;157(7):

7 A 67 yo woman returns to clinic for follow-up of her DM and HTN. Routine labs are as follows: Na: 139 mmol/l, K: 3.9 mmol/l, Cl: 92 mmol/l, tco2: 22 mmol/l, BUN: 24 mg/dl, Cr: 1.3 mg/dl. CKD-Epi 39 ml/min/1.73m2. Urinalysis reveals 1-2 RBC s/hpf, 0 WBC, 0 casts. Albumin:Cr ratio: 572 mg/g. Which of the following is the appropriate CKD classification? G3aA1 G3aA2 G3bA4 G3bA3

8 Pts with CKD stage 3 in 2008, followed to % progressed to dialysis 42% died For comparison: In the general Medicare population without CKD, 22% died in the same time frame

9 A 28 yo Caucasion man presents to clinic for a DOT exam. PMH is significant only for being overweight. He takes no medications. BP: 130/76, HR: 72. He reports no significant findings on ROS. UA demonstrates a ph of 5.5, no protein, no bili, no ketones, 5-10 RBC s/hpf, 0 WBC s/hpf. BMP shows a BUN of 19 mg/dl and a Cr of 1.1 mg/dl. A repeat UA with micro 1 month later reveals a ph of 6, no protein, no bili, no ketones. 3-5 RBC s/hpf, 0 WBC s/hpf. The previous year you note he also demonstrated 5-10 RBC/s/hpf on his UA. Which of the following is the MOST appropriate next step? Order a non-contrast CT Refer to nephrology Order a urine Culture Refer to urology No further follow-up required

10 Risks for Malignancy Age >35 years Smoking history in which the risk correlates with the extent of exposure Occupational exposure to chemicals or dyes (benzenes or aromatic amines), such as printers, painters, and chemical plant workers History of gross hematuria History of chronic cystitis or irritative voiding symptoms History of pelvic irradiation History of exposure to cyclophosphamide History of a chronic indwelling foreign body History of exposure to aristolochic acid History of analgesic abuse, which is also associated with an increased incidence of carcinoma of the kidney

11 A 63 yo man with CKD G2A2 (baseline cr 1.2 mg/dl), DM X 8 years (last A1C was 7.5%), and HTN comes to clinic for a 6 month follow-up. BP is 145/86 (baseline 132/70), pulse 72. On exam nothing notable except some edema at his ankles. Labs are as follows: Na: 135 mmol/l, K: 5.3 mmol/l, tco2: 20 mmol/l, BUN: 42 mg/dl, Cr: 1.7 mg/dl UA: SG: 1.010, ketones neg, RBC s 3-5/hpf, WBC s 0, 1+ protein Alb:Cr: 2.8mg/g (1 year prior 324 mg/g) Which of the following actions is the next BEST step to address his proteinuria? Increase his insulin, follow-up in 3 months Increase his diuretic, follow up in 1 month Increase his Lisinopril, recheck labs in 2 weeks Refer to nephrology for biopsy Repeat labs in 1 week, modify meds if no change in labs

12 Diabetes Care 2017 Jan; 40(1):

13 A 72 yo man with CKD G4A2 presents to clinic with complaints of SOB, orthopnea, DOE and increased LE edema. Home medications include 80 mg oral furosemide daily, Lisinopril 40 mg orally daily, carvedilol 25 mg orally twice daily, and amlodipine 10 mg orally daily. Home medications include 80 mg oral furosemide daily, Lisinopril 40 mg orally daily, carvedilol 25 mg orally twice daily, and amlodipine 10 mg orally daily. BMP: Na: 132 mmol/l, K: 5.2 mmol/l, tco2: 18 mmol/l, BUN: 56 mg/dl, Cr: 2.4 mg/dl Albumin 2.3 g/dl Assuming you now admit the patient, what is the MOST appropriate diuretic prescription? 40 mg IV furosemide 100 mg IV furosemide 2 mg IV bumetanide 40 IV furosemide plus 5 mg oral metolazone

14 Maximum Effective IV Dose (Ceiling Dose) Normal Kidney Function Moderate CKD (GFR mls/min) Severe CKD (GFR <20 mls/min) furosemide 40 mg 120 mg 200 mg bumetanide 1 mg 3 mg 10 mg torsemide 20 mg 50 mg 100 mg ethacrynic acid 100 mg???? 40 mg PO furosemide = 20 mg IV furosemide = 1 mg bumetanide (IV or PO) = 20 mg torsemide (IV or PO) = 50 mg ethacrynic acid (IV or PO) Sharp Trial: No benefit to continuous infusion. Starting dose should be times home dose - given IV. If no response in 2 hours, double dose and an administer again.

15 A 51 yo woman with HTN and CKD stage G3bA2 (CKD-Epi 44) nephropathy presents to clinic for routine follow-up. Blood pressure is controlled on Lisinopril and HCTZ and her in clinic reading is 130/72 mmhg. She takes no other medications. She does not smoke and there is no family history of cardiovascular disease. Her lipid panel is as follows: Total Cholesterol: 205 mg/dl. LDL 140 mg/dl. HDL: 42 mg/dl. (AHA/ACC CV risk prediction is 2.5% over 10 years. Which of the following statements regarding cardiovascular risk protection in her is MOST correct? She has CKD so initiate a statin LDL is >130 mg/dl so initiate a statin Her 10 yr cardiovascular risk prediction is <7.5 % so no statin is advised Her HDL is >40 mg/dl so no statin is advised

16 KDIGO Guidelines

17 A 42 yo man presents to clinic with complaints of fatigue. PMH significant G3bA1CKD secondary to ADPKD. Current egfr is 44 ml/min/1.73m2. K: 4.9 mmol/l, BUN: 55 mg/dl, Cr: 1.4. Hgb: 8 g/dl. Iron studies show: serum iron = 48 mcg/dl, ferritin = 95 ng/ml, and TIBC = 290 mg/dl TSAT: 17% Which of the following is the MOST appropriate next step? Initiate erythropoietin Initiate oral iron Obtain a bone marrow biopsy Obtain a colonoscopy

18 AJKD. 47 (5), Suppl 3; May 2006: S23 If ANEMIC, findings of iron deficiency CKD Dialysis Ferritin May be as high 500 May be as high 1000 (or higher!) TSAT <20% <20% Note that Anemia of CKD and Iron deficiency is associated with a Ferritin >100: This is different than for non CKD patients!

19 A 57 yo woman with CKD G4A2, egfr 28 ml/min/1.73m2, is seen in nephrology and is being counseled regarding kidney transplant and dialysis. As part of her evaluation, immunization status is reviewed and discussed. Which of the following statements regarding her CKD and immunizations is MOST correct? She cannot receive live vaccinations (Zoster) Hepatitis B vaccination is recommended Influenza vaccinations reduce mortality Pneumococcal vaccine is not recommended

20 CKD patients are considered immunocompromised Hepatits B Seroconversion Rate T-Cell, B-cell and macrophage function are all diminished Increased risk of infections With vaccination Decreased hospitalizations Influenza and pneumococcal Reduced risk of death Post-transplant disseminated varicella Always be preparing for potential transplant VACCINATE. EARLIER IS BETTER.

21 A 72 yo woman is seen in clinic for routine follow-up of her CKD G4A2, HTN, dyslipidemia, CAD. Today her Cr is 3.0 mg/dl, BUN is 48 mg/dl. K is 4.9 mmol/l. BP is 142/84. Lungs are clear. She has trace edema. You haven t seen her for a while as she lives an hour away and her car was in for repairs so missed her last appointment. At her last visit her Cr was 2.5 mg/dl Which of the following statements regarding dialysis and transplant is MOST correct? An AVF should be placed (HD), she is not a candidate for transplant A PD catheter should be placed and she should be referred for transplant A tunneled catheter should be placed, she should be referred for transplant She is not a candidate for dialysis or transplant and hospice should be recommended Every available renal replacement choice (home hemodialysis, center dialysis, peritoneal dialysis, transplant) is an option and all must be discussed

22 Key Points: There is NO specific disease state or age at which a Renal replacement modality is not recommended Outcomes are best when modality matches patient choice which can be dependent upon many factors. Pts should receive information, tour facilities, meet staff and patients No access can be placed until a modality has been chosen (unless and emergency) it takes ~ 3 months to mature a fistula, 6 weeks to mature a PD catheter. Tunneled access (catheter) is considered sub standard and is for emergency use only. Transplant referral should be initiated once below 20 ml/min. Patients may choose to forgo any renal replacement therapy. However, all options should still be presented as few patients have any real understanding of what dialysis is or is not (many myths out there). In those situations hospice is completely appropriate. Note: Acute, ICU dialysis chronic dialysis. They are NOT the same thing, outcomes are different and the purpose is different. Generic living wills that say No dialysis often fail to make this distinction.

23

24 A 47 yo woman presents to her clinic with complaints of headache and elevated blood pressures at home. PMH is positive only for 2 prior pregnancies and live births. She denies any new medications. BP: 165/84 mmhg. Previously 3 months ago she was 128/70. BMP: K: 5.6 mmol/l, BUN: 56 mg/dl, Cr: 3.8 mg/dl (baseline 1.0 mg/dl) Albumin 3.4 g/dl UA: SG: 1: protein, + ketones, RBC s/hpf, 3-5 WBC s/hpf, few hyaline casts Pr:Cr = 1000 mg/g Which of the following serologic tests would be MOST helpful in narrowing your differential? ANCA s Complements HIV and Hepatitis studies ANA

25 WHAT W/U WOULD BE APPROPRIATE TO DISTINGUISH THE ETIOLOGY? 1) Hematuria / RBC Casts 2) HTN 3) Renal Failure Low complements (immune complex disease) Normal complements 1) Post infectious 2) Infective Endocarditis 3) Lupus 4) Cryoglobulinemia 5) Membranoproliferative ANCA + 1) Granulomatosis with polyangitis 2) Microscopic Polyangitis 3) Churg Strauss 4) Renal limited ANCA Anti GBM + 1) Good pastures syndrome 2) Anti GBM renal disease