A GUIDE TO DETECTING AND DELAYING PROGRESS OF CHRONIC KIDNEY DISEASE

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A GUIDE TO DETECTING AND DELAYING PROGRESS OF CHRONIC KIDNEY DISEASE Rugmini Warrier, MD Lincoln Nephrology and Hypertension LEARNING OBJECTIVES Describe screening tools, like GFR and ACR for early

1 A GUIDE TO DETECTING AND DELAYING PROGRESS OF CHRONIC KIDNEY DISEASE Rugmini Warrier, MD Lincoln Nephrology and Hypertension LEARNING OBJECTIVES Describe screening tools, like GFR and ACR for early detection, diagnosis and monitoring of CKD Define and classify CKD to guide treatment approaches Recognize evidence-based management strategies that will help delay progression in at risk patients and improve outcomes Referral criteria to nephrology 1

2 WHAT IS CKD? Group of disorders Varying etiologies Altered kidney (1) structure or (2) function DEFINED BY: National Kidney Foundation-Kidney Disease Outcome Quality Initiative : NKF-KDOQI 2002 Kidney Disease Improving Global Outcome: KDIGO Presence of Kidney damage (structure) Imaging abnormalities: PKD, hydronephrosis Lab abnormalities: Urinary sediment Pathologic abnormalities: Kidney biopsy Increased urinary albumin excretion 2

3 2. Altered Kidney function GFR: Glomerular filtration rate Varies with age, gender, race, nutritional status <60 ml/min/1.73 m2 is considered CKD 60 considered marker because... Not one isolated GFR Abnormal GFR lasting more than 3 months defines CKD 75% Labs report GFR along with creatinine GFR Sum of filtration rates of all nephrons together True GFR measured by Iothalamate or Inulin ESTIMATED GFR or egfr from creatinine Normal GFR: 130 ml/min/1.73 m2 for men and 120 ml/min/1.73 m2 for women Decreases with age: 7.5 ml/min every decade of life Normal GFR does not mean normal kidneys 3

4 CREATININE Derived from muscle metabolism Released into blood at a constant rate Freely filtered across glomerulus Not metabolised by kidney 10% secretion by tubules Affected by muscle mass Variations can happen in production and secretion GFR GFR x Serum Creatinine=Urine volume x Urine creatinine GFR= (Urine volume x Urine creatinine) / Serum creatinine 24 hour Urine creatinine clearance can be calculated Usual daily creatinine excretion is mg/kg In practice we do creatinine and urea clearance in 24 hour urine volume More cumbersome 4

5 egfr Takes into account other variables that can affect creatinine generation Cockgroft-Gault Equation MDRD Equation: Modification of Diet in Renal Diseases CKD-EPI Equation Cystatin C: low molecular weight protein, produced by all nucleated cells, not affected by diet, filtered by glomerulus, not secreted GFR Calculator National Kidney Foundation Average Measured GFR by Age in People Without CKD Coresh J, et al. Am J Kidney Dis. 2003;41(1):

6 GFR Stable GFR does not mean stable disease. Can still have proteinuria Normal GFR does not mean normal kidneys GFR not accurate if not steady state, for example in hospitalized patients Improvement of GFR does not mean improved kidneys in all cases. Could be loss of muscle mass, hyperfiltration GFR equations not very accurate in extremes of weight, transplant patients.. NKF recommends egfr by CKD-EPI as more accurate egfr/ Creatinine Comparison Age Sex Race SCr mg/dl egfr ml/ min per CKD-EPI Weight in lbs Height in Ft/in egfr Adj for BSA 25 M AA F Hispanic M Asian F Caucasian

7 Old Classification of CKD as Defined by Kidney Disease Outcomes Quality Initiative (KDOQI) Modified and Endorsed by KDIGO Stage Description Classification by Severity 1 Kidney damage with GFR 90 normal or increased GFR 2 Kidney damage with mild decrease in GFR GFR of Classification by Treatment T if kidney transplant 3 Moderate decrease in GFR GFR of recipient 4 Severe decrease in GFR GFR of D if dialysis 5 Kidney failure GFR <15 D if dialysis Note: GFR is given in ml/min/ m² National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002;39(suppl 1):S1-S266 KDIGO, Kidney Disease: Increasing Global Outcomes Assign GFR Category GFR Categories in CKD Category GFR Terms Clinical Presentations G1 90 Normal or high Markers of kidney damage (nephrotic syndrome, nephritic syndrome, tubular syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, G Mildly decreased* asymptomatic radiologic abnormalities, hypertension due to kidney disease) G3a Mildly to moderately decreased G3b Moderately to severely decreased G Severely decreased Mild to severe complications: o Anemia o Mineral and bone disorder Elevated parathyroid hormone o Cardiovascular disease Hypertension Lipid abnormalities o Low serum albumin G5 <15 Kidney failure Includes all of the above Uremia GFR = ml/min/1.73m 2 *Relative to young adult level In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfill the criteria for CKD. Refer to a nephrologist and prepare for kidney replacement therapy when GFR <30 ml/min/1.73m 2. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-7

8 ALBUMINURIA Normal urine has small amounts of albumin <10 mg/day Kidney disease can increase glomerular permeability Spot ACR: Albumin/ Creatinine ratio: mg/gm AER: Albumin excretion rate: 24 hour urine sample. Confirmation First morning void is preferable Nephrotic range proteinuria: >3.5 gm/day or UPCR > 3000 mg/g Definitions: Albuminuria and Proteinuria Normal Albuminuria Albumin-to-creatinine ratio <30 mg/g creatinine Moderately Increased Albuminuria (Microalbuminuria) Albumin-to-creatinine ratio mg/g creatinine 24-hour urine albumin mg/d Severely Increased Albuminuria (Macroalbuminuria) Albumin-to-creatinine ratio >300 mg albumin/g creatinine 24-hour urine albumin >300 mg/d Proteinuria (+) urine dipstick at >30 mg/dl >200 mg protein/g creatinine 24-hour urine protein >300 mg/d 8

9 Assign Albuminuria Category Albuminuria Categories in CKD Category ACR (mg/g) Terms A1 <30 Normal to mildly increased A Moderately increased* A3 >300 Severely increased** *Relative to young adult level. ACR mg/g for >3 months indicates CKD. **Including nephrotic syndrome (albumin excretion ACR >2220 mg/g). Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1- CLINICAL EVALUATION OF A PATIENT WITH CKD History Physical Examination Labs: RFP, Urine analysis, UPCR/ ACR Special tests: Serology Depending on CKD STAGE: PTH, Vit D, Phos 9

CKD Risk Factors Modifiable Diabetes Hypertension History of AKI Frequent NSAID use Non-Modifiable Family history of

10 CKD or AKI from urinary obstructio Voiding symptoms Diabetics, older men, anticholinergics, opiates Partial obstruction Urine output variable Dx: Ultrasound Kidney sizes normally cm < 10 cm implies CKD Rx: foley/nephrostomy tube 19 CKD Risk Factors Modifiable Diabetes Hypertension History of AKI Frequent NSAID use Non-Modifiable Family history of kidney disease, diabetes, or hypertension Age 60 or older (GFR declines normally with age) Race/U.S. ethnic minority status 10

Classification of CKD Based on GFR and Albuminuria Categories: Heat Map Albuminuria categories Description and range Prognosis of CKD by GFR and Albuminuria Categories A1 A2 A3 Normal to mildly

11 Classification of CKD Based on GFR and Albuminuria Categories: Heat Map Albuminuria categories Description and range Prognosis of CKD by GFR and Albuminuria Categories A1 A2 A3 Normal to mildly increased Moderately increased Severely increased <30 mg/g <3 mg/mmol mg/g 3 29 mg/mmol 300 mg/g 30 mg/mmol GFR categor ies (ml/mi n/1.73 m 2 ) Descrip tion and range G1 Normal or high 90 G2 Mildly decreased G3a Mildly to moderately decreased G3b Moderately to severely decreased G4 Severely decreased G5 Kidney failure <15 Green: low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk. KDIGO 2012 Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. Adjusted* Cardiovascular Mortality Risk by egfr and albuminuria *adjusted to the incidence rates of a 60 year-old, non-hispanic white male Astor et al. Am J Epidemiol 167: (2008) 11

12 Reversible causes Decreased renal perfusion: Hypovolemia Hypotension NSAIDs, Diuretics Nephrotoxic drugs: Contrast, NSAIDs, Aminoglycosides, Bactrim, Vancomycin Urinary tract obstruction Diabetes and hypertension are leading causes of kidney failure Prevalent Cases Prevalence per million Trends in (a) prevalent ESRD cases and (b) adjusted* prevalence of ESRD, per million, by primary cause of ESRD, in the U.S. population, *Point prevalence on December 31 of each year; Adjusted for age, sex, and race. The standard population was the U.S. population in 2011 ESRD patients 12

13 HYPERTENSION CONTROL IN CKD Present in 80-85% patients with CKD Uncontrolled HTN increases proteinuria and CVS complications in CKD Optimal BP uncertain Target should be individualized Volume expansion is a major contributor Thiazides not used when GFR<30 HYPERTENSION CONTROL IN CKD ACEI/ ARB: Proteinuric CKD. Diabetic or not Non dihydropyridine CCB: Diltiazem and Verapamil has antiproteinuric effect Mineralocorticoid receptor antagonists: additive effect to RAS inhibition RAS inhibition effect less with high salt intake. Use salt restriction and diuretics 13

14 HYPERTENSION CONTROL IN CKD Type 1 Diabetes: ACEI Type 2 Diabetes: ARB Non Diabetic Proteinuria: ACEI or ARB Non Proteinuric CKD(<500 mg/day): If edema, use diuretic. If not, any antihypertensive NO ACEI/ ARB combination: More renal adverse effects, more hyperkalemia Slowing CKD Progression: ACEi or ARB Risk/benefit should be carefully assessed in the elderly and medically fragile. Check labs 2 weeks after initiation. If less than 25% SCr increase, continue and monitor. If more than 25% SCr increase, stop ACEi and evaluate for RAS and volume contraction. Continue until contraindication arises, no absolute creatinine cutoff. Better proteinuria suppression with low Na diet and diuretics. Avoid volume depletion. 1) Kunz R, et al. Ann Intern Med. 2008;148: ) Mann J, et al. ONTARGET study. Lancet. 2008;372:

15 HYPERTENSION CONTROL IN CKD Goal BP: More intensive BP control slows down CKD progression in proteinuric patients, <130/80 SPRINT TRIAL: Excluded Proteinuric pts, Had CKD pts. No difference in progression to ESRD. Actually there was increased risk of 30% decline in GFR PKD trial: No difference in GFR decline between intensive BP control(95-110) compared to less intensive( ) Relationship Between Achieved BP and Decline in Kidney Function from Primary Renal Endpoint Nondiabetes Trials MDRD. N Engl J Med AIPRI. N Engl J Med REIN. Lancet AASK. JAMA Hou FF, et al. N Engl J Med Parsa A et.al. NEJM 2013 Diabetes Captopril Trial. N Engl J Med Hannadouche T, et al. BMJ Bakris G, et al. Kidney Int Bakris G, et al. Hypertension IDNT. NEJM RENAAL. NEJM ABCD. Diabetes Care (Suppl) Update from Kalaitzidis R and Bakris GL In: Handbook of Chronic Kidney Disease. Daugirdas J (Ed.) 15

16 Managing Hyperglycemia Hyperglycemia is a fundamental cause of vascular complications, including CKD. Poor glycemic control has been associated with albuminuria in type 2 diabetes. Risk of hypoglycemia increases as kidney function becomes impaired. Declining kidney function may necessitate changes to diabetes medications and renally cleared drugs. Target HbA1c ~7.0%. Can be extended above 7.0% with comorbidities or limited life expectancy, and risk of hypoglycemia. NKF KDOQI. Diabetes and CKD: 2012 Update. Am J Kidney Dis 2012;60: Managing Hyperglycemia SGLT 2: expressed in proximal tubules and mediates glucose reabsorption. SGLT 2 inhibitors: promote glucose excretion Trials using Empagliflozin(JARDIANCE) and Canagliflozin(INVOKANA): secondary outcomes of incident/ worsening nephropathy was reduced in the drug group compared to placebo Issues include: Urosepsis, Hypotension (osmotic diuresis, volume contraction), AKI (especially in pts using diuretics or ACEI) METFORMIN: Contraindicated if GFR<30ml/min/1.73 m2 16

17 Lipid Disorders in CKD A 32% reduction in LDL 17% reduction in primary outcome (nonfatal MI, coronary death, nonhemorrhagic stroke, arterial revascularization). No reduction in CKD progression, overall or CAD mortality, other individual CAD endpoints. Baigent C, et al. Study of Heart and Renal Protection (SHARP) Lancet 2011;11: LIPID DISORDERS IN CKD Commonest is hypertriglyceridemia due to decreased clearance, also accelerated by secondary hyperparathyroidism More risk in Diabetics and Nephrotic syndrome Primary prevention in Non HD CKD pts controversial CKD considered CAD equivalent Treat with statins if CKD AND CAD Fibrates need dose adjustment 17

10-Year Coronary Risk Based on Age and Other Patient Characteristics Future 10-year coronary risk based on patient characteristics. Unadjusted rates from 1,268,029 participants.

18 10-Year Coronary Risk Based on Age and Other Patient Characteristics Future 10-year coronary risk based on patient characteristics. Unadjusted rates from 1,268,029 participants. 1,2 CABG, coronary artery bypass grafting; CHD, coronary heart disease; CKD, chronic kidney disease; CVA, cerebrovascular accident; DM, diabetes mellitus; MI, myocardial infarction; PTCA, percutaneous transluminal 1) Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. Kidney Int Suppl. 2013;3: ) Hemmelgarn BR et al Overview of the alberta OTHER FACTORS FOR CKD PROGRESSION Avoid NSAIDs Avoid hypotension Smoking cessation Low sodium diet Dose adjustment of renally excreted meds Weight loss in obese patients 18

19 Complications of Kidney Failure Start in Stage 3 and Progress Malnutrition Fluid Overload Water Overload Acid Base Imbalance Acidic Blood Electrolyte Abnormalities Kidney Failure Bone Disease Brittle bones and fractures Anemia/blood loss Decrease production of red blood cells Hypertension Cardiac Disease Vascular Disease Anemia in CKD Due to decrease in Erythropoietin production Individualize erythropoiesis stimulating agents (ESA) therapy Start ESA if Hb <10 g/dl, and maintain Hb <11.5 g/dl. Ensure adequate Fe stores. Appropriate iron supplementation is needed for ESA to be effective. ESA usually not required for CKD related anemia until stage 4/5. Diagnostic workup of anemia is particularly important if severity of anemia is disproportionate to CKD staging. Important to avoid transfusion in transplant candidates. If transfused use leukocyte filter to reduce HLA sensitization. 19

20 CKD-Mineral Bone Disorder (MBD) Testing CKD Stage Calcium, Phosphorus PTH 25(OH)D Stage 3 Every 6-12 months Once then based on CKD progression Stage 4 Every 3-6 months Every 6-12 months Once, then based on level and treatments Stage 5 Every 1-3 months Every 3-6 months Use CKD progression, presence or absence of abnormalities, treatment response, and side effects to guide testing frequency. CKD-MBD: Chronic Kidney Disease Mineral and Bone CKD-MBD Treat with D3 as indicated to achieve normal serum levels IU D3 po qd is cheaper and better absorbed than 50,000 IU of D2 monthly dose. Limit phosphorus in diet, with emphasis on decreasing packaged products - Refer to renal RD. May need phosphate binders. DEXA doesn t predict fracture risk in CKD

21 Metabolic acidosis Tendency to retain hydrogen ions when GFR falls. Often becomes apparent at GFR <25-30 ml/min/1.73m 2. More severe with higher protein intake. May contribute to bone disease, protein catabolism, decreased myocardial contractility, malaise, hypotension and progression of CKD. Sodium bicarbonate causes less volume overload than sodium chloride (reason unknown) 3 times more risk of GFR decline if HCO3 less than 25 compared to HCO3 >25 in AASK trial Fruits and Vegetables diet Metabolic Acidosis. Correction of metabolic acidosis may slow CKD progression and improve patients functional status. 1,2 egfr ml/min/1.73m 2 Bicarbonate mmol/l; treated with sodium bicarbonate for 2 years. 2 1) Mahajan, et al. Kidney Int. 2010;78: ) de Brito-Ashurst I et al J Am Soc Nephrol 2009;20:

22 Metabolic Acidosis Maintain serum bicarbonate > 22 mmol/l. Start with meq/kg per day. Sodium bicarbonate tablets: 325mg, 625 mg tablets; 1 g = 12 meq. Sodium citrate solution: 1 meq/ml. Avoid if on aluminum phosphate binders. Baking soda: 54 mmol/level tsp(54meq). Chronic Management of Hyperkalemia Loop or thiazide diuretics. Laxatives: As effective as cation exchange resins in sorbitol. Those that induce secretory diarrhea may be more effective (e.g. bisacodyl). Cation exchange resins: Sodium polystyrene sulfonate (KAYEXALATE) Mechanism: Bound Na+ exchanged for K+ in colonic/ rectal lumen. Likely: Accompanying sorbitol induces diarrhea. Patiromer: a non-absorbed, cation exchange polymer that contains a calcium-sorbitol counterion, increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract 22

23 Risk Factors for Infection in People with CKD Advanced age High burden of coexisting illnesses (e.g., diabetes) Hypoalbuminuria Immunosuppressive therapy Nephrotic syndrome Uremia Anemia and malnutrition High prevalence of functional disabilities Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3: Vaccination in CKD Annual influenza vaccine for all adults with CKD, unless contraindicated. Polyvalent pneumococcal vaccine when egfr <30 ml/min/1.73m 2 and at high risk of pneumococcal infection (e.g., nephrotic syndrome, diabetes, receiving immunosuppression), unless contraindicated. Offer revaccination within 5 years. Hepatitis B immunization when GFR <30 ml/min/1.73m 2. Confirm response with appropriate serological testing. Use of a live vaccine should consider the patient s immune status (e.g., immunosuppression). Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:

24 Key Points on Medications in CKD CKD patients at high risk for drug-related adverse events. Several classes of drugs renally eliminated. Consider kidney function and current egfr (not just SCr) when prescribing meds. Minimize pill burden as much as possible. Remind CKD patients to avoid NSAIDs. No Dual RAAS blockade. Any med with >30% renal clearance probably needs dose adjustment for CKD. No bisphosphonates for egfr <30 ml/min/1.73m 2. Avoid GAD for egfr <30 ml/min/1.73m 2. Common Medications Requiring Dose Reduction in CKD Allopurinol Gabapentin o CKD 4- Max dose 300mg qd o CKD 5- Max dose 300mg qod Reglan o Reduce 50% for egfr< 40 o Can cause irreversible EPS with chronic use Narcotics o Methadone and fentanyl best for ESRD patients Lowest risk of toxic metabolites Renally cleared beta blockers o Atenolol, bisoprolol, nadolol Digoxin Some Statins & Fibrates o Lovastatin, pravastatin, simvastatin. Fluvastatin, rosuvastatin Antimicrobials o Antifungals, aminoglycosides, Bactrim, Macrobid 24

25 Education and Counseling Ethical, psychological, and social care (e.g., social bereavement, depression, anxiety). Dietary counseling and education on other lifestyle modifications (e.g., exercise, smoking cessation). Involve the patient, family and children if possible. Offer literature in both traditional and interactive formats. Use educational materials written in the patient s language. Assess the need for low-level reading materials. Use internet resources and smartphone apps as appropriate. Use visual aids such as handouts, drawings, CDs, and DVDs. Involve other health care professionals in educating patients/families. Be consistent in the information provided. Mental Health Counseling Psychiatric illnesses like depression are associated with many chronic diseases. Depression is linked to early CKD, progressive CKD, kidney failure, hospitalization and increased mortality. 1-4 Patients with GFR <60 ml/min/1.73m 2 should undergo regular assessment for impairment of functioning and well-being. 5 1) Palmer S, et al. Am J Kidney Dis. 2013;62: ) Hedayati S, et al. Am J Kidney Dis. 2009;54(3): ) Kimmel P, et al. Kidney Int. 2000;57: ) Tsai Y, et al. Am J Kidney Dis. 2012;60:

26 Who Should be Involved in the Patient Safety Approach to CKD? Kidney damage and normal or GFR Kidney damage and mild GFR Moderate GFR Severe GFR Kidney failure Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 GFR Primary Care Practitioner Nephrologist Consult? Patient safety The Patient (always) and other subspecialists (as needed) Impact of Primary Care CKD Detection with a Patient Safety Approach Ideal Patient Time-Course Following CKD detection Improved diagnosis creates opportunity for strategic preservation of kidney function. Fink et al. Am J Kidney Dis. 2009,53:681-26

27 Indications for referral to Nephrology egfr <30 ml/min/1.73m2 ACR >300mg/g Hematuria not due to urological conditions Urinary sediment abnormalities Inability to identify a cause for CKD Serum K >5.5 meq/l Resistant hypertension (4 or more agents) Indications for referral to Nephrology Recurrent or extensive nephrolithiasis Hereditary kidney disease Atypical progression of CKD: rapid drop of >25 % decline of GFR or >5ml/min/1.73m2 drop in GFR/year Difficult to manage complications like anemia, hyperphosphatemia or volume overload 27

Observational Studies of Early vs. Late Nephrology Consultation Chan M, et al. Am J Med. 2007;120:1063-1070. http://download.journals.elsevierhealth.com/pdfs/journals/0 002-9343/PIIS000293430700664X.

28 Observational Studies of Early vs. Late Nephrology Consultation Chan M, et al. Am J Med. 2007;120: /PIIS X.pdf KDIGO CKD Work Group Kidney Int Suppls 2013;3:1 Additional Online Resources for CKD Learning National Kidney Foundation: United States Renal Data Service: CDC s CKD Surveillance Project: National Kidney Disease Education Program (NKDEP): 28

29 Case Question 1 Which of the following patients have CKD? year old male with Type 2 diabetes, egfr 32ml/min/1.73 m2 and ACR<30mg/g year old male with Type 2 diabetes, egfr 50 ml/min/1.73 m2 and ACR 1500mg/g year old male Type 1 diabetes, egfr 120 ml/min/1.73 m2 and ACR 500mg/g year old female, no diabetes, creatinine 1.0, egfr 120ml/min/1.73 m2, urine analysis showing 3+protein and red cell casts year old female s/p renal transplant, creatinine All of the above Case Question 2 A 55 year-old Caucasian-American man, with a history of type 2 diabetes (15 years), hypertension (3 years) dyslipidemia (5 years) and cardiovascular disease (myocardial infarction 3 years ago). He was recently diagnosed with CKD. His most recent labs reveal an egfr of 45 ml/min/1.73m 2 and an ACR of 38 mg/g. Which of the following should be avoided? A. ACE and ARB in combination B. Daily low-dose aspirin C. NSAIDs D. Statins E. A and C 29

30 Case Question 3 Which of these patients should be treated with ARB?( if no allergy) year old male with Type 2 diabetes, egfr 32ml/min/1.73 m2 and ACR<30mg/g, BP 156/94mmHg year old male with Type 2 diabetes, egfr 50 ml/min/1.73 m2 and ACR 1500mg/g, BP 156/94mm Hg year old male Type 1 diabetes, egfr 120 ml/min/1.73 m2 and ACR 500mg/g, BP 156/94mmHg year old male, non diabetic, BP 156/94mm Hg, hypertensive nephrosclerosis, creatinine 1.5, ACR <30 mg/g 5. All of the above 6. All except 4 Case Question 4 All of the following adult patients should be referred for nephrology consultation, EXCEPT? A. Initial visit: egfr 26 & 3 months later: egfr 28 (ml/min/1.73m 2 ) B. Initial visit: egfr 55, & 3 months later: egfr 43 confirmed with repeat egfr 45 (ml/min/1.73m 2 ) C. Initial visit: ACR 450 & 3 months later: ACR 355 (mg/g) on both dates the egfr >60 ml/min/1.73m 2 D. Initial visit: egfr >60 & 3 months later: egfr >60 (ml/min/1.73m 2 ) with personal history of Autosomal Dominant Polycystic Kidney Disease E. Initial visit: egfr 42 & 3 months later: egfr 44 (ml/min/1.73m 2 ) on both dates the ACR <30 mg/g 30

31 TAKE HOME POINTS Assess GFR and proteinuria as tools to detect CKD Identify factors to prevent progression PCP to co manage complications of CKD Referral to Nephrology when appropriate References Dr Michael Choi, NKF president Dr Les Spry, MD. Lincoln Nephrology NKF educational resources Online: uptodate.com Various Journals 31

CKDinform: A PCP s Guide to CKD Detection and Delaying Progression

CKDinform: A PCP s Guide to CKD Detection and Delaying Progression Learning Objectives Describe suitable screening tools, such as GFR and ACR, for proper utilization in clinical practice related to the