Identifying and Managing Chronic Kidney Disease: A Practical Approach

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1 Identifying and Managing Chronic Kidney Disease: A Practical Approach S. Neil Finkle, MD, FRCPC Associate Professor Division of Nephrology, Department of Medicine, Dalhousie University Program Director, Adult Nephrology, Dalhousie University

2 Disclosure Nil conflicts to disclose

3 Learning Objectives Recognize progressive renal disease Understand how the egfr and ACR are used to stratify patients at risk for progressive kidney disease Know investigation strategies for CKD Identify the complications of renal disease Identify when to refer to a Nephrologist

4 Overview Chronic Kidney Disease Markers of Renal Function Differential diagnosis CKD Stages CKD Risk factors for progression Clinical features Referral guidelines CKD Work-up and Management

5 Clinical Case 1 Edward DeYoung 70 year-old male from Yarmouth Hypertension X 25 years Diabetes 12 years, HgA1C often > 10 IHD with stable angina Smoker ½ ppd X 50 years Meds : ECASA 81 mg OD, Metoprolol 50 mg bid, Gliclazide O/E BP 160/90 Cr 250 Urinalysis 2 g/l protein, nil else albumin:creatinine ratio (ACR) 50 mg/mmol

6 Clinical Case 2 Roberta Kline 83 year-old female from Inverness Hypertension X 30 years OA knees Meds : Ibuprophen 300mg qid prn, Amlodipine 5 mg od O/E BP 150/90 Cr 130 Urinalysis trace protein, hyaline casts Urine albumin:creatinine ratio (ACR) 2.4 mg/mmol

7 Clinical Case Questions Is this CKD? What stage CKD? What is the likely cause of CKD? Should the patient be referred to Nephrology?

8 Renal Function

9 Renal Function GFR (ml/min) Glomerular filtration rate Sum of the flitration of all functioning nephrons Gives an estimate of nephron mass Various measures Creatinine clearance egfr (CKD EPI) Inulin clearance gold standard, rarely used

10 egfr GFR = 141 min (S cr /κ, 1) α max(s cr /κ, 1) Age [if female] [if black] There s a App for that! Qx MD Calculate App Store or Google Play MDCalc.com GFR > 90 normal < 60 CKD < 15 kidney failure, often approaching dialysis

11 Chronic Kidney Disease

12 Chronic Kidney Disease Definition Sustained (> 3 months) abnormalities of renal function Anatomic Radiographic Biomarkers Urinary Abnormalities

14 CKD by egfr Criteria Decreased glomerular filtration rate (GFR) <60 ml/min/1.73m normal GFR in young adults is approximately 125 ml/min/1.73m 2 Common in the elderly population Measure egfr over time to determine if kidney function is improving, stable or is declining egfr is calculated using the CKD-EPI 2009 equation Serum creatinine, age, gender and race

15 Causes of CKD

16 CKD Causes Diabetes Hypertension Ischemic Nephropathy Chronic Glomerulonephritis Chronic Interstitial Nephritis Cystic Renal Disease Chronic Obstruction Chronic Pylonephritis

17 CKD Staging and Classification KDIGO Guidelines 2012

19 CGA Staging: Cause Assign cause of CKD based on presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic findings Glomerular disease Tubulointersitial disease Vascular disease Cystic & congenital disease

20 CGA Staging Glomerular disease Vascular disease i.e. Diabetes i.e. Hypertension Cause Tubulointerstitial disease i.e. Systemic infections Cystic and congenital disease i.e. Polycystic kidney disease

21 Tip: CKD Stage 3 has been subdivided into 3a & 3b to improve risk stratification

24 Blood Pressure Targets People with CKD should be treated with BP lowering drugs to maintain a BP below 140/90 mmhg If albuminuria is present (ACR > 3.0 mg/mmol) a consistent BP below 130/80 should be achieved All pts with diabetes should maintain a consistent BP below 130/80

26 CKD Stages Clinical Features

27 CKD Stages Stage 1 (egfr> 90) nil Stage 2 (egfr 60-89) Hypertension, mild elevation PTH

28 CKD Stages Stage 3 (egfr 30-59) Reduced Ca absorption Reduced phosphate excretion Marked elevation PTH Renal anemia

29 CKD Stages Stage 4 (egfr 15-29) Metabolic Acidosis Hyperkalemia Renal replacement therapy planning

30 CKD Stages Stage 5 (egfr <15) Salt & water retention (looks like CHF) Anorexia, Vomiting Pruritis

31 CKD Progression Male gender Younger Age Low GFR (?< 45 ml/min) Hypertension Diabetes Proteinuria > 1 g/d ACR > 30 mg/mmol

32 CKD Evaluation and Management

33 CKD Screening

34 Evaluation in CKD Diagnosis (type of kidney disease) Severity, assessed by level of kidney function Complications, related to level of kidney function Risk for loss of kidney function Risk for cardiovascular disease

35 Treatment CKD Specific therapy, based on diagnosis Evaluation and management of comorbid conditions Slowing the loss of kidney function

36 Treatment CKD Prevention and treatment of complications of decreased kidney function Preparation for kidney failure and kidney replacement therapy

37 Medication in CKD Review of medications: Dosage adjustment based on level of kidney function Detection of potentially adverse effects on kidney function or complications of chronic kidney disease Detection of drug interactions Therapeutic drug monitoring (Digoxin, Lithium)

38 Medications to Use Cautiously in CKD Metformin, (Insulin may need reduction in dose) Lithium Digoxin Allopurinol Opiates Benzodiazepines Gabapentin

39 S - Sulfa A ACE Inhibitors D - Diuretics Sick Day Medication Adjustment with risk AKI M - Metformin A Angiotenisin Receptor Antagonists N - NSAID S SGLT2 inhibitors KDIGO 2013

40 Reversible Causes Renal Disease Obstruction Prerenal Causes Medications NSAIDs, Sulfa ACEI/ARB in setting severe RAS or prerenal state

41 Reversible Causes Renal Disease Medications Aminglycosides PPIs (colchicine not really) Bisphosphates NSAIDs TMP/SMX, teteracyclines Other Radiocontrast

42 CKD Management Complications CKD Anemia Metabolic Acidosis Mineral Metabolism Hyperkalemia Malnutrition Hypertension

43 RAS Inhibitor first line treatment (2D)

44 Nephrology Referral

45 Kidney Failure Risk Equation

50 When to Refer Acute Kidney Injury CKD patients with egfr <30 ml/min Rapidly progressive CKD Cause CKD unclear ACR > 30 mg/mol (> 60 mg/mmol) Especially if progressive decline egfr

51 CKD Work-Up

52 CKD Work-Up Serial Creatinines differentiate ARF vs. CKD Gauge rate of progression Electrolytes Calcium, Phosphate, Albumin Urinalysis Urine albumin:creatinine ratio (ACR) instead of 24 hr urine for protein Renal Ultrasound

53 Management While Waiting on Referral Stop NSAID, PPI D/C Metformin if egfr < 30 Urinalysis Renal Ultrasound Serial Cr s to gauge rapidity of decline

54 Back to Case 1 Edward DeYoung 70 year-old male from Yarmouth Hypertension X 25 years Diabetes 12 years, HgA1C often > 10 IHD with stable angina Smoker ½ ppd X 50 years Meds : ECASA 81 mg OD, Metoprolol 50 mg bid, Gliclazide O/E BP 160/90 Cr 250 currently, year ago Urinalysis 2 g/l protein, nil else ACR 50 mg/mmol

55 Back to case 1 Is this CKD? What stage CKD? What is the likely cause of CKD? Should the patient be referred to Nephrology?

56 Back to case 1 Is this CKD? Yes No Answer Yes - Cr 225 one year prior dx CKD egfr 24 ml/min a year ago What stage CKD? Stage 1 Stage 2 Stage 3 Stage 5 Answers: Stage 3, egfr 22 ml/min, specifically G3bA3 the red zone, KRFE 19% at 2 years, 48% at 5 years

58 Back to case 1 What is the likely cause of CKD? A) Diabetes B) Ischemic kidney disease C) Hypertension D) Polycystic Kidney Disease Answer A, B and C are correct

59 Back to case 1 Should the patient be referred to Nephrology? Yes No Answer Yes egfr < 30 ml/min, ACR > 30 mg/mmol High risk for progressive kidney disease

60 Back to Case 2 Roberta Kline 83 year-old female from Inverness Hypertension X 30 years OA knees Meds : Ibuprophen 300mg qid prn, Amlodipine 5 mg od O/E BP 150/90, Weight 65 kg Cr 130 currently, Cr years ago Urinalysis trace protein, hyaline casts ACR 2.4 mg/mmol

61 Back to case 2 Is this CKD? Yes No Answer Yes, Cr years ago (egfr 37 ml/min) What stage CKD? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 5 Answer C, egfr 34 ml/min, stage G3bA1

63 Back to case 2 What is the likely cause of CKD? A) Hypertension B) Renal senscence C) NSAIDs analgesic nephropathy D) Diabetes E) Polycystic Kidney Disease Answer A, B, and C are correct

64 Back to case 2 Should the patient be referred to Nephrology? -Yes -No Answer No Not required at present. Stable egfr > 30 ml/min KFRE 1% at 2 years, 3% at 5 years

65 Back to case 2 Should the patient be referred to Nephrology? Yes No Answer No Not required at present. Stable egfr > 30 ml/min How should this patient be managed? Remove and nephrotoxins Serial bloodwork BP goal 140/90

66 Summary Chronic Kidney Disease Markers of Renal Function Differential diagnosis CKD Stages CKD Risk factors for progression Clinical features Referral guidelines CKD Work-up and Management

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