8 th Annual Congress of the Bangladesh Society of Medicine Dhaka, Bangladesh March 23-24, Jeffrey P. Harris MD, FACP

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1 8 th Annual Congress of the Bangladesh Society of Medicine Dhaka, Bangladesh March 23-24, 2008 The Internist and the Pre-End Stage Renal Disease Patient Jeffrey P. Harris MD, FACP

Country: Bangladesh Population: 130 million Number of kidney and urology patients: 10 million Number of acute renal failure/year: 12-15 thousand Number of Chronic renal failure/year:

2 Country: Bangladesh Population: 130 million Number of kidney and urology patients: 10 million Number of acute renal failure/year: thousand Number of Chronic renal failure/year: thousand Total Doctors: 30 thousand Medical College: 25 Total no of Nephrologist: 60 Total no of Urologist: 60 Total no of postgraduate trainee in Nephrology: 40 Kidney Foundation

3 Bangladesh: CAUSES OF CHRONIC RENAL FAILURE Existing Patients ( ) New Patients (1998) Glomerulonephritis 47% 40% Diabetic nephropathy 24% 31% Hypertension 13% 15% Obstructive uropathy 8% 8% Unknown 10% 6% Kidney Foundation

4 Overview I. Why is optimizing care of advanced chronic kidney disease (CKD) patients important? II. III. What s involved in following the new advanced CKD guidelines? What practical approaches/tools can we use to assure guidelinebased care?

5 I. Why is optimizing care of advanced CKD patients important? The number of patients with kidney failure is rising

6 Prevalent counts & adjusted ESRD rates, by race Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age & gender. USRDS, 2001

7 Prevalent counts & adjusted ESRD rates, by ethnicity Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age & gender. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity. USRDS, 2001

8 Prevalent counts & adjusted ESRD rates, by primary diagnosis Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age, gender, & race. USRDS, 2001

9 Adjusted prevalent ESRD rates: 2001 (per million population) Point prevalent ESRD patients; Medical Evidence form data; by HSA; rates adjusted for age, gender, & race. USRDS, 2001

10 I. Why is optimizing care of advanced CKD patients important? 2. Advanced CKD involves multiple complex issues: 1. Anemia 2. Bone disease 3. Hypertension 4. Nutrition 5. Dyslipidemia 6. Counseling and rehabilitation 7. Preparation for renal replacement These 7 areas are addressed by the RPA guidelines *Renal Physicians Association Clinical Practice Guideline #3: Appropriate Patient Preparation for Renal Replacement Therapy, October 2002

11 I. Why is optimizing care of advanced CKD patients important? Intervention makes a difference Ofsthun, N. Kidney International. 63(5): , Used with permission from Kidney International.

12 Cardiac Disease Predicts Morbidity and Mortality in ESRD and CKD

13 Intervention makes a difference

14 Intervention makes a difference Held, AJKD 1996, 28 (Suppl. 2):58-78, USRDS DMMS l 1,997 patients incident in 1993 No venipuncture of the non-dominant arm use dorsum of hand when possible

15 Intervention makes a difference Poor outcomes related to delayed referral of CKD patients have been documented by numerous papers over the last decade

16 Impact of Timing of Nephrology Referral and Pre-ESRD Care on Mortality Risk Among New ESRD Patients in the US. USRDS Dialysis M/M Study, n =2,264 57% had not seen a nephrologist 1 year prior to dialysis 34% had permanent vascular access,11% fistula; 25% were using EPO 32% had first nephrologist encounter <4 months prior (LR) Late referrals had lower serum albumin and Hct (11% using EPO), lower fraction with permanent vascular access/more catheters The 28% who saw nephrologist at least twice in the year prior to dialysis had mortality benefit: RR = 0.8 Stack, AG. AJKD 41: , 2003

17 Intervention makes a difference BP less than 130/80 Use of ACEI or ARB agent Attention to nutrition Treatment of anemia Treatment of hyperphosphatemia Treatment of hyperlipidemia and other CV risk factors Referring patients to a nephrologist for an early opinion Proactive permanent vascular AV fistula

18 Early treatment makes a difference Brenner et al, 2001

19 II. What s involved in following the new advanced CKD guidelines? 1. Identify patients with advanced CKD 2. Plan: Develop and communicate a management plan 3. Manage: Provide ongoing monitoring and treatment

20 II. What s involved in following the new advanced CKD guidelines? 1. Identify patients with advanced CKD Measure creatinine in patients at high risk for CKD (e.g., diabetes, hypertension, elderly, cardiovascular disease, other) Calculate GFR Flag patients with low GFR (e.g., on problem list)

21 II. What s involved in following the new advanced CKD guidelines? 2. Plan: Develop and communicate a management plan Select patient goals within the 7 guideline areas Decide who is responsible for each aspect of advanced CKD care (nephrologist vs non-nephrologist) In general For each patient

22 II. What s involved in following the new advanced CKD guidelines? 3. Manage: Provide ongoing monitoring and treatment Order and track laboratory tests Adjust therapy based on targets Educate patients appropriate to their disease stage, capabilities, and preferences

23 CKD Identification CKD Risk Factors: Indicators of Kidney Damage: Hypertension Diabetes Age > 60 Family history of CKD Nephrotoxic drug exposure including NSAIDs Cardiovascular disease History of acute renal failure Autoimmune disease Urologic disorders Systemic infection Cancer Ethnic minority Proteinuria Hematuria Other urine sediment abnormalities Structural (imaging) abnormalities GFR <60 Other abnormal blood tests GFR is preferred over creatinine alone for assessing kidney function See Potential Complications in CKD: Identification and Action Plan

24 Serum Creatinine can Overestimate Creatinine Clearance

25 Cockcroft-Gault Calculator Plasma creatinine (PCR) mg/dl umol/l 1.1 Weight (wt) kilograms pounds 57 Gender Male Female Age 42 Creatinine Clearance 59.7 (140 Age) x Weight Cockcroft-Gault equation: C Cr = 72 x S x (0.85 if female) Cockcroft D, Gault MD. Nephron, 16:31-41, 1976 Cr

26 Plasma creatinine 1.1 (mg/dl) Bun mg/dl mmal/l 20 Albumin g/dl g/l 4.3 Age GFR MDRD Calculator for Adults Note that the equation does not require weight because the result is reported normalized to m body surface area, which is an accepted average adult surface area. In adults, the best equation for estimating glomerular filtration rate (GFR) from serum creatinine is the MDRD equation GFR (ml/min/1.73 m )=186 x (P ) x(age) x( if female) x (1.210 if African CR American) 42 African American Yes No Gender Male Female Calculate Reset GFR value: ml/min/1.73 m * *Disclaimer: This is most accurate for GFRs 60 ml/min/1.73 m 2 or less Abbreviated MDRD Study equation: GFR=186x(S ) x (Age) x(0.742 if female)x(1.210 if black) Cr

27 Date Name Title Organization Address City, State ZIP Dear Lab Director [Insert Name] As you are aware, there are now million people in the U.S. with chronic kidney disease (CKD). The number of patients with CKD has been steadily increasing, in spite of evidence that kidney failure can be significantly delayed, or even averted, with early detection. I would like to encourage you and your laboratory to join in the efforts to assist physicians in the early diagnosis of kidney disease. Specifically, your laboratory can help physicians achieve this goal by providing an estimated glomerular filtration rate (GFR) with all serum creatinine results. Additional information on the rationale and suggested methods for reporting estimated GFR is available on the National Kidney Disease Education Program (NKDEP) web site at Your support is vital to the success of this program. Please contact me if you have any questions or concerns. Sincerely yours, Name Title

29 GFR Young adult normal ml/min/1.73m Declines with age Stage 1 - >90 ml/min/1.73m 2 = kidney damage with normal GFR Stage 2 - <90 ml/min/1.73m 2 = kidney damage with mildly decreased GFR 2 Stage 3 - <60 ml/min/1.73m = 50% loss of function Complications of renal disease begin to appear 17% of people >60yo have GFR< Stage 4 - <30ml/min/1.73 = 75% loss of function Stage 5 - <15ml/min/ % of patients in the US begin dialysis at this point Stage % of US population Stage 5 0.1% 100 fold more US patients in Stages 1-4 than Stage 5 2

30 ALGORITHM FOR MANAGEMENT OF HYPERTENSION 1 Check blood pressure at every office visit (at least every 3 months) BP 130/80 BP 130/80 Advise therapeutic life style changes* No On ACEI or ARB? Add ACEI or ARB Yes Intensify antihypertensive therapy 1 * Therapeutic lifestyle changes (TLC) include weight reduction, the DASH diet, salt restriction, physical activity, and moderation of alcohol.(jnc-vii) 1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy

31 Blood Pressure Control: Recommended Guidelines

32 Blood Pressure Control: Slows Rate of Progression

33 Blood Pressure Control: Reduces Proteinuria.

34 Use of ACE-I to delay CKD

35 Combined ACE/ARB Therapy helps to Lower Proteinuria.

36 Diabetic Control Goal HgbA1c <7

37 ALGORITHM FOR MANAGEMENT OF ANEMIA 1 Check Hb every 3 months Perform complete workup for anemia including iron studies Patient is anemic? * Yes No Iron deficiency** identified? Yes Iron Therapy No Prescribe EPO/analogue and check BP at every dose Patient remains anemic? * Yes No * Anemia = <12 g/dl for women, <13 g/dl for men ** Iron deficiency = TSAT < 20% or ferritin < 100 mcg/ml 1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy

38 ALGORITHM FOR MANAGEMENT OF BONE DISEASE 1 Measure calcium, phosphorus and ipth levels All normal ipth level high* and phosphorus level normal or high ipth level normal and Phosphorus level high** Check calcium and phosphorus levels at least every 3 months Normal Low phosphorus diet Measure 25 (OH) vit D Low*** Prescribe vit D 2 and low phosphorus diet Low phosphorus diet Phosphorus level high Re-check phosphorus levels after 1 month Phosphorus level normal Prescribe phosphate binder ipth level still high Repeat ipth levels in 3 months ipth levels normal Prescribe 1,25 vitamin D analogue *High ipth level: >100 pg/ml or >1.5 times the upper limit of normal for each assay used **High Phosphorus level: >4.5 mg/dl ***Decreased 25 (OH) vitamin D: < 30 ng/ml NB: Caution should be used with vitamin D analogue when serum calcium is in the upper range of normal. 1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy Check calcium, phosphorus and ipth levels at least every 3 months

39 ALGORITHM FOR MANAGEMENT OF DYSLIPIDEMIAS 1 Monitor for dyslipidemia at presentation, 3 months after change in status and annually thereafter. Measure triglycerides, LDL, HDL, total cholesterol Yes Evaluate for secondary causes (comorbidities* and medications**) Patient has dyslipidemia? No Secondary cause* identified? No Yes Treat dyslipidemia*** Manage secondary cause * Comorbidities = hypothyroidism, diabetes mellitus/hyperglycemia, nephrotic syndrome, alcohol excess, chronic liver disease ** Medications = beta-blockers, diuretics, corticosteroids, calcineurin inhibitors (especially cyclosporin), sirolimus, oral contraceptives, anticonvulsants, antiretroviral therapy *** Suggested target levels = LDL 100 mg/dl, non-hdl cholesterol 130 mg/dl, fasting triglycerides 500 mg/dl 1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy

40 Lipid Control NCEP Guidelines Treat pt s with CKD as if they have CAD or Diabetes: Goal LDL < 100

41 ALGORITHM FOR MANAGEMENT OF NUTRITION 1 Monitor body weight and serum albumin every 3 months Evaluate for causes of malnutrition Is there evidence of malnutrition*? No Non-advanced CKD related cause identified? Yes (advanced CKD related malnutrition) Offer diet assessment and nutritional counseling * Malnutrition = Unintentional decrease in body weight by more than 5% OR decrease in serum albumin ( 4.0 g/dl for Bromo-Cresol- Green or 3.7g/dL for Bromo-Cresol-Purple) or decrease from baseline by 0.3 g/dl with either assay ** Dietary recommendations include energy intake kcal/kg body weight/day, and protein intake 0.6 g/kg body weight/day 1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy No Offer nutritional assessment and counseling** by qualified personnel Is the malnutrition corrected? No Initiate renal replacement therapy if GFR 20mL/min Yes

42 ADVANCED CKD PATIENT MANAGEMENT FLOW SHEET Patient Name: Action/Measure (Area of Guidance) Creatinine/GFR Target Decrease rate of GFR decline Hemoglobin (Anemia) g/dl Every 3 months Minimum Frequency / / / / / / / / / / / / / / / / Depends on stage, rate of change, and clinical factors Bicarbonate (Bone disease) >22 mmol/l Every 3 months Phosphorus (Bone disease) <4.5 mg/dl Every 3 months Low phosphorus diet prescribed Phosphate binder prescribed Calcium (Bone disease) mg/dl Every 3 months ipth (Bone disease) Not >100 pg/ml or 1.5xnormal Every 3 months if Ca or PO4 abnormal 25(OH) Vitamin D (Bone disease) >30 ng/ml If ipth abnormal Blood pressure (Hypertension) 130/80 mmhg Every 3 months ACEI or ARB dose increased or new agent added Unintentional Every 3 Body Weight Weight loss months (Nutrition) < 5% Albumin (Nutrition) LDL (Lipid) >4.0 g/dl by BCG assay, or >3.7 g/dl by BCP assay < 100 mg/dl Every 3 months 3 months following a change in status, then annually RRT modality discussion (Timing)

43 Morbidity and Mortality in ESRD:Diabetics

44 Summary What is involved in following the new RPA Advanced CKD guidelines: Identify patients with advanced CKD Develop and communicate a management plan Manage: Provide ongoing monitoring and treatment

45 Goals of Management Early recognition/screening Timely introduction of therapies to Slow Rate of Decline in GFR. Blood Pressure control ACE-I/ARB s Diet (Diabetic Control) Diagnosis directed therapy (i.e. Cytoxan/Prednisone for SLE) Identification and Management of Common Co-Morbid conditions. CHF, IHD, chronic fluid overload. Control of metabolic complications. Treatment on Anemia Prevention of Bone Disease Acidosis Malnutrition Coordinate Transition to Renal Replacement Therapy (RRT) Education Protect non-dominant arm from venipuncture once CrCl<60 ml/min Early Access Placement (AVF when CrCl <20-24 ml/min or RRT needed in <18 months).

46 Links National Kidney Foundation (NKF). Clinical Practice Guidelines. GFR calculator. Hypertension Dialysis and Clinical Nephrology (HDCN). Nephron Information Center. Clinical Practice Guidelines. Patient information. GFR calculator. National Institute of Diabetes & Digestive & Kidney Diseases (NIDDKD). edrugsrenal which takes you to the FreewarePalm website. Click on Download edrugsrenaljf4.zip. And follow their download instructions. General information on performing Palm/hand-hold PC device downloads is available on the RPA home page at

47 Useful Websites for Glomerular Filtration Rate (GFR) Formulas for the PC User Calculation Formula Used for all sites is MDRD Useful Programs for Glomerular Filtration Rate (GFR) Calculations for the Palm/Hand-Held PC User (Using the MDRD Equation) MedCalc and click on Palm Downloads in the menu to the upper left or go straight to Click on MedCalc link which takes you to FreewarePalm website. Click on Download medcalc en.zip and then follow their directions. MedMath which takes you to FreewarePalm website. Click on Download medmath.zip. Follow their instructions

The Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009

The Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009 Teresa Northcutt, RN BSN Primaris Program Manager, Prevention - CKD MO-09-01-CKD This material was prepared by Primaris,