The future is here. It s just not widely distributed yet. William Gibson

Transcription

1 The future is here. It s just not widely distributed yet. William Gibson

2 CHRONIC KIDNEY DISEASE MANAGEMENT A NEW PARADIGM Aaron Cass, MD, FRCPC Nephrologist, Fraser Health January 22, 2014

3 Where Are We Going Today? Why care? The challenges of diagnosis A walk through the BC Health Services Guideline Worked examples

4 Why all the fuss about chronic kidney disease? Common Bad Underrecognized Preventable/Postponable

5 Diagnosis How we used to do it Serum creatinine High levels mean less function, but how much? Cr = 100 in a 70 kg, 35 year old man Cr = 100 in a 50 kg, 80 year old woman Do they have the same kidney function?

6 Diagnosis How we do it now egfr: What s this all about? Ml/min/1.73m2

7 The Perils of GFR Derived by MDRD equation Underestimates true GFR at higher ages and normal or near normal values Unreliable with extremes of body size, high/low protein diets Septra, cipro and fibrates interfere Exercise and hydration status interfere

8 Redefining CKD CKD: Either kidney damage or decreased kidney function for 3 or more months. Kidney Damage: Persistent proteinuria Abnormal urinalysis Abnormal renal imaging

9 Clinical Pearl Always follow up an abnormal urinalysis! What the Courts and College have had to say

10 So What s Abnormal? Stage Description egfr 1 Kidney damage + N or incr. GFR >=90 2 Kidney damage + Mild decr. GFR Moderately decr. GFR Severely decr. GFR Kidney failure <15 or dial

11 An Approach to CKD Identification, Evaluation and Management of Patients with Chronic Kidney Disease Guidelines and Protocols Advisory Committee, BC Health Services, 2004

12 Identify High Risk Populations Diabetes Hypertension Cardiovascular disease Family history of kidney disease First Nations and Pacific Islanders

13 Screen High Risk Populations Every 1-2 years with serum creatinine and random urine tests (no 24 hour collections!) Urine tests Urinalysis (WBCs, RBCs, casts) Albumin/creatinine ratio - abnormal if > 2.8 (F) or 2.0 (M) on 2 of 3 tests done 1 wk 2 mo apart

14 Screen High Risk Populations If normal, repeat q1-2 years and follow BP Need a means of easily identifying (stickers, electronic flags) If abnormal, further evaluation required

15 Evaluate Patients with an Abnormal Screen Stage Recommendations 1 U/S, egfr and ACR q yearly 2 As above, and nephro referral if egfr decline > 10% annually or rise in proteinuria 3 U/S, egfr and ACR q 6mo, nephro referral as above 4 U/S, egfr and ACR q 6mo, nephro referral 5 Urgent nephro referral (dial, tx, palliation)

16 Determine the Cause Renal U/S Check urinalysis Look for egfr decline > 10%/year Note constitutional symptoms Note sudden or severe onset of symptoms (e.g. edema without obvious cause)

17 Identify and Meet Care Objectives An enormous list Key items: BP, DM, regular testing Use the flowsheet provided Consider standing labwork orders

18 Blood Pressure Measure every visit Target 130/80 Preferential use of ACE/ARB ISN T THIS RISKY IN CKD? No additional benefit if N ACR

19 The Glomerulus

20 ACEI/ARB in CKD Monitoring <15% fall in GFR acceptable Recheck Cr, K in 2 weeks Tell pts when to hold

21 Diabetes HbA1C q 3 months Target < 7%

22 Serial Kidney Function Testing Measure creatinine q 6-12 months and after changes in meds or clinical status Target < 10% decline in GFR annually Measure urine ACR q 6-12 months Use ACE/ARB Target 50% reduction from baseline

23 Cardiovascular Disease Leading cause of morbidity and mortality in CKD patients Measure cholesterol profile yearly Target LDL < 2.0, Total chol/ldl < 4.0 in high risk, normal renal function what about CKD?

24 Cardiovascular Disease Age > 50, GFR < 60 but no HD/PD/TX, statin or statin/ezetrol regardless of profile Age > 50, CKD, GFR > 60, statin Age 18-49, CKD, no HD/PD/TX, statin if Known CAD, DM, CVA, est d 10 yr incidence CAD > 10% If HD/PD, do not start statin, ezetrol

25 Cardiovascular Disease If on statin/ezetrol at HD/PD start, continue If TX, statin

26 Medication Reviews Limit exposure to nephrotoxins (NSAIDs, COX-2s, aminoglycosides, contrast dye) Consider adjustment or discontinuation Metformin and bisphosphonates relatively contraindicated if GFR <30 Lithium and digoxin need levels checked

27 Conditions Associated with CKD Anemia (Hb < 120, TSAT < 20%, ferr < 100) High PO4 (PO4 > 1.4) Low Ca (Ca < 2.2) High PTH (PTH > N) Low albumin (Alb < N) Low bicarbonate

28 Anemia Hb 105, TSAT 12%, Ferritin 40 WHY Iron deficiency (is there a source?) Erythropoetin deficiency TREATMENT Iron 600 mg po qhs

29 New insights about anemia Exogenous erythropoeitin will raise Hb Targeting N values causes increased CV morbidity/mortality Patients feel better and have less prbcs Lower threshold to initiate, lower target range

30 High PO4 PO4 1.9 WHY Less GFR, so more PO4 retained TREATMENT Calcium with each meal Dietary changes

31 Low Ca Ca 2.0 WHY High PO4, low Vitamin D TREATMENT Address high PO4 first, then address low Ca

32 High PTH PTH 12.5 WHY High PO4, low Ca, low Vitamin D TREATMENT Activated Vitamin D (not regular)

33 Low Albumin Albumin 33 WHY Malnutrition and inflammation TREATMENT Address nutrition Address cause of inflammation

34 Low Bicarbonate Healthy kidneys excrete excess acid NH3 + H = NH4 Less renal mass = Less ammoniagenesis H builds up in blood, binds to HC03 to create H20 + CO2 and serum HCO3 drops Treatment: NaHC03 (but has a salt load!)

35 Other areas Weight and BMI (including diet, salt) Smoking cessation Vaccinations Psychosocial health

36 Support Patient Self- Management Patient goals Self-monitoring Community resources

37 Meet Care Objectives Create register/flag charts Use flowsheets Have organized recall system Review regularly

38 An Example 62 year old male, HTN and DM 1) Patient identified as high risk chart flagged 2) Screen Cr 110, egfr = 64 ml/min Urinalysis (R and M) unremarkable Alb/Cr #1 = 3.5, #2 = 4.3 Patient is CKD Stage 2

39 An Example 3) Evaluate patients with abnormal screen Serial kidney function measurements and urine testing: egfr and ACR q yearly; nephro referral if egfr decline > 10% annually or rise in proteinuria 4) Determine the cause Renal U/S Urinalysis unremarkable Screen for constitutional symptoms

40 An Example 5) Identify Care Objectives BP 160/90, start ACE, repeat Cr, K in one week. If still above 130/80, titrate up dose, rechecking Cr, K with each dosage change Add in other agents as needed Titrate ACE to achieve 50% or more reduction in proteinuria

41 An Example TChol = 5.2, LDL = 3.2, HDL = 0.9, TG = 2.4, TChol/HDL = 5.8 Start statin DM Hb A1c = 8.5%, treat as per usual practice

42 An Example Monitoring (includes assessment of associated conditions) HbA1C q 3months; Cr, urine ACR q yearly Lipids, Hb, ferritin, TSAT, Ca, PO4, alb, PTH q yearly Patient given a standing lab requisition Flowsheet created in chart

43 An Example Encourage to stop smoking Stop ibuprofen Salt reduction Flu shot, pneumovax Self BP-monitoring Review him in six months has he met targets?

44 Where We ve Been A new way of defining CKD A seven step model of care 1) Identify 2) Screen 3) Evaluate 4) Seek Cause 5) Plan Care 6) Support 7) Review

45 The Bottom Line Screen Your High Risk Patients DM and BP control ACE/ARB Standing lab orders Regular review