CKD: Recognition, Prevention and Management

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8//6 CKD: Recognition, Prevention and Management Objectives: Participants will be able to: Recognize Chronic Kidney Disease (CKD) Identify ways to prevent CKD Keep them kidneys happy Manage CKD and

1 8//6 CKD: Recognition, Prevention and Management Objectives: Participants will be able to: Recognize Chronic Kidney Disease (CKD) Identify ways to prevent CKD Keep them kidneys happy Manage CKD and know when to refer to nephrology specialist PROBLEM High personal and economic burden to individual, family, society, nation and world Largely preventable but not prevented High Unawareness of individuals and medical professionals Lack of robust research results on which to base decisions Why is awareness of CKD important? Preventing, reducing, and delaying damage is only possible when patients and providers are aware of CKD and make changes in lifestyle and healthcare decisions Shortage of Nephrologists 4 Why should we address CKD? CKD is a progressive disease estimated to affect over 6 million U.S. citizensmoving from asymptomatic early stages - to The natural history of CKD can be changed with early intervention 5 National Kidney Foundation 00 6

8//6 End Stage Renal Disease OR MORE OFTEN FROM CKD TO 7 8 PREMATURE

the General Population (GP) vs ESRD Patients 00 Annual CVD mortality

female GP black GP white dialysis m ale dialysis fem ale dialysis

lity wa s defined as dea th due to arrhythmias,ca rdiomy opathy,

disease, and pulmonary edema Foley RN et al. Am J Kidney Dis.

2 8//6 End Stage Renal Disease OR MORE OFTEN FROM CKD TO 7 8 PREMATURE DEATH FROM CARDIOVASCULAR EVENTS Cardiovascular Disease Mortality in the General Population (GP) vs ESRD Patients 00 Annual CVD mortality (%) >85 Age (years) GP male GP female GP black GP white dialysis m ale dialysis fem ale dialysis black dialysis white 9 Ca rdiova s c ular dise a s e (CVD) morta lity wa s defined as dea th due to arrhythmias,ca rdiomy opathy, cardiac arrest, myocardial infarction, atherosclerotic heart disease, and pulmonary edema Foley RN et al. Am J Kidney Dis ; : S -S9 0 What is Chronic Kidney Disease? Per KDIGO Guidelines Recognize Chronic Kidney Disease Marker/s of kidney damage or decreased function as measured by egfr Present for months With implications for health

8//6 Marker of kidney damage ( or more) Albuminuria (ACR > 0 mg/g) Urine sediment abnormalities Electrolyte abnormalities (tubular d/o) Inferred/histological detected abnormality Image detected

Rise in scr after significant loss of nephron function Varies among individuals Varies within individuals over time Normal vs abnormal level differs among groups 4 creatinine is the same CAUTION: Not

7 m Normal GFR or stage CKD if kidney damage is also present 66 ml/ min/.7 m Stage if kidney damage is also present 46 ml/ min/.7 m Stage CKD NKF 00 5 6 Should everyone be screened for CKD?

3 8//6 Marker of kidney damage ( or more) Albuminuria (ACR > 0 mg/g) Urine sediment abnormalities Electrolyte abnormalities (tubular d/o) Inferred/histological detected abnormality Image detected structural abnormality History of kidney transplantation egfr vs Serum Creatinine (scr) Why use egfr instead of scr to detect and monitor kidney disease? Rise in scr after significant loss of nephron function Varies among individuals Varies within individuals over time Normal vs abnormal level differs among groups 4 creatinine is the same CAUTION: Not all serum Serum creatinine. mg/ dl. mg/ dl. mg/ dl Who and How to Screen for CKD GFR as estimated by the MDRD equation Ki dney function 98 ml/ min/.7 m Normal GFR or stage CKD if kidney damage is also present 66 ml/ min/.7 m Stage if kidney damage is also present 46 ml/ min/.7 m Stage CKD NKF Should everyone be screened for CKD? Mass screening not supported by evidence Target screening of those at high risk DM HTN Family history of kidney disease Age 60+ Practical list of those at high risk for CKD Individuals with Diabetes, Hypertension, Urinary stones, History of acute kidney injury, Family history of CKD, Exposure to renal toxic drugs Populations at risk Persons 60 years + Certain ethnic groups (African Americans, Hispanics, Asians, Pacific Islanders, and American Indians), Exposed to chemical or environmental conditions, Living below poverty level. 7 8

4 8//6 How to Screen egfr (MDRD, CKD-Epi, cystatin C) Albumin to Creatinine Ratio (ACR) morning specimen best months Other tests to help determine cause Kidney U/S: absence of DM, HTN, other obvious cause Serology: to determine possible AKI, myeloma or glomerulonephritis Consider consultation with or referral to Nephrology if cause unclear 9 0 PREVENTION OF CKD AND PROGRESSION PREVENTING CKD AND PROGRESSION Advance Practice Nurses play a key role in all settings KDIGO gives specific recommendations to guide practitioners Blood Pressure and RAAS Target CKD adults +/ - DM ACR <0 <40/90 Target CKD adults +/ - DM ACR >0 0/80 Age considerations ACE-I or ARB for HTN +DM ACR >0 ACE-I or ARB all with ACR >00 CKD and risk of AKI All adults with CKD at increased risk of AKI Predictor of acute kidney decline following radiocontrast and major surgery CKD increases risk of AKI and AKI increases risk of CKD 4 4

5 8//6 Glycemic Control Target Hgb A c 7 % o r l es s - CKD adult to prevent microvascular complications including kidney disease Target Hgb A c 7. 5 % - CKD adult with comorbidities/limited life expectancy /risk of hypoglycemia Manage and 5 6 Individualized FREQUENCY OF TESTING CKD is classified based on: Cause (C) GFR (G) Albuminuria (A) KDIGO 0 Album inur ia c at egor ies Description and range A A A Nor m al t o m ildly Moderately increased Severely increased inc r ea s ed <0 m g/g 0-99 mg/g 00 m g/g < m g/m m ol - 9 mg/mmol 0 m g/mmol More frequent lower egfr and/or higher albuminuria GFR c at egor ies ( m l/ m in/. 7 m Description and range G Nor m al or high 90 G Mildly decreased Mildly to moderately Ga decr eased Moderately to severely Gb 0-44 decr eased G4 Severely decreased 5-9 * * * * G5 Kidney f ailur e <5 Adapted with permission from KDI GO 0 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney I nt. 0;Suppl.: Lifestyle, Protein and Dietary Intake Physical exercise compatible with CV health; aim 0 min activity 5 x wk; BMI 0-5; smoking cessation Protein intake: 0.8g/kg/day; avoid high protein diet (>.g/kg/day) Salt intake: < gm/day sodium (5 gm sodium chloride); decrease to.5 gm/day CKD stage G4 &5 Managing CKD Progression and Complications DM and HTN CKD Anemia CKD Mineral and Bone Disease (CKD-MBD) CKD Metabolic Acidosis Cardiovascular risks: Hyperlipidemia, anticoagulation therapy Hyperuricemia and PPI studies ongoing 9 0 5

6 8//6 Medication Management and Safety in CKD RED FLAG RED FLAG Dosage changes to avoid toxicity D/C potentially nephrotoxic renally excreted drugs in seriously ill in Ga-G5 Metformin: caution GFR 0-44 and d/c <0 Check before use OTC, herbs, supplements Nephrotoxic/cytotoxic drugs closer monitoring WHAT CHA GONNA DO WHAT CHA GONNA DO WHEN THEY COME TO YOU?? DON T DO IT!!!! AVOID NSAIDS: affects renal blood flow and damages tubules CAUTIOUS USE PPIs AVOID IDODINE CONTRAST DYE AVOID GADOLINIUM DYE IN DIALYSIS PATIENTS Renal consideration for common outpatient medications Analgesics Antimicrobials Blood Pressure and cardiac meds Hypoglycemics Miscellaneous 4 Risk of Infections, AKI, Hospitalizations and Mortality ral to Kidney Specialist -4 X higher Major infections complications Offer flu and Pneumonia vaccines GFR <0 should get Hep B series Higher hospitalization and mortality Partnering with Patient and Nephrology specialists aid in preventing progression and complications Both egfr and albuminuria levels should be considered when referring Highest mortality dialysis Pts (>50% CVD) 5 6 6

7 8//6 ral Recommended AKI/abrupt sustained fall egfr GFR <0 Consistent albuminuria (ACR >0) >5% drop egfr from baseline Sustained decline egfr >5 per year U/A red cell casts (RBC >0) CKD and refractory HTN on meds Persistent abnormalities of serum K+ Hereditary Kidney Dz; recurrent stones Take Home Points CKD affects many growing are everywhere NPs are frontline can help identify CKD and delay progression Recomm: good general health; medication and testing caution; watch for and treat CVD and infection; refer when see rapid or consistent progression 7 8 ences Thorp M L, Eastman L, Smith DH, Johnson EC. Managing the burden of chronic kidney disease. Disease Management.006;9():5-. Coresh J, Selvin E, Stevens LA, et al. Prevalence of Chronic Kidney Disease in the United States.JAMA.007; 98 (7), Centers for Disease Control and Prevention. (04). Kidney disease and diabetes. Available at National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). (0). Kidney Disease Statistics for the United States. Retrieved from eses_stats_508.pdf 9 Fox CH, Brooks A, ZayasLE, McClellan, W, Murray B. Primary care physicians knowledge and practice patterns in the treatment of chronic kidney disease: An Upstate New York practice-based Research Network (UNYNET) study. J Am Board of Fam Med. 006;9():54-6. Israni RK, Shea JA, Joffe MM, Feldman, HI. Physician characteristics and knowledge of CKD management. Am J Kidney Dis. 009;54():8-47 Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 0 clinical practice guideline for the evaluation and management of chronic kidney disease.kidney IntSuppl. 0;:-50. National Kidney Foundation. Kidney Disease Facts. Available at: National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disese evaluation, classification, and stratification. Am J Kidney Dis. 00;9(suppl):S-S66. Nation Kidney Foundation. Low income linked to higher levels of kidney disease in African Americans. Publication Date November 5, 0. Available at: -Kidney- Disease Inker LA, Astor BC, Fox CH et.al. KDOQI US Commentary on the 0 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD. Am J Kidney Dis. 04;6(5):7-75. Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, SequistTD, and the US Kidney Disease Outcomes Quality Initiative. A Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician. Am J Med 06 (in press) Lipska KJ, Bailey CJ, Inzucchi SE. Use of metformin in the setting of mild-to -moderate renal insufficiency. Diabetes Care. 0;4:4-47. Salpeter SR, Greyber E, P asternak GA, Salpeter EE. Risk of f atal and nonf atal lactic acidosis with metformin use in type diabetes mellitus. Cochrane Database Syst Rev. 00;4:CD US Food and Drug Administration. FDA Drug Safety Communication (00): new warnings for using gadolinium-based co nt rast agen t s in pat ien ts w ith kid ney d ysf un ctio n. gov/drugs/drugsafety/ucm966.htm. Accessed January 7, 04. Wood, S, Petty, D, Fay, M., and Lewington, A. Assessing kidney function in oral anticoagulatant prescribing: An aid for safer drug and dose choices. British Journal of Cardiology. 0; 0(); Xie, Y, et. al. Proton Pump Inhibitors and risk of incident CKD and progression to ESRD. Journal of the American Society of Nephrology. 05. doi: 0.6 8/asn