Chronic renal failure

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1 Chronic renal failure Alexander Woywodt MD FRCP Consultant Physician and Nephrologist / Hon. Senior Lecturer Lancashire Teaching Hospitals NHS Foundation Trust Carnforth 13 th th October 2010

2 Menu Epidemiology & stages How to measure Management, BP control and CV risk Tips and pitfalls How / where to get help

3 Incident rates of renal replacement therapy Rate per million population Wales N Ireland Scotland England Year RPH: 560 dialysis (Feb 2010) and 400 transplant

4 A silent epidemic (USRDS 2007) Diabetes worlwide 2001: 151 Mio 2010: 221 Mio Zimmet et al., Nature 2001; 414:

5 Chronic renal failure and type II diabetes a deadly combination For comparison: T2, N0, M0 pancreatic cancer - five-year survival rate 27%

6 Stages GP practice of patients K/DOQI. Am J Kidney Dis 2002; 39:S1.

7 How to measure or estimate renal function What we usually measure is the serum creatinine GFR 29 ml/min GFR 130 ml/min Serum creatinine 120 umol/l Serum creatinine 120 umol/l

8 How to measure or glomerular filtration rate (GFR) Options to measure GFR include Direct measurement (isotope GFR) Estimation acc. to Cockroft and Gault Estimated GFR (egfr) Creatinine clearance (Cx = (Ux X V)/Px)) The egfr is an estimate of renal function for use in the GP world, in MAU and A&E. It is NOT REPEAT NOT an accurate measure of renal function. It is particularly unreliable at the extremes of age and muscle mass Glasgow, Hunter, folio 84r Flemish manuscript, 15 th th century

9 Management of CKD GFR Ml/min/1.73m 2 >=90 Identification of patient; diagnosis (e.g.biopsy) BP control Glycaemic control Avoid preventable Damage Protect forearm veins CVD risk reduction Smoking cessation Statins Choice of modality Preparation for dialysis; Control of symptoms In the very elderly: is dialysis appropriate <15 or dialysis Dialysis or Transplant

10 Chronic renal failure out of the woodwork 72 year old man with hypertension and IHD. New to your practice Blood pressure 180/100. Creatinine 200 umol/l (GFR 28) Dipstick trace positive for proteine Referral to nephrology. WHAT CAN BE DONE UNTIL THEN? Make sure referral letter contains comorbidity, all medication, time course of creatinine. Ultrasound. Ultrasound L kidney 9.8 cm, R kidney 9.5 cm

12 Avoid preventable damage: contrast media angiography The same patient is scheduled for a coronary angiogram. He is now on Frusemide, Aspirin, Simvastatin, Metoprolol, Irbesartan, Doxazosin and a thiazide diuretic. Contrast-mediated renal failure is common and often preventable Is the indication compelling? Make sure the cardiologist knows (to limit amount of dye + Skip LV angiogram) Admission?. Stop ARB and all diuretics the evening before. Hydrate.

13 Protection of forearm veins Hands off, please!

14 Hypertension and progression Hypertension and renal failure a marriage that needs to be prevented!

15 Blood pressure control Home monitoring is key No coffee or smoking Cuff size (obese patients) Both arms White coat hypertension (when I see my boss...) Masked hypertension (9% of Italians and mostly men Circulation. 2001; 104: 13)

16 Only add-on dizziness Excellent add-on e.g. evening Low potential for trouble If compliant with diuretics and Beta-Bl. Admission? Mi no xid il Doxazosin Alpha-MD Moxonidin Loop diuretics Beta- Blocker CCB Thiazides ACE-I ARB If compliant + renovascular unlikely beware of Spironolactone And NSAID If other Indication or stress If pregnant If edema and thiazides not enough Low potential for trouble If mild edema Avoid if low clearance

17 ACE inhibitors and ARBs The 72 year-old patient is now on Amlodipine 5mg OD BP is 160/95. ACE inhibitor? ARB? Check for abdo bruit and renal size and be careful in vasculopaths ARB cause less hyperkalaemia than ACEI (Bakris, Kidney International 2000; 58: 2084) Avoid concomitant use of Spironolactone and NSAIDs Do not use if potassium 5.5 or higher CHECK POTASSIUM AND CREATININE!!

18 Drug treatment of hypertension: Some tips and tricks Establish home monitoring Start new drugs weekends and evenings Do not start two drugs at once Patient must know that treatment is permanent Start with low risk drugs at low dose. Be passionate about plans Dosette for the elderly

19 CKD is a major cardiovascular risk factor in its own right Lancet 2010; 375:

20 Statins and cardiovascular outcomes in ESRD: The 4D study Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. Wanner C; Krane V; Marz W; Olschewski M; Mann JF; Ruf G; Ritz E N Engl J Med 2005 Jul 21;353(3): No difference in outcomes between atorvastatin and placebo This study was limited to type II diabetics + ESRD The SHARP trial : Statins in CKD (expected to report in November 2010)

21 Statins and CKD Statins significantly reduced the risk of all-cause and cardiovascular mortality in CKD patients [...]. Statins appear to be safe in this population. Cochrane Database Syst Rev Apr 15;(2):CD CKD Grade GFR >90ml/min/1.73m 2 GFR 60-89ml/min/1.73 m 2 GFR 30-59ml/min/1.73m 2 GFR 15-29ml/min/1.7 3m 2 GFR <15ml/min/1. 73m 2 Atorvastatin 1 No dose adjustment required Simvastatin 2 Dose adjustment should not be necessary Doses above 10mg/day should be carefully considered and if deemed necessary implemented cautiously Rosuvastatin 3 No dose adjustment necessary 5mg is recommended starting dose 40mg dose contraindicated All doses contraindicated If administered, patients with CKD should be treated with the lowest dose of statin that reduces the LDL-C to less than 100 mg/dl (2.6 mmol/l). UPTODATE

22 Aspirin Low-dose aspirin should also be considered in hypertensive patients without a history of cardiovascular disease if older than 50 years, with amoderate increase in serum creatinine or with a high cardiovascular risk.in all these conditions, the benefit-to-risk ratio of this intervention (reduction in myocardial infarction greater than the risk of bleeding) has been proven favorable ESH 2007 Aspirin reduced major cardiovascular events by 66% (95% confidence interval [CI], 33% - 83%) in those with a baseline GFR of less than 45 ml/min per 1.73 m2. No significant increase in bleeding HOT study subgroup analysis Jardine M, WCN 2009

23 Smoking and renal failure Orth SR, Clin J Am Soc Nephrol 3: , 2008

Chronic renal failure and diabetes A 72 year-old patient with type II diabetes. Diet has failed. The HbA1c is 8.4%. Serum creatinine is 180 umol/l. BP is 160/95.

24 Chronic renal failure and diabetes A 72 year-old patient with type II diabetes. Diet has failed. The HbA1c is 8.4%. Serum creatinine is 180 umol/l. BP is 160/95. Dipstick is + for protein. monitor egfr Be careful about metformin and avoid if GFR<30 Sulphonylureas accumulate BP control is key Glitazones: no definitive data

25 Late referral - early death Schwenger et al., DMW 2003; 128(22):

26 Pre-dialysis education and choice of modality Peritoneal diaysis In-centre HD Home HD

27 When is dialysis appropriate or inappropriate?

28 One-year survival on dialysis as a function of age!!

29 One-year survival on dialysis as a function of age UK renal registry, 2007 cohort

30 Dialysis in nursing home residents leads to functional decline Kurella Tamura M et al. N Engl J Med 2009;361:

31 Conclusion: All renal patients should... Do home blood pressure monitoring and have a blood pressure of 120/80 (there is a leaflet for download on the website) Avoid NSAIDs and COX-2 inhibitors (there is a leaflet ) Protect their forearm veins (there is a ) Have an LDL < 100, stop smoking and be considered for aspirin if risk factors

32 Patient information

33 How to get help Paris, Bibliotheque Nationale gr 2243 folio 10v Nicolaus Salernitanus 12 th century

34 Conflict of interest This talk is sponsored by Sankyo (Olmesartan) I have previously given talks sponsored by Abbott, Amgen, Novartis, Pfizer and Sankyo I have no other involvement with any company that manufactures drugs for CKD, hypertension or cardiovascular disease. I am on no company advisory board and hold no shares (none)

Chronic renal failure

Chronic renal failure Dr. Alexander Woywodt Consultant Physician and Nephrologist / Hon. Senior Lecturer Lancashire Teaching Hospitals NHS Foundation Trust Fleetwood 23rd June 2009 Menu Epidemiology &