Chronic renal failure

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

2 Menu Epidemiology & stages Management Tips and pitfalls Resources and referral

3 Epidemiology

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 clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.

7 Management of CKD Identification of patient; diagnosis (e.g.biopsy) CVD risk reduction Smoking cessation Statins? BP control Glycaemic control Avoid preventable damage Home BP monitoring Protect forearm veins Choice of modality Preparation for dialysis; Control of symptoms In the very elderly: is dialysis appropriate Dialysis

8 Chronic renal failure out of the woodwork 72 year old man with hypertension Blood pressure 180/100. Creatinine 200 umol/l (GFR 28) Dipstick trace positive for proteine Referral to nephrology. Appointment in 4 weeks WHAT CAN BE DONE UNTIL THEN? Make sure referral letter contains comorbidity, all medication, time course of creatinine. Ultrasound would be superb Ultrasound L kidney 9.8 cm, R kidney 9.5 cm

9 Avoid preventable damage: NSAIDS Ivan Klasnic Avoid NSAID in CKD COX-2 inhibitors no better What else is wrong in this pic?? Topical treatment should be ok

10 Avoid preventable damage: angiography The same patient is scheduled for coronary angiography as an outpatient. He is now on Frusemide, Aspirin, Simvastatin, Metoprolol, Irbesartan, Doxazosin and a thiazide diuretic. Contrast-mediated renal failure is common and often preventable The risk relates to GFR, renal disease, amount and type of contrast and hydration Is the indication compelling? Admit. Stop ARB and all diuretics the evening before. Hydrate. Acetylcysteine: conflicting data Limit amount of dye. Skip LV angiogram if possible Post-procedural dialysis: no convincing data

11 Blood pressure control After 5 minutes of rest Arm on level of the heart No coffee or smoking Cuff size (obese patients) Both arms White coat hypertension Masked hypertension (9% of Italians Circulation. 2001; 104: 13) Home monitoring

12 Blood pressure and progression 100 No Treatment Current Treatment Early Treatment GFR (ml/min/ ) 10 Kidney Failure Time (years)

13 Only add-on dizziness Excellent add-on e.g. evening Low potential for trouble Doxazosin Moxonidin CCB plus diuretics and Beta-Bl. Admission? Mi no xi dil Alpha-MD Beta- Blocker Loop diuretics ACE-I ARB Thiazides If compliant + renovascular unlikely Beware of spironolactone If other Indication or stress If pregnant If edema and thiazides not enough Low potential for trouble If mild edema Avoid if low clearance

Drug treatment of hypertension: Some tips and tricks Establish home monitoring Start new drugs on weekends Start new drugs in the evenings Do not start two drugs at once Patient must know that

14 Drug treatment of hypertension: Some tips and tricks Establish home monitoring Start new drugs on weekends Start new drugs in the evenings Do not start two drugs at once Patient must know that treatment is permanent If patient very elderly or compliance and/or doctor-patient relationship fragile: start with low risk drugs at low dose. Head for early (and visible) success Be passionate about plans, particulary with multiple prescribers Dosette for the elderly

15 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 ARBs safer than ACE inhibitors Start Enalapril 5mg BD Avoid concomitant use of Spironolactone and NSAIDs Do not use if potassium 5.5 or higher CHECK POTASSIUM AND CREATININE!!

16 Protection of forearm veins Hands off, please!

17 CKD and hypertension as a gateway to cardiovascular risk Hypertensive patients without overt cardiovascular disease but with high cardiovascular risk ( 20% risk of events in 10 years) should also be considered for statin treatment even if their baseline total and LDL serum cholesterol levels are not elevated 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 guidelines 2007

18 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 will definitively answer the question of whether low glomerular filtration rate or dialysis are indications for cholesterol lowering treatment for the prevention of cardiovascular events and progression to end stage renal disease.

19 Statins and CKD CKD Grade GFR >90ml/min /1.73m 2 GFR 60-89ml/min/1. 73m 2 GFR 30-59ml/min/1.73 m 2 GFR 15-29ml/min/1. 73m 2 GFR <15ml/min/ 1.73m 2 Atorvastatin 1 No dose adjustment required Simvastatin 2 Rosuvastatin 3 Dose adjustment should not be necessary No dose adjustment necessary 5mg is recommended starting dose 40mg dose contraindicated Doses above 10mg/day should be carefully considered and if deemed necessary implemented cautiously All doses contraindicated

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

21 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. Do egfr Be careful about metformin and avoid if GFR<30 Sulphonylureas accumulate BP control is key Glitazones: no definitive data

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

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

24 Late referral - early death Lost opportunity to benefit from reno-protective treatment Lost opportunity to avoid ESRD and the need for dialysis Lost opportunity to benefit from adequate preparation (access) Lost opportunity to come to terms with ESRD Extra costs difficult to gauge, have been estimated at 1 billion $ / year in USA (Jungers, NDT (2002) 17: ); Lifetime cost of preventable ESRD: per patient)

25 Patient information

26 One-year survival on dialysis as a function of age

27 When is dialysis appropriate or inappropriate?

A hopeless case 81 year-old female Clearance 12 ml/min Acute pulmonary edema severe aortic stenosis (opening area 0.7 cm2) and severe mitral stenosis in the lead.

28 A hopeless case 81 year-old female Clearance 12 ml/min Acute pulmonary edema severe aortic stenosis (opening area 0.7 cm2) and severe mitral stenosis in the lead. Severe stenosis of the RCA and LAD The cardiac surgeons felt that double-valve replacement and bypass surgery was inappropriate; The FEV1 was 1.15 l/s. Haemodialysis-> frequent flyer with the cardiac arrest team

29 A (not so) hopeless case Intermittent peritoneal dialysis begun on Feb 1, 2006 Home oxygen withdrawn mid-february Return of good diuresis Dialysis paused April 2006 Had another 1 ½ years off dialysis with reasonable quality of life Died peacefully in December 2007

30 Guidelines

31 Cardiovascular risk management Patient education Statins and Aspirin Communication Timely discussion In the very elderly Avoid preventable damage Blood pressure control Smoking cessation Timely referral

Chronic renal failure

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 Menu Epidemiology