CHRONIC RENAL FAILURE: WHAT THE PRIMARY CARE CAN OFFER. The annual conference of the Lebanese Society of Family Medicine October 2017 Dr Hiba AZAR

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1 CHRONIC RENAL FAILURE: WHAT THE PRIMARY CARE CAN OFFER The annual conference of the Lebanese Society of Family Medicine October 2017 Dr Hiba AZAR

2 OUTLINE: A journey through CKD Screening for CKD: The why, the who and the how Slowing the progression of CKD Management of complications of CKD: the anemia, the hyperkalemia and the CKD-MBD

3 Screening for CKD: The why CKD is a silent disease. CKD is a leading cause of mortality, primarily via in increase in cardiovascular mortality. Progression of CKD can be slowed.

4 Screening for CKD: The who Not for everybody Population at risk: Diabetes. Hypertension. Systemic diseases, autoimmune diseases. Family history of kidney disease. Certain ethnicities. Recurrent kidney stones and UTIs.

5 Screening for CKD: The who

6 Screening for CKD: The how DO NOT rely on creatinine alone. Always use calculators of egfr, CKD-Epi or MDRD.

7 Screening for CKD: The how 18 years old male. Creatnine 1.2 mg/dl CKD EPI= 88 ml/min 85 years old lady Creatinine 1.2 mg/dl CKD EPI= 41ml/min

8 Screening for CKD: The how DO NOT ask for microalbuminuria alone in the urine spot

9 Screening for CKD: The how Microalbuminuria 40 mg/dl Microalbuminuria 40 mg/dl Creatininuria 1,3 g/dl Creatininuria 0.3 g/dl UAER= 30 mg/g UAER= 133 mg/g

10 Screening for CKD: The how Creatinine for calculation of egfr. UAER. General exam of the urine. Renal ultrasound.

11 Screening for CKD: The how

12 Slowing the progression of CKD

13 Slowing the progression of CKD Very strong correlation between CKD, microalbuminuria and CVD mortality. CKD doubles the risk of heart failure. Increase in the risk of stroke, atrial fibrillation, coronary heart disease, peripheral artery disease irrespective of age and ethnicity. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. Lancet 2013

14 Slowing the progression of CKD In patients with mild to moderate CKD, the risk of cardiovascular mortality is much higher than the risk of reaching end stage kidney disease. Only in stage 4 CKD, the risk of end stage kidney disease surpasses the risk of CV mortality. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. Lancet 2013

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16 Slowing the progression of CKD Lifestyle modifications Therapeutic interventions

17 Slowing the progression of CKD- lifestyle modifications Smoking cessation Dietary counseling: Na< 2g/day Dietary counseling: Protein intake 0.8 g/kg/day Decreases CV mortality in general population. Tobacco use is associated with progression of CKD. Cessation effect not documented Enhances effect of ACEi and ARBs on the proteinuria reduction and decrease the progression of CKD Protein intake more than 1.3 g/kg/day should be avoided Reduction of BMI to 25 kg/m2 Regular physical exercise, 30 min five times weekly Associated with reduction of cardiovascular mortality of 13% ACP clinical practice guidelines 2013

18 Slowing the progression of CKDtherapeutic interventions BP reduction to < 140/90 mm Hg for CKD patients and lower if proteinuria Use of RAAS inhibitors No room for associating ACEi and ARB Glycemic control Lipid control Antiplatelet therapy Uric acid lowering treatment Adjust according to age, comorbidities, progression of CKD, tolerance Reduction in albuminuria, positively affects renal prognosis (beware SI, high K) Aim for an HbA1c of 7 or less unless advanced CKD, comorbidities and high risk of hypoglycemia Statins. Decrease of CV risk, no clear effect on renal progression. Adjust dose of fibrates. No specific recommandations No specific guidelines if asymptomatic ACP clinical practice guidelines 2013

19 The anemia The incidence of anemia increases with the severity of kidney disease

20 The anemia Manifestations: fatigue, decreased tolerance to effort, cold intolerance, general malaise, irritability. Normocytic, normochromic anemia. Due to the decrease in EPO production by kidney. Iron deficiency is frequent: decreased oral intake, increased loss, decreased absorption, inflammation and increased demand with ESA therapy. Iron stores should be regularly checked and repleted in CKD patients, before starting and during treatment with EPO.

21 The anemia Suggested scheme for monitoring for anemia by KDIGO CKD w/o anemia CKD/anemia w/o ESA CKD/anemia with ESA egfr>45 ml/min Once yearly egfr>45 ml/min Twice yearly Every 2 to four weeks at initiation egfr< 45 ml/min Twice yearly egfr< 45 ml/min Every 3 Months Then every 3 months KDIGO guidelines Kidney International 2012

22 The anemia Guidelines for iron therapy in CKD patients

23 The anemia KDIGO guidelines for the management of anemia ESA should be started after repletion of iron stores if Hb level is lower than 10g/dl. Aim for a Hb level between 11 and 12g/dl. Hb should not increase by more than g/dl every month. Hb above 12 g/dl under ESA therapy is associated with increased risk of stroke and worsening hypertension KDIGO guidelines Kidney International 2012

24 The hyperkalemia Hyperkalemia is a common clinical problem in CKD patients. Particularly in diabetics and with the use of RAAS inhibitors. Kovesdy CP, Am J Med 128: , 2015

25 The hyperkalemia Murray et al KI 2016

26 The hyperkalemia Diet. Use of diuretics. Correct metabolic acidosis. Avoid use of other drugs affect K levels. Sodium polystyrene sulfonate: a lot of controversies about efficacy and safety. Mostly used in the acute setting. Contraindicated if ileus, postoperative setting, opioids... Risk of colonic necrosis

27 The hyperkalemia Patiromer: recently approved by FDA for use in acute and chronic hyperkalemia. Nonabsorbal polymer that exchanges potassium for calcium. Decreases safely K by Meq/l. GI side effects. Interaction with other medications... Effect of calcium load in CKD patients? Zirconium cyclosilicate: ZS 9. Exchanges K for Na and hydrogen. Decreases K by meg/l. SI: edema. Not yet approved by FDA.

28 The hyperkalemia

29 The CKD-MBD Calcium Phosphorus PTH Vitamin D FGF23 Renal osteodystrphy Adynamic bone disease osteomalacia

30 The CKD-MBD Prevalence of abnormal mineral metabolism in CKD Levin et al KI 2007; 71:31-38

31 The CKD-MBD

32 The CKD-MBD

33 The CKD-MBD Dg of biochemical abnormalities

34 The CKD-MBD Dg of biochemical abnormalities

35 The CKD-MBD Dg bone disease

36 The CKD-MBD Dg of vascular calcifications

37 The CKD-MBD Management

38 The CKD-MBD Management

39 The CKD-MBD

40 Thank you for your attention