Chronic Kidney Disease The 6 Pillars. Dr. Tiina Podymow Associate Professor Division of Nephrology McGill University Health Centre

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1 Chronic Kidney Disease The 6 Pillars Dr. Tiina Podymow Associate Professor Division of Nephrology McGill University Health Centre

2 None Disclosures

3 Objectives 1. Describe evidence-based measures to slow the progression of chronic renal disease 2. Recognize and treat the complications of renal failure in an evidence-based manner including anemia, bone metabolism disorders, and electrolyte abnormalities 3. Recognize the importance of ongoing medication reviews in patients with decreasing egfr 4. Recognize when and how to plan for long-term renal replacement therapy and/or renal transplantation

4 Poll Everywhere I am a: Community Internist Trainee (Stu/Res/Fel) Family Physician Academic Internist

6 Case 73M divorce lawyer, referred to nephrology clinic Cr 180 µmol/l PMHx COPD CABG age 64 AAA rupture/repair age 65 Afib on warfarin Medications Bisoprolol Atorvastatin Warfarin Perindopril Omeprazole Synthroid Isosorbide mononitrate Vitamin D ROS: no hematuria, some ankle edema, occasional ibuprofen

7 Questions/Objectives What is the cause of his chronic kidney disease? What is the likely course of his CKD? Likelihood of needing dialysis? What is the best stabilization/preservation strategy What are the six pillars? When should patients be referred to nephrology?

8 Labs

10 What is the likely cause of CKD? Burned out glomerulonephritis e.g. IgA Diabetic nephropathy Glomerulosclerosis The cause is not especially relevant to management and prognosis

11 Urine Protein Interpretation Microalbumin: answers the question: is the endothelium healthy? < 1.9 yes it is >1.9 no it might not be Urine protein/cr is a surrogate for 24 hour urine collection and protein quantification

12 Urine Protein Dipstick:.3 (which is 1+) U protein/cr ratio is equivalent to 0.5 g/24 hour urine Urine microalbumin is positive- upper normal is 1.9 mg/mmol

13 Urine Protein Quantification <1 gram tubular or hemodynamic (glomerulosclerosis- ischemic nephropathyhypertensive nephropathy) 1-3 g nondiagnostic- could be tubular or glomerular >3 g/24 h is always glomerular 13

14 Patient s diagnosis Glomerulosclerosis U protein ~ 1 g/day Relatively stable Cr

15 Hypertensive Glomerulosclerosis Bright: hard pulse means granular kidneys on autopsy Meaning: hypertension clinically predicts glomerulosclerosis on autopsy

16 Glomerulosclerosis Hypertension alters the endothelial lining of glomerular capillaries Leads to atherosclerosis and scarring of the glomerulus Normal glomerulus Glomerulosclerosis

17 Natural History of Hypertension MR FIT trial 322,000 men, 16 year follow up correlating blood pressure to end-stage renal disease of any cause

18 MR FIT trial NEJM1996 Jan 4;334(1):13-8.

19 1-4% needing dialysis does not seem so bad But it is.. The number of hypertensive patients is so large that even the small percentage at risk means a large number of people with renal failure

21 Question If I told you that this patient also had a history of type 2 diabetes x 15 years, could his CKD be attributable to diabetic renal disease? Yes No

22 Diabetes Clinically: 1. Microalbuminuria 2. Albuminuria 3. nephrotic proteinuria 4. Cr 5. renal failure Kimmelstiel Wilson lesions

23 Diabetic Renal Disease Type 1: 4-17% on dialysis at 20 years Type 2: 1-10% Kimmelstiel Wilson lesions

24 U ptn vs. Cr in 41F with Diabetic Nephropathy

25 Is there any difference in prognosis between: 1. 73M glomerulosclerosis egfr of 30 ml/min 2. 41F with diabetic nephropathy egfr 30 ml/min?

26 73M glomerulosclerosis: what is the likelihood of needing dialysis? to calculate GFR

27 73M egfr 31

28 41F DM nephropathy egfr 31 high U alb/cr

29 Course of CKD due to glomerulosclerosis Prognosis is actually quite good Patients tend to be very volume sensitive- Cr fluctuates No NSAIDS Dose meds to GFR 30 ml/min (mdrd.com and Uptodate)

30 Poor prognosis Course of CKD due to Diabetic Nephropathy Type 1: 4-17% on dialysis at 20 years from onset Type 2: 1-10% Kimmelstiel Wilson lesions

31 Chronic Glomerulonephritis IgA: 20% at 10 years on dialysis FSGS 25% Membranous 15%

32 AD Polycystic Kidney Disease progression to end-stage renal failure most commonly occurs in middle age and later Dialysis: age 40, 50, 60, and age 75

33 Slowing the Progression of Chronic Kidney Disease

34 The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI)

36 Hypertension in CKD Hypertension is found in 85% with stage 3 CKD High systemic BP transmitted to the glomerulus Hypertension almost always accelerates the loss of renal function BP is the most important thing to control to limit progression of CKD to dialysis

37 Hypertension and CKD Most patients with renal failure have hypertension and need more than 3 meds to control it Hydrochlorothiazide no longer works after~ CrCl <30 ml/min ACEI/ARB- expect a rise in Cr of 15%- this is OK (represents lowered intraglomerular pressure (good), not failing kidney)

38 Doubling Cr Jafar, T. H. et. al. Ann Intern Med 2003;139:

39 Hypertension and proteinuria conspire to accelerate chronic kidney disease

40 Proteinuria from Diabetes Diabetes type 1 and type 2 are the commonest causes of chronic renal failure leading to dialysis In patients with microalbuminuria treatment of blood pressure to <120/75 mm Hg and use of ACEI or ARBs can reverse proteinuria Before these drugs, all patients with proteinuria and CKD ended up on dialysis Takes ~ 10 years from onset of DM for microalbuminuria to occur

41 Type 1 diabetes Lewis NEJM 1993 Captopril, the first ACEI, alters the natural history of diabetes as we knew it (PCr >1.5) 25% on dialysis with placebo vs. 12% on ACEI

42 Blood Pressure Goals BP goal for uncomplicated hypertension is <140/90 mm Hg, Proteinuria > 1 g/day with CKD, the BP goal is <130/80 mm Hg. HOWEVER: No benefit in patients with <1 g/day proteinuria- target 140/90

44 BP recommendations in CKD Am J Kidney Dis. 2013;62(2):

45 The 6 Pillars

46 Chronic Renal Insufficiency 1. Anemia 2. Bone disease 3. Volume overload 4. Hypertension 5. Increased K 6. Acidosis

48 At what egfr would you first expect anemia, acid base disturbances, etc. 50 ml/min 40 ml/min 30 ml/min 20 ml/min 10 ml/min

49 1. Anemia in CKD CrCl below 30 ml/min- usually ml/min Approach to Hb <100 Target Hb? 1. Check Fe, IBC, % sat and fix iron stores. 2. Then use ESA (erythrocyte stimulating agents) erythropoetin or darbopoetin and not more or less (increased mortality)

50 2. Secondary Hyperparathyroidism/ Bone disease Comes down to Ca/PO4/ and PTH PO4 rises in renal failure Parathyroid is stimulated to PTH this is secondary hyperparathyroidism PO4 uses free Ca and bone for buffer (so Ca can become low) Vitamin D is not converted to 1,25 vit D 50

52 Management Want normal Ca and PO4 Target PTH 5 x normal (~50 max) Low PO4 diet renal diet Binders: CaCO3, Sevelamer, Lanthanum bind PO4 in gut Vitamin D = Calcitriol is 1,25 vitamin D and it suppresses PTH BUT it increases PO4 by increasing its gut absorption (so control PO4 first before Rxing) Cinacalcet (Sensipar)- a calcimimetic for the calcium sensing receptor in the parathyroid gland- medical parathyroidectomy for patients with 3o hyperpth 52

53 Ca ( ) PO4 (N ) PTH pmol/l (target is 35-50) Rx Normal 3 35 Normal Normal Normal 3 on 35 CaCO3 Normal Normal 300 (tertiary hyperpth) Low PO4 diet +Start CaCO3 Start 1,25 vit D (calcitriol) Start sevalemer or lanthanum Start sevalemer or lanthanum Start cinacalcet 53

54 3. Volume overload Really becomes a management issue if LVEF is low Fluid restriction Furosemide in renal failure doses BEWARE of pre renal failure

55 4. Acidosis The kidney can t generate bicarbonate Want to give bicarb? 500 BID or TID Target bicarb >21 mmol/l Bicarbonate Supplementation Slows Progression of CKD JASN September 1, 2009 vol. 20 no. 9 55

56 5. Increased K Renal diet Avoid K increasing meds- NSAIDS (not to mention that they kill the kidney) Kayexelate is a poor long term solution- it is poorly tolerated

58 6. Dialysis Planned start, with a functioning fistula or CAPD catheter GFR 10 ml/min followed monthly in nephrology clinic Guided by, but not based on GFR Based on how the patient feels If the patient starts to have decreased appetite, nausea, feels unwell, trouble concentrating with GFR 15 ml/min or less- start that day or the next

59 6. Dialysis planning Need at least 8 weeks for a surgically created fistula to mature Save an arm

60 Peritoneal Dialysis 6 weeks for a Tenchoff catheter site to heal

61 CKD egfr 30 ml/min Treat or consider 1. Hb and Fe/ESA treatment 2. Ca PO4 PTH 3. HCO3 4. K 5. Volume status 6. Prepare for dialysis- save an arm BP to target Dose medications to current GFR (Uptodate), and hold the ones that are overtly nephrotoxic like NSAIDS

62 When to refer to a Nephrologist? U protein 3 g/day

63 AKI on CKD CKD patients are especially volume sensitive NSAIDs, aminoglycoside antibiotics, and radiocontrast media commonly aggravate renal disease NSAIDS with ACEI/ARB = AKI educate patient to NEVER take Ibuprofen (Advil, Motrin), Aleve, Celebrex etc. (often Rx by surgery) Aspirin or Tylenol are fine

64 Summary Use U albumin and U protein/cr ratio to diagnose and risk stratify Use MDRD.com and kidneyfailurerisk.com BP is the most important thing for secondary prevention, to limit progression of CRF to dialysis use ACEI/ARB for proteinuric patients Remember the 6 pillars Dose meds to to egfr Nephrologist should co-follow egfr 30 ml/min

The Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009

The Diabetes Kidney Disease Connection Missouri Foundation for Health February 26, 2009 Teresa Northcutt, RN BSN Primaris Program Manager, Prevention - CKD MO-09-01-CKD This material was prepared by Primaris,