Managing Chronic Kidney Disease: Reducing Risk for CKD Progression

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1 Managing Chronic Kidney Disease: Reducing Risk for CKD Progression Arasu Gopinath, MD Clinical Nephrologist, Medical Director, Jordan Landing Dialysis Center Objectives: Identify the most important risks for CKD progression and potential interventions to mitigate that risk Discuss the new CKD initiative at Intermountain Healthcare Review the supports being build into icentra to assist in decision making

2 Management of CKD progression Arasu Gopinath, MD

3 Management of CKD progression IHC CKD CPM

4 Management of CKD progression 1. Lipids in CKD 2. Proteinuria/ Albuminuria 3

5 Why is managing lipids in CKD important? Cardiovascular disease is the most common cause of morbidity and mortality in CKD CVD mortality is 3 6 times above matched general population As much as 10 fold higher in ESRD Lipids in CKD In addition, dyslipidemias may contribute to CKD progression (CARE/ TNT). Lower serum HDL cholesterol is an independent predictor of CKD progression (MDRD). 4

6 How does CKD change the lipid profile? CKD decreases HDL CKD increases Triglycerides 5

7 Lipids in CKD 6

8 LDL LDL is not a reliable tool to assess coronary risk in CKD The degree of excess risk due to increased LDL decreases as GFR decreases. in ESRD, lowest LDL levels have highest mortality.

9 LDL levels less reliable as CKD worsens As egfr declines, so does the hazard ratio of higher LDL levels 2.6 mmol/l is 100 mg/dl Each additional 1 mmol/l is 39 mg/dl

10 Summary recommendations by KDIGO 1. rule out remediable causes of secondary dyslipidemia. 2. establish the indication for treatment (YES or NO) and select agent and dose. 3. treat according to a fire and forget strategy

11 1. Secondary Causes of Dyslipidemia Medical conditions Nephrotic syndrome Hypothyroidism Diabetes Excessive alcohol consumption Liver disease Medications 13 cis retinoic acid Androgens Anticonvulsants Oral contraceptives Highly active anti retroviral therapy Corticosteroids Diuretics Cyclosporine Beta blockers Sirolimus

12 2. Indications for treating dyslipidemia in CKD In adults < 50 yrs use statin alone if history of known CAD, MI, DM, stroke or CV risk > 10 % In adults >50 yrs with CKD 1 2, use statin alone In adults >50 yrs with CKD 3 5 (ND), use statin or statin/ ezetimibe combo In ESRD, do not initiate statins. If already on statin or statin/ezetimibe, continue.

13 Suggested Algorithm (IHC CKD CPM) KDIGO suggests 10% but we have adopted IMC lipid CPM

14 Fire and forget 3. KDIGO recommended statin doses

15 SHARP Trial Lancet 377: , 2011

16 Albuminuria a marker of kidney damage [increased glomerular permeability] Legend UACR level Old nomenclature Normal 0 10 mg/g Mildly increased 30 mg/g Moderately increased mg/g microalbuminuria Severely increased mg/g macroalbuminuria Nephrotic > 2200 mg/g

17 Classification of CKD Based on GFR and Albuminuria Categories: Heat Map IHC CKD CPM

18 Relative risk of outcomes in CKD 17

19 Albuminuria in the CPM

20 Albuminuria management in the IHC CKD CPM

21 Goals of managing albuminuria

22 Medication algorithm to control albuminuria

23 IHC DATA Statin use in CKD Albuminuria in CKD RAAS blockade Hypertension control

24 IHC data on statin use in CKD CKD Patients who should be on a Statin N Age > 50 (UACR > 30 or egfr 15 59) (N= adults > 50 < 75) 32% 75,097 Other CKD patients > 50 (no CKD indication for a statin) 38% 55,966

25 IHC data on CKD patients with documented ACR and/ or egfr CKD Patients with ACR and GFR Test N ACR but no egfr 3% 4328 egfr but no ACR and no urine dipstick that is 0 for protein 33% 52,153 CKD and no egfr or ACR 5% 8,358 Yes GFR No N ACR Yes 95,511 4,328 99,839 No 52,153 8,358 60, ,664 12, ,350 CKD = Problem list, ICD 9 billing code, ACR >=30*, egfr <60* lower percentages are better 12 months of data

26 IHC Data on Albuminuria and RAAS blockade CKD Patients on an ACE/ARB N CKD with ACR>300 57% 3298 CKD and Diabetes with ACR>=30 66% 8452 Based on prescription orders One year of data Higher percentages are better IMG only due to CPOE used for orders

27 IHC Data on Hypertension control in CKD CKD Patient Blood Pressure In Control N ACR>300 (goal <130/80) 55% 6801 All other CKD (goal <140/90) 88% (CKD = Problem list, ICD 9 billing code, ACR >=30, egfr <60 Any blood pressure in the system Average of the last year BP) CKD Patient Blood Pressure In Control** ACR>300 <130/80 25% All other CKD <140/90 63% **Adding criteria that BP is in control if no BP in the last year

28 Summary LIPIDS In adults < 50 yrs use statin alone if history of known CAD, MI, DM, stroke In adults >50 yrs with CKD 1 2, use statin alone In adults >50 yrs with CKD 3 5 (ND), use statin or statin/ ezetimibde combo RAAS blockade screen for and monitor albumunuria goal BP < 130/80 if albuminuria > 30 mg/g goal BP < 140/90 if albuminuria < 30 mg/g monitor Se creatinine and potassium as appropriate when on therapy with RAAS blockade.

29 KDIGO guidelines References Ref: 1. KDIGO.org/home/guidelines/lipids 2. Lipid Management in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2013 Clinical Practice Guideline, Ann Intern Med. 2014;160(3): IHC CKD CPM